Abstract
As we move toward an era of precision medicine, novel biomarkers of disease will enable the identification and personalized treatment of new endotypes. In asthma, fractional exhaled nitric oxide (FeNO) serves as a surrogate marker of airway inflammation that often correlates with the presence of sputum eosinophils. The increase in FeNO is driven by an upregulation of inducible nitric oxide synthase (iNOS) by cytokines, which are released as a result of type-2 airway inflammation. Scientific evidence supports using FeNO in routine clinical practice. In steroid-naive patients and in patients with mild asthma, FeNO levels decrease within days after corticosteroid treatment in a dose-dependent fashion and increase after steroid withdrawal. In difficult asthma, FeNO testing correlates with anti-inflammatory therapy compliance. Assessing adherence by FeNO testing can remove the confrontational aspect of questioning a patient about compliance and change the conversation to one of goal setting and ways to improve disease management. However, the most important aspect of incorporating FeNO in asthma management is the reduction in the risk of exacerbations. In a recent primary care study, reduction of exacerbation rates and improved symptom control without increasing overall inhaled corticosteroid (ICS) use were demonstrated when a FeNO-guided anti-inflammatory treatment algorithm was assessed and compared to the standard care. A truly personalized asthma management approach—showing reduction of exacerbation rates, overall use of ICS and neonatal hospitalizations—was demonstrated when FeNO testing was applied as part of the treatment algorithm that managed asthma during pregnancy. The aim of this article is to describe how FeNO and the NIOX VERO® analyzer can help to optimize diagnosis and treatment choices and to aid in the monitoring and improvement of clinical asthma outcomes in children and adults.
Highlights
ASTHMA AND THE BEGINNING OF THE AGE OF PRECISION MEDICINEFifteen years ago, I was interviewed for a research fellowship
Weighted Deming regression analysis of the three possible pairs of measurements showed no evidence of bias relating to the order of testing with an estimated bias of \2 % for all pairs; these findings provided further evidence of repeatability
Increased fractional exhaled nitric oxide (FeNO) levels ([25 ppb) in children prescribed inhaled corticosteroid (ICS) was associated with reduced treatment adherence [32, 75], and improved ICS adherence correlated with a greater reduction in FeNO in patients with difficult-to-treat asthma [29, 32]
Summary
ASTHMA AND THE BEGINNING OF THE AGE OF PRECISION MEDICINE. I was interviewed for a research fellowship. I think the two eminent professors leading the questioning were quietly enjoying themselves. I was finding the experience quite jolly until I was asked a simple but insightful question. One of my interviewers (a respiratory pediatrician and superb researcher) looked me in the eye and asked, ‘Are you a lumper or a splitter?’ I fumbled for a few poorly chosen words and played for time by suggesting that it depended upon the context, but I did not give a illuminating answer. I cannot honestly recall whether I decided whether I was, at heart, a lumper or a splitter.
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