Asthma is one of the most widespread diseases on the planet.¹ But when it comes to treatment and management, control has been difficult to accomplish for many. The common method for adjusting an asthma control regimen is stepwise—using easily apparent markers like frequency of symptoms, use of rescue medication, and asthma attacks.^2,3

The stepwise approach falls short.

If the markers increase, treatment is stepped up—and likewise stepped down if symptoms seem well under control. But even in countries offering free healthcare, control has been demonstrably poor. A survey of 8000 patients across 11 European countries found nearly half experienced uncontrolled symptoms, and a further third described their disease as only partially-controlled.⁴

And evidence exists that asthma is also being overtreated, or even misdiagnosed—unnecessarily exposing patients to the side effects that sometimes accompany the therapy.^5,6

Increasing interest in objective measures.

Because of the alarming disparity in therapy-needed versus therapy-received, there is a growing interest in more objective measures to inform both management and diagnosis. One proposed method involves measuring the amount of nitric oxide (NO) that a patient exhales. This is abbreviated as FeNO—fractional exhaled nitric oxide.

FeNO marks the type of airway inflammation that’s caused by eosinophils (as in allergic asthma), which accounts for over 50% of asthma cases. This is a type of asthma that responds well to steroid treatment.⁷
Tracking FeNO could enable physicians a non-invasive—yet objective—guide for stepping up (or down) the level of inhaled corticosteroids (ICS) they prescribe their patients. In 2011, the American Thoracic Society issued strong guidance to US healthcare professionals saying as much—despite what at the time was fairly light evidence.⁸

Combined data from three randomized controlled trials involving over 1000 adults indicated that the number of participants experiencing an asthma attack trended lower in the FeNO group (odds ratio 0.60, 95% confidence interval 0.43 to 0.84).⁹

Conclusions

As encouraging as initial data suggests, the question remains whether FeNO can be used as a more precise measure to tailor asthma treatment than symptom checkers currently in use, such as the peak flow meter. Can FeNO improve control for some, by triggering an appropriate ICS dose increase—while reducing over-treatment for others?

Time will tell. But it is only one piece of the solution, as adherence to inhaled steroids, inhaler technique, and appropriate self-management, are all necessary elements to improved clinical outcomes.

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References

1. Vos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;386:743–800. dx.doi.org/10.1016/S0140-6736(15)60692-4

2. Scottish Intercollegiate Guidelines Network, British Thoracic Society. British guideline on the management of asthma: a national clinical guideline. sign.ac.uk/guidelines/fulltext/141 (accessed 3 August 2016).

3. Global Initiative for Asthma. Global strategy for asthma management and prevention (2016 update). Available from ginasthma.org/gina-reports (accessed 3 August 2016).

4. Price D, Fletcher M, Van der Molen T. Asthma control and management in 8,000 European patients: the REcognise Asthma and LInk to Symptoms and Experience (REALISE) survey. NPJ Primary Care Respiratory Medicine 2014;12;24. dx.doi.org/10.1038/npjpcrm.2014.9

5. O’Byrne PM, Reddel HK, Colice GL. Does the current stepwise approach to asthma pharmacotherapy encourage over-treatment? Respirology 2010;15:596-602. dx.doi.org/10.1111/j.1440-1843.2010.01728.x

6. Looijmans-van den Akker I, van Luijn K, Verheij T. Overdiagnosis of asthma in children in primary care: a retrospective analysis. British Journal of General Practice 2016;66(644):e152-7. dx.doi.org/10.3399/bjgp16X683965

7. Price D, Ryan D, Burden A, Von Ziegenweidt J, Gould S, Freeman D, et al. Using fractional exhaled nitric oxide (FeNO) to diagnose steroid-responsive disease and guide asthma management in routine care. Clinical and Translational Allergy 2013;3:37. dx.doi.org/10.1186/2045-7022-3-37

8. Dweik RA, Boggs PB, Erzurum SC, Irvin CG, Leigh MW, Lundberg JO, et al. An official ATS clinical practice guideline: Interpretation of exhaled nitric oxide levels (FENO) for clinical applications. American Journal of Respiratory and Critical Care Medicine 2011;184:602-15. dx.doi.org/10.1164/rccm.9120-11ST

9. Petsky HL, Kew KM, Turner C, Chang AB. Exhaled nitric oxide levels to guide treatment for adults with asthma. Cochrane Database of Systematic Reviews 2016;(8):CD011440 dx.doi.org/10.1002/14651858.CD011440.pub2