Howraman Meteran

Asthma in patients with psoriasis

DEAR EDITOR, We read with interest the report by Fang et al. of the relationship between psoriasis and asthma in a large retrospective case–control study from Taiwan. The study found a 1 38-fold increased risk of asthma among patients with psoriasis, with an increasing risk according to higher age of the patients. However, although adjustment for age, sex and selected comorbidities was performed, the study lacked important confounder control, particularly for smoking and body mass index. We studied the association between self-reported asthma and psoriasis in a previously well-described population of 34 781 Danish twins, aged 20–71 years, from the nationwide Danish Twin Registry. Psoriasis was identified by the question, ‘Has a doctor ever told you that you have, or have had psoriasis?’, whereas asthma was identified by the question, ‘Do you have, or have you ever had, asthma?’ The prevalences of psoriasis and asthma were 4 2% and 8 7%, respectively. In accordance with the study by Fang et al., we found an increased prevalence of asthma in individuals with psoriasis (10 9% vs. 8 5%), odds ratio (OR) 1 32 [95% confidence interval (CI) 1 11–1 57, P = 0 002], which remained statistically significant after adjustment for sex, age, smoking, body mass index and hospital-diagnosed chronic obstructive pulmonary disease (COPD) (OR 1 27, 95% CI 1 06–1 54; P = 0 011) (Table 1). However, adjusting also for selfreported atopic dermatitis diluted the association further (OR 1 20, 95% CI 0 99–1 45; P = 0 064), possibly due to the strong association between atopic dermatitis and asthma and/ or to recall bias and diagnostic mix-up between atopic dermatitis/other eczemas and psoriasis. Similarly, in line with the study from Taiwan, we found a higher adjusted risk of asthma in the older age group (50– 71 years) (OR 1 61, 95% CI 1 21–2 15; P = 0 001) compared with the younger age group (20–49 years) (OR 1 09, 95% CI 0 85–1 40; P = 0 51; P-value for different risks = 0 021). Furthermore, we found that the association between psoriasis and asthma was due predominantly to an increased risk of nonatopic asthma (adjusted OR 1 47, 95% CI 1 12–1 92; P = 0 005), and not atopic asthma (OR 1 19, 95% CI 0 93– 1 52; P = 0 18), using self-reported allergy to pollen, pets or dust as a proxy for atopic asthma. Finally, we found that the association between psoriasis and asthma was observed predominantly for adult-onset asthma (age at onset of asthma ≥ 18 years of age) (adjusted OR 1 40, 95% CI 1 10–1 79; P = 0 006), and not childhood-onset asthma (OR 1 06, 95% CI 0 78–1 44; P = 0 72). We also identified patients with psoriasis through the Danish National Patient Registry [International Classification of Diseases, 8th revision (ICD-8) codes 68693-4, 69609-10, 69609-19 and 69609-99; and ICD-10 code L40 0-9]. This registry records all hospitalizations and outpatient visits in Denmark. The prevalence of psoriasis by this definition was 0 6%. The risk of asthma was increased among individuals with hospital-diagnosed psoriasis compared with individuals without hospital-diagnosed psoriasis (12 5% vs. 8 7%) (OR 1 50, 95% CI 0 98–2 28; P = 0 058). This was observed particularly among the older age group (50–71 years; OR 2 12, 95% CI 1 22–3 68; P = 0 007), but less so among the younger age group (20–49 years; OR 1 07, 95% CI 0 55–2 05; P = 0 85). The risk of asthma remained statistically significantly increased in the older age group after adjustment for

Heredity of chronic bronchitis: a registry-based twin study.

BACKGROUND Smoking is a major risk factor for lung diseases and lower respiratory symptoms, but since not all smokers develop chronic bronchitis and since chronic bronchitis is also diagnosed in never-smokers, it has been suggested that some individuals are more susceptible to develop chronic bronchitis due to genetics. OBJECTIVE To study the relative influence of genetic and environmental factors on the variation in the susceptibility to chronic bronchitis. METHODS In a population-based questionnaire study of 13,649 twins, 50-71 years of age, from the Danish Twin Registry, we calculated sex-specific concordance rates and heritability of chronic bronchitis. The response rate was 75%. RESULTS The prevalence of chronic bronchitis was 9.3% among men and 8.5% among women. The concordance rate for chronic bronchitis was higher in monozygotic twins than in dizygotic twins among women; 0.30 vs. 0.17, but not among men; 0.15 vs. 0.18. The heritability of chronic bronchitis adjusted for smoking and age was 55% (36-71%) in women, whereas the susceptibility to chronic bronchitis in men for 25% (8-41%) was ascribable to familial environment but not to genetic factors. CONCLUSIONS Chronic bronchitis shows a moderate familial aggregation, particularly in women. Increased susceptibility to respiratory disease among female smokers relative to male smokers may have a genetic origin.

Novel monoclonal treatments in severe asthma

ABSTRACT Aim: To provide a general overview of the current biological treatments and discuss their potential anti-asthmatic effects. Data sources: We reviewed articles in PubMed found using the search words “Asthma/therapy AND antibodies, monoclonal/therapeutic use AND cytokines.” Study selections: Only articles published in English since 2000 were considered. The search identified 29 studies; 8 additional studies were found by hand search, generating 37 studies. Results: Of the 37 studies investigating biological treatments of asthma, 5 were on the effects of anti-IgE (omalizumab); 12 on anti-IL-5; 8 on anti-IL-13; 5 on anti-IL-4R-α; 3 on anti-IL-9; one on TNF-α; one on anti-IL-2R-α; one on TSLP (Thymic Stromal Lymphopoietin); and one on OX40L. Sample sizes ranged from 3 to 943 participants. Studies of therapies targeting IgE, IL-2, IL4R-α, IL-5, and IL-13 showed some efficacy, whereas those targeting TSLP, IL-9, and TNF-α lacked convincing effectiveness. Conclusion: Research on the biological treatment of asthma shows promising results. While anti-IgE (omalizumab) has been used in the treatment of asthma for some years, anti-IL-5 has recently been approved for use. The efficacy of results of other large studies with a longer duration is needed to draw a firm conclusion. Such studies should not only focus on clinical outcomes, but also consider asthma-related quality of life. Knowledge on the asthma phenotypes and identification of biomarkers associated with these will be useful for physicians considering the right treatment for the asthma patient.

Self-reported intake of fruit and vegetables and risk of chronic obstructive pulmonary disease: A nation-wide twin study

BACKGROUND Although smoking is the major risk factor for chronic obstructive pulmonary disease (COPD) many patients with obstructive lung function suggesting COPD are never-smokers. Therefore, other lifestyle factors have been suggested as risk factors. AIMS i) To examine the association between self-reported intake of fruit and vegetables and risk of COPD and ii) to examine whether the association between these traits are due to underlying genetic factors. METHODS 12,449 twins, aged 40-80, from the Danish Twin Registry were recruited. The participants completed a questionnaire on medical history and lifestyle factors and participated in clinical examination. COPD was defined according to ATS/ERS recommendations. Multivariate logistic regressions were used to estimate the risk of COPD in individuals with a low intake of fruit and vegetables. Co-twin control analyses were performed to examine whether the association between fruit and vegetables and COPD is explained by genetic factors. Self-reported physician-diagnosed asthmatic individuals were excluded. RESULTS Of the 11,458 individuals were included in the analyses, 48% of the participants were males. Mean age was 58.9 (years)±SD 9.6, mean BMI (kg/m2)26.6 ± SD 4.4. A multivariate logistic regression, including sex, age and BMI showed that both smoking, no and heavy drinking and physical inactivity were independent predictors of COPD. There was a significant frequency-pendent association between intake of fruit and vegetables and increased risk of COPD. Conditional logistic regression analyses showed that the association might be controlled by genetic factors. CONCLUSIONS This study shows that low intake of fruit and vegetables is associated with an increased risk of COPD and the association might be under influence of genetic factors.

FeNO-based asthma management results in faster improvement of airway hyperresponsiveness

Asthma is characterised by inflammation and respiratory symptoms. Current asthma treatment is based on severity of asthma symptoms only. Exhaled nitric oxide fraction (FeNO) is not recommended by the Global Initiative for Asthma guidelines. The aim was to compare the usefulness of a FeNO guided versus symptom-based treatment in achieving improved asthma control assessed by airway hyperresponsiveness (AHR). 80 asthmatic patients were included in a double-blinded, parallel, randomised controlled trial with follow-up visits after 8, 24 and 36 weeks. Treatment was tailored using either a FeNO or Asthma Control Questionnaire (ACQ) based algorithm. Inclusion criteria were asthma symptoms and a provocative dose causing a 15% fall in forced expiratory volume in 1 s <635 mg mannitol. At each visit AHR, FeNO, ACQ and blood tests were performed. No differences between the two groups were found at inclusion. AHR from 8 to 24 weeks was improved in the FeNO group compared to the ACQ group (response dose ratio (RDR) geometric mean (95% CI): 0.02 (0.01–0.04) versus 0.05 (0.03–0.07), respectively, p=0.015). AHR to mannitol at 36 weeks showed no differences between the two groups (mean difference RDR (95% CI): −0.02 (−0.05–0.02), p=0.3). Total doses of inhaled steroid and number of exacerbations were similar (p>0.05). When using FeNO as a treatment management tool, lowering of airway responsiveness occurred earlier than using ACQ. However, airway responsiveness and asthma control after 9 months were similar. Asthma management using FeNO provides faster asthma control but is similar to symptom-based management after 9 months http://ow.ly/DGNf30lqGJm

The impact of different spirometric definitions on the prevalence of airway obstruction and their association with respiratory symptoms

The fixed ratio criterion of forced expiratory volume in 1 s/forced vital capacity <0.70 for diagnosing airway obstruction may overdiagnose the condition, particularly in the elderly, so the lower limit of normal (LLN) is recommended as the most appropriate criterion. Our aim was to compare LLN versus fixed ratio on the prevalence of chronic obstructive pulmonary disease (COPD) and examine the association between respiratory symptoms and airway obstruction defined by LLN and fixed ratio. 12 449 twins aged 40–80 years participated in a nationwide survey using the Danish Twin Registry. They completed a questionnaire, underwent clinical examination and recorded prebronchodilator spirometry. Individuals with self-reported asthma were excluded. Clinical COPD was defined by respiratory symptoms together with airway obstruction. 10 329 individuals were included, with a mean±sd age of 58.4±9.6 years and mean body mass index of 26.6±4.4 kg·m−2; 20% were current smokers, 37% former smokers and 43% never-smokers; and 48% were male. The prevalence of LLN airway obstruction (LLN-AO) and fixed ratio airway obstruction (FR-AO) was 5.6% and 18.0%, respectively (p<0.001). Overall, 26% reported current respiratory symptoms, but 50% of those with LLN-AO had respiratory symptoms compared to 39% with FR-AO, p<0.001. The prevalence of clinical LLN-COPD and fixed ratio COPD was 2.6% and 6.3%, respectively (p<0.001). Individuals with LLN-AO had a significantly higher probability of reporting respiratory symptoms compared with both healthy individuals and FR-AO when adjusted for sex, age and ever-smoking. The use of fixed ratio more than doubled the prevalence of clinical COPD compared with LLN, this being more pronounced with increased age, and identified subjects with a lower prevalence of respiratory symptoms than LLN-AO. Prevalence of airway obstruction in a nationwide twin population http://ow.ly/x4QR30g1rId