Improving asthma control and oral immunotherapy protocols

Increasing the dose of inhaled corticosteroids (ICS) may bring asthma under control during an exacerbation. Zhang et al have undertaken a systematic review and meta‐analysis to compare increased with stable doses of ICS.1 They used a standard approach searching three databases to 02 August 2018 and included only parallel group randomized clinical trials. They found a total of 8 trials (N = 3866). Quality was mixed with only four judged to be at low risk of bias. Increasing the dose of ICS was associated with a significantly re‐ duced risk of needing systematic corticosteroids compared with a stable dose (odds ratio 0.82, 95% confidence interval 0.70‐0.97). But when looking at subgroups, it was only effective for adults and when ICS was quadrupled. Extra‐fine particle formulations of ICS have better lung deliv‐ ery characteristics than fine particle formulations. Kuo et al have looked to see whether or not they improve clinical asthma out‐ comes.2 A total of 24 adult patients were changed to extra‐fine par‐ ticle hydrofluoroalkane beclomethasone dipropionate (mean dose 355μg). Compared with previously, asthma control questionnaire and asthma quality of life questionnaire scores improved at 8 weeks (−0.53, 95% confidence interval −0.83, −0.23 and 0.69, 0.35, 1.04, respectively) (Figure 1). There were also significant reductions in symptoms and reliever use. None of the lung function, FeNO nor blood eosinophils changed. With this clinically significant improve‐ ment in patient outcomes, a randomized controlled trial should be undertaken to evaluate the effectiveness of extra‐fine particle ICS in clinical practice. Peanut oral immunotherapy (OIT) has been demonstrated to be effective but it is associated with severe adverse reactions. Brandström et al have assessed whether combining omalizumab therapy with peanut OIT can improve the safety of this approach.3,4 A total of 23 adolescents with peanut allergy were included. Omalizumab was commenced, and then, the OIT dose was increased from 280 to 2800 mg peanut protein over 8 weeks. Finally, omali‐ zumab was withdrawn on the basis of clinical symptoms and baso‐ phil activation test results. All the participants reached the 2800 mg maintenance peanut dose. There were hardly any adverse reactions on full‐dose omalizumab (Figure 2). These were though seen off omalizumab and only half of the participants continued with OIT after omalizumab was stopped, so not quite the panacea we were hoping for.