The Management of Severe Asthma - An Indian Perspective.

Epidemiologically the burden of asthma in India is alarming with a median prevalence of 7%. As the symptoms of asthma ascend the severity ladder, the prediction of the cause of asthma is important from the treatment point of view. The GINA 2020 states that the management of asthma should be individualized as per the patient depending on patient phenotype. The goal of asthma treatment is to achieve good control of symptoms, to reduce exacerbations and to improve quality of life. Guidelines recommend adapting the level of treatment to the level of disease severity, and this approach has been demonstrated to be effective in the majority of asthma patients overall. However, it is known that a small but significant proportion of patients do not achieve adequate control despite optimized treatment, and these patients are frequently prescribed high doses of oral steroids in an attempt to achieve control. For patients with severe uncontrolled asthma, monoclonal antibodies (mAbs) against IgE or IL-5 are available as add-on treatments to inhaled corticosteroid (ICS) plus long-acting ß2-agonist (LABA) therapy. With a plethora of available modalities, the fact still remains that there is a large treatment gap and the number of people living with asthma in India is predicted to be around 30 million. This article reviews the phenotypes/endotypes of asthma described in India and the current therapies for management.

An early Indian experience with benralizumab - A compendium on severe asthma cases: a case series.

Background: Severe eosinophilic asthma (SEA), one of the phenotypes of asthma that is characterized by elevated blood eosinophil counts, is a common cause of uncontrolled asthma. Patients with SEA often experience severe persistent symptoms and have frequent exacerbations despite optimal inhaler therapy. They also have poor lung function and quality of life (QoL). Benralizumab (Fasenra), a monoclonal antibody, has been approved for managing cases of SEA. This series of six cases, the first of its kind from India, aims to add to the real-world evidence of benralizumab in India. Methods: Benralizumab 30 mg (once in four weeks for the first three doses followed by a dose every eight weeks for two years) was administered in six patients with symptoms of cough, breathlessness on exertion, and wheezing, diagnosed with SEA. The following were the endpoints assessed: (i) overlap between high immunoglobulin E (IgE) and eosinophilic asthma; (ii) reduction of exacerbations; (iii) withdrawal of oral corticosteroids; and (iv) improvement in lung function and QoL. Results: In all cases, management with benralizumab resulted in optimal clinical and functional improvement, a decline in systemic steroid use, and improved QoL. Conclusions: The cases presented here are the first of their kind in the Indian asthmatic population with all SEA patients demonstrating significant improvement in symptoms with the use of benralizumab.

Navigating patient journey in early diagnosis of lung cancer in India.

Lung cancer (LC) is one of the leading causes of cancer deaths worldwide. In India, the incidence of LC is increasing rapidly, and a majority of the patients are diagnosed at advanced stages of the disease when treatment is less likely to be effective. Recent therapeutic developments have significantly improved survival outcomes in patients with LC. Prompt specialist referral remains critical for early diagnosis for improved patient survival. In the Indian scenario, distinguishing LC from benign and endemic medical conditions such as tuberculosis can pose a challenge. Hence, awareness regarding the red flags-signs and symptoms that warrant further investigations and referral-is vital. This review is an effort toward encouraging general physicians to maintain a high index of clinical suspicion for those at risk of developing LC and assisting them in refering patients with concerning symptoms to specialists or multidisciplinary teams as early as possible.

Experience with mepolizumab in adults with severe eosinophilic asthma: a case series from India.

Severe asthma can be associated with eosinophilic or allergic phenotypes or both. Eosinophilic inflammation is associated with exacerbations and disease severity due to biological activity of interleukin-5 (IL-5). Patients with severe asthma have reported reduced lung function and poor health-related quality of life (HRQoL) and may require systemic corticosteroids for its management. Thus, treatment targeting IL-5 can help improve quality of life and reduce the use of systemic corticosteroids in severe asthma. Mepolizumab is approved for treating severe eosinophilic asthma as it helps reduce exacerbations, improve lung function and asthma control, and reduce the use of systemic glucocorticoids. This further helps in enhancing HRQoL of these patients. This case series includes four adult patients suffering from severe eosinophilic asthma who were treated with mepolizumab.

Study of inflammatory markers and BODE index in chronic obstructive pulmonary disease.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable disease characterized by progressive airflow limitation and associated with enhanced chronic inflammatory response of the airways to a variety of noxious stimuli. The current concept of COPD, however, extends beyond the respiratory system to include a variety of extrapulmonary manifestations which includes raised inflammatory markers. METHODS: This was a single, center observational open-labeled case-controlled study which included fifty patients of diagnosed COPD and 50 age- and gender-matched controls. All patients were evaluated by detailed history taking, pulmonary function test, 6-min walk test, and calculation of BODE scores. Levels of serum inflammatory markers such as cortisol, tumor necrosis factor alpha, interleukin-6 (IL-6), lactate dehydrogenase, and C-reactive protein were estimated using standard quality equipments. OBSERVATIONS: Majority of the patients in the study and control groups were males and were aged above 40 years. Thirty-eight of the fifty COPD patients had BODE scores of more than 3. All the studied inflammatory markers were significantly higher in the COPD group as compared to the control group. Of all the studied markers, only IL-6 showed a significant correlation with BODE index, i.e., higher IL-6 values were associated with higher BODE scores. No correlation was seen between the other markers and BODE scores. CONCLUSIONS: Our data suggest that IL-6 is a biomarker that correlates with BODE score. IL-6 as a target for therapy in COPD needs to be further studied. Follow-up studies are needed to validate findings.

Diagnostic Efficacy of Normalization of Corneal Deformation Variables by the Intraocular Pressure in Glaucomatous Eyes.

PURPOSE: To analyze the diagnostic efficacy of normalization of corneal deformation variables by the IOP in healthy, primary-angle closure (PACG), and primary open angle glaucoma (POAG) patients. METHODS: Fifty-nine healthy, 83 POAG, and 57 PACG eyes, matched for age and pachymetry, were included in a prospective, observational, cross-sectional study. Goldmann applanation tonometry (GAT-IOP), Corvis-ST IOP, IOPg (Goldmann correlated), and IOPcc (cornea compensated) from the ocular response analyzer were acquired. Corneal hysteresis (CH) and corneal resistance factor (CRF) from the ORA, and deformation amplitude (DA) from Corvis-ST were analyzed. Further, ratios of CH, CRF, and DA to IOP were assessed among the groups and defined as new variables (e.g., ratio [CH, IOPcc] was the ratio of CH to IOPcc). RESULTS: Goldmann applanation tonometry-IOP, IOPcc, and IOPg of PACG and POAG eyes were significantly higher than normal (P < 0.05). Corvis-ST IOP of healthy eyes was similar to POAG (P > 0.05) but lower than PACG (P = 0.02). Corneal hysteresis and CRF of PACG and POAG were significantly lower than normal (P < 0.0001). The ratio (CH, IOPcc), ratio (CRF, IOPcc), and ratio (DA, IOPcc) of healthy eyes were significantly higher than those of PACG and POAG eyes (P < 0.0001). The sensitivity and specificity of ratio (CRF, IOPcc) and ratio (DA, IOPcc) was significantly better than CRF and DA alone in PACG eyes (P < 0.001). However in POAG, only the sensitivity and specificity of ratio (DA, IOPcc) was significantly better than DA alone (P < 0.001). CONCLUSIONS: Presence of glaucoma may be indicated better by ratio variables than by CH, CRF, or DA alone.