The edition · Pulmonology
Every year of waiting costs remission in severe asthma, and normal lungs lose 20 to 30 mL of FVC a year
Across 9,241 patients in three registries, the odds of clinical remission twelve months after starting a biologic fell by 14% for every decade of asthma beforehand - and by nearly half for every 10 g of lifetime oral steroid.
The edition in brief
Five findings and a pearl for the pulmonology desk. A cohort study pooling the International Severe Asthma Registry, the US CHRONICLE registry and the UK Optimum Patient Care Research Database - 9,241 patients across 26 countries - found that the longer a patient waited for a biologic, the less they got from it: odds of clinical remission at 12 months fell to 0.86 for every 10 years of asthma before starting, 0.78 per decade of potential severe asthma, 0.24 per unit of pre-biologic lung function impairment, and 0.54 for every 10 g of lifetime cumulative oral corticosteroid. A meta-analysis of 251 studies covering 606,398 patients with idiopathic pulmonary fibrosis puts real prevalence figures on its comorbidities - hypertension 39%, dyslipidaemia 30%, reflux 27%, diabetes 21% - consistently higher than in trial cohorts, with only lung cancer consistently associated with mortality. An FDA generic application supplement for triamcinolone acetonide is administrative and specifies no formulation. A systematic review of 35 cohorts and over 365,000 participants establishes the normal ageing benchmark for forced vital capacity: peak in the mid-20s, then continuous decline of about 26 mL a year in women and a biphasic 22 then 36 mL a year in men, roughly 20 to 30 mL annually - the number against which any interstitial lung disease trial's preserved lung function should be read. The practice-changer is a crossover trial of daridorexant 50 mg for five nights in 16 adults with severe untreated obstructive sleep apnoea: no clinically meaningful change in apnoea-hypopnoea index or nocturnal saturation, and 32.5 minutes more total sleep. Plus a pearl on checking inhaler technique.
Every decade of waiting costs remission in severe asthma
Refer eligible patients for biologic assessment at the point they qualify, and record cumulative steroid dose and lung function trajectory while they wait.
Comorbidity in real-world pulmonary fibrosis runs well above the trial cohorts
Manage the cardiovascular and reflux burden in IPF actively - it is commoner in clinic than the antifibrotic trials imply, and it is where the trial evidence is thinnest.
Generic triamcinolone acetonide supplement - administrative, and the record does not say which formulation
Nothing to change in prescribing - but start recording oral corticosteroid exposure in grams, because the cumulative total is what predicts what a biologic will later achieve.
Normal lungs lose 20 to 30 mL of FVC a year - the benchmark ILD trials have been missing
Use 20 to 30 mL a year as the normal FVC decline when judging whether a patient's trajectory - or a trial's effect size - is really abnormal.
Watch the inhaler being used before changing the drug
Watch the patient use their own inhaler before escalating therapy, and check the dose counter while you are there.
Daridorexant did not worsen breathing in severe untreated sleep apnoea
In a patient with severe sleep apnoea and genuine insomnia, a dual orexin receptor antagonist is a defensible option - but the evidence is 16 patients over five nights.
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