The edition · Pulmonology
FeNO of 65 ppb or more ruled asthma in and under 20 ppb largely ruled it out, in a meta-analysis validated in primary care
A Lancet Respiratory Medicine analysis gives usable thresholds for suspected asthma with normal spirometry — and shows blood eosinophils add nothing. Also: pooled TETON trials of inhaled treprostinil in IPF, dupilumab cut COPD admissions, and GLP-1 agonists did not prevent new sleep apnoea in type 2 diabetes.
The edition in brief
A meta-analysis of 30 studies in people with suspected asthma and normal spirometry found exhaled nitric oxide (FeNO) predicted airway hyper-responsiveness well in adults (AUC 0.80) and fairly in children (0.75); at primary care prevalence, FeNO 65 ppb or more gave an 80% positive predictive value and under 20 ppb a 93% negative predictive value, validated in a prospective primary care cohort, while blood eosinophils performed poorly and added nothing. Accuracy fell within two weeks of starting inhaled corticosteroids. In 1,191 patients with idiopathic pulmonary fibrosis in the pooled TETON-1 and TETON-2 trials, inhaled treprostinil reduced 52-week FVC decline by 112 ml against placebo and improved five of six secondary endpoints; cough was the main adverse effect. Pooled BOREAS and NOTUS data showed dupilumab reduced emergency visits or admissions in eosinophilic COPD by 38% and systemic steroid use for exacerbations. In 206,000 UK adults with type 2 diabetes and obesity, GLP-1 agonists were not associated with less new obstructive sleep apnoea than DPP-4 inhibitors (HR 1.07).
IPF: pooled TETON trials show inhaled treprostinil slowed FVC loss by about 110 ml a year
Inhaled treprostinil slowed lung function loss in IPF by about 110 ml over a year in two replicate trials; watch for its approval and place alongside existing antifibrotics.
Dupilumab reduced emergency visits and admissions in eosinophilic COPD by 38%
In COPD with eosinophils of 300 or more and exacerbations despite maximal inhaled therapy, dupilumab reduces admissions and steroid courses.
GLP-1 agonists were not associated with less new sleep apnoea than DPP-4 inhibitors in type 2 diabetes
Screen obese patients with type 2 diabetes for sleep apnoea even on a GLP-1 agonist; the drug was not associated with fewer new diagnoses.
Test before you treat suspected asthma
Do objective tests for asthma before the first inhaled steroid dose whenever possible.
Suspected asthma with normal spirometry: FeNO thresholds to rule in and rule out
In adults with suspected asthma and normal spirometry, check FeNO before treatment: 65 ppb or more rules in, under 20 ppb largely rules out, and eosinophils add nothing.
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