Utility of fractional exhaled nitric oxide suppression as a prediction tool for progression to biologic therapy.

RATIONALE

The utility of fractional exhaled nitric oxide ( ) suppression (FeNOSuppT) to identify non-adherence to inhaled corticosteroid (ICS) treatment has previously been reported, but whether it can predict clinical outcome remains unclear.

OBJECTIVES

We examined the utility of FeNOSuppT in prediction of progression to biologic agents or discharge from specialist care.

METHODS

FeNOSuppT was measured at home using remote monitoring technology of inhaler use alongside daily measurement over 7 days. Long-term clinical outcomes in terms of progression to biologic agent or discharge from specialist care were compared for non-suppressors and suppressors.

MEASUREMENTS AND MAIN RESULTS

Of the 162 subjects, 135 successfully completed the test with 81 (60%) positive suppression tests. Subjects with a negative FeNOSuppT were more likely to proceed to biologic therapy (39 of 54 patients, 72%) compared to those with a positive FeNOSuppT (35 of 81 patients, 43%, p=0.001). In subjects with a positive FeNOSuppT, predictors of progression to biologic therapy included higher dose of maintenance steroid at initial assessment and prior intensive care unit admission. These subjects had a significant rise in between post-suppression test and follow-up (median, 33 (IQR 25-55) 71 (IQR 24-114); p=0.009), which was not explained by altered corticosteroid dose.

CONCLUSIONS

A negative FeNOSuppT correlates with progression to biologic therapy. A positive FeNOSuppT, with subsequent maintenance of "optimised" , predicts a subgroup of patients in whom asthma control is preserved with adherence to high-dose ICS/long-acting β2 agonist and who can be discharged from specialist care.