Background65% of people with severe asthma and a FeNO ≥45 ppb are non-adherent to inhaled corticosteroids (ICS). Digital devices recording both time-of-use and inhaler technique identify non-adherence and ICS responsiveness but are not widely available. As the NEXThaler™ dose counter only activates at an inspiratory flow of 35 L/min, this may provide an alternative to identifying ICS responsiveness.ObjectiveTo assess ICS adherence and responsiveness in severe asthma using beclometasone/formoterol (200/6 mcg) NEXThaler™ (BFN) dose-counting.MethodsSevere asthmatics with a FeNO ≥45 ppb were invited to use BFN in place of their usual ICS/long-acting β2-agonist (LABA). FeNO, ACQ6, lung function and blood eosinophil count were monitored for 3 months. A log10ΔFeNO ≥0.24 was used to define FeNO suppression as the primary marker of ICS responsiveness at day 28.Results27/48 (56%) patients demonstrated significant FeNO suppression at month 1 (median pre-114, post-48 ppb, p<0.001). A small but significant reduction occurred in FeNO non-suppressors. ACQ6 fell a median 1.2 units in FeNO suppressors (p<0.001) and 0.5 units in non-suppressors (p=0.025). These effects were sustained until month 3 in FeNO suppressors with a significant improvement in FEV1 and blood eosinophils. 67% (18/27) of those with baseline ICS/LABA prescription refills of ≥80% were FeNO suppressors suggesting prior non-adherence despite adequate prescription collection. 79% of FeNO suppressors did not require biologics within mean 11.4 months from initial dose counting.ConclusionBFN dose counting identifies ICS responsiveness in severe asthma with the implication that these patients may not need to progress to biological therapies.

Background: 65% of people with severe asthma and FeNO ≥45 ppb are non-adherent to inhaled corticosteroids (ICS). Digital monitoring that records both time-of-use and inhaler technique can identify non-adherence and ICS responsiveness but these devices are not readily available. As the dose counter on the NEXThaler™ only counts down when an inspiratory flow of 35 L/min is achieved, this may present an alternative to identifying ICS responsiveness. Aim: To use BDP/formoterol (200/6 mcg, 2 bd) NEXThaler® (BFN) dose-counting to assess ICS responsiveness in severe asthma. Methods: Severe asthmatics with a FeNO ≥45 ppb were trained to use BFN in place of their usual ICS/LABA. Patients re-attended 28 days later and the dose count was recorded. Day 0 and 28 FeNO, ACQ6 and blood eosinophils were recorded. A log10∆FeNO ≥0.24 defined FeNO suppressors among the study group, confirming ICS responsiveness. Results: All patients(n=25)completed day 28 follow up.12/25 (48%) suppressed their FeNO (median[IQR] pre 104[68-173], post 46[25-54] ppb, p<0.0001). A smaller reduction occurred in FeNO non suppressors (pre 121 [77-198], post 86[64-183] ppb, p=0.015). ACQ6 and blood eosinophil count fell in FeNO suppressors (ACQ mean±SEM pre 2.9[±0.3], post1.9 [±0.3] p=0.0012); Eos median[IQR] pre-0.43[0.32-0.9], post 0.15[0.11-0.33], p=0.016 [n=8]). Of 9 people with baseline ICS/LABA prescription refills of >75%, 6 were FeNO suppressors suggesting prior non-adherence. Conclusion: Nexthaler™ dose counting demonstrates that 50% of people in a severe asthma service with FeNO ≥45 ppb respond to ICS when used regularly. This approach may miss some people with non-intentional non-adherence due to inhaler technique errors.

Background: Biologic medications for severe asthma enable maintenance oral corticosteroid (mOCS) reduction or cessation for many patients. However, there is a small risk of emergent adrenal insufficiency in patients withdrawing from mOCS, and little consensus about how to monitor or avoid this. Aim: Assess the success rate of a bespoke formal mOCS withdrawal pathway for severe asthma patients on biologics. Methods: Patients on mOCS and biologics, who had reduced mOCS to 5mg Prednisolone daily, entered the mOCS withdrawal pathway. Prednisolone was further reduced by 1mg every 6 weeks to 3mg daily then serum cortisol was checked. Patients with cortisol ≥25 nmol/L followed a 20-week prednisolone weaning plan until mOCS cessation and had cortisol re-checked 12 weeks after cessation. Patients with cortisol below 25 nmol/L were referred for endocrinology assessment and not included. Patients received education about adrenal insufficiency symptoms and 'sick day rules'. Results: 39 patients followed the pathway. 33 patients (85%) successfully weaned off mOCS, and 6 patients were unable to. In successfully weaned patients mean (SD) cortisol on 3mg Prednisolone was 244 (162) nmol/L, rising to 317 (119) nmol/L 12 weeks after completion of weaning (p=0.01). In 6 patients who failed to wean, mean (SD) cortisol on 3mg Prednisolone was 107 (94) nmol/L. Reasons for weaning failure were symptoms of adrenal insufficiency or cortisol <25 nmol/L at 12 weeks after mOCS cessation. These patients remain on 2-5mg of Prednisolone. There were no serious adverse events. Conclusion: Our pathway facilitated successful withdrawal of mOCS in 85% of patients with cortisol ≥25 nmol/L on 3mg Prednisolone, with no adverse events.

BACKGROUND: Nonadherence in difficult-to-control asthma can be identified using 7-day FeNO suppression testing where patients take additional fluticasone via Diskus with an Inhaler Compliance Assessment (INCA) acoustic monitoring device attached, and self-measure FeNO at home. However, this is inconvenient for patients attending a tertiary center and limited by FeNO meter availability. It is not known if this approach alters clinical outcomes. OBJECTIVES: To examine patient acceptability and the effectiveness of replacing usual combination inhaled corticosteroid (ICS)/long-acting b2-agonist (LABA) therapy with a fluticasone/salmeterol Diskus 500DINCA for 28 days as the initial intervention, compared with the 7-day FeNO suppression test, and to explore clinical outcomes after INCA monitoring. METHODS: A service evaluation of FeNO suppression testing was undertaken in clinical practice. RESULTS: Twenty-one of 23 subjects offered replacement of their usual ICS/LABA with fluticasone/salmeterol DINCA as the initial intervention accepted and completed 28 days of monitoring. Fourteen (66.6%) patients reduced their FeNO by >42% (FeNO suppressors), accompanied by improvements in forced expiratory volume in 1 second, Asthma Control Questionnaire, and blood eosinophils, similar to the 7-day test (n = 74). Twenty-two of 62 (35.5%) FeNO suppressors progressed to biological therapy, compared with 24 of 33 (72.7%) nonsuppressors (P = .0006). FeNO suppressors taking maintenance prednisolone (n = 13) who did not receive biological therapy reduced the median baseline dose from 10 to 3 mg, with further reductions limited by adrenal suppression. CONCLUSION: Replacing existing inhaled therapy with fluticasone/salmeterolDINCA for 28 days is acceptable to the majority of people with difficult-to-control asthma and identifies prior medication nonadherence. INCA monitoring coupled with clinical support potentially improves patient adherence and asthma control, preventing unnecessary progression to biological therapy. (C) 2020 American Academy of Allergy, Asthma & Immunology

Inhaled corticosteroids (ICS) are the core component of asthma treatment and the only maintenance therapy known to prevent asthma death. There is currently no evidence that biologics prevent asthma death in people with asthma, and as such, biologics cannot be recommended as an alternative to ICS therapy. Taking the time to assess adherence and provide interventions and education to support patients in asthma self-management has been shown to improve patient outcomes. It is therefore our responsibility as healthcare professionals to ensure that patients are supported, educated and motivated to adhere to ICS therapy before progressing to biologic therapies.

Background: In the UK, the criteria to withdraw mepolizumab therapy from patients with severe eosinophilic asthma include failure to achieve 50% reduction in exacerbation rate or a clinically important reduction in maintenance oral corticosteroids. Aim: To characterise the patients who failed to continue receiving mepolizumab Methods: Retrospective review of a clinical database and case notes for patients who received mepolizumab in Glenfield hospital, Leicester UK, between May 2017 to Feb 2020. Results: 21 out of a total 94 patients with severe eosinophilic asthma who received mepolizumab during the study period, had treatment stopped, the causes are listed in table 1. From the group considered to have failed mepolizumab therapy, 4/15 patients had underlying immunodeficiencies including common variable immune deficiency and specific antibody deficiency that required regular immunoglobulin therapy, 2/15 with bronchiectasis and recurrent bronchitis initiating prophylaxis Azithromycin therapy and 3/15 patients who requested treatment withdrawal due to lack of perceived benefits. The remaining 6/15 patients were deemed by the MDT to have failed mepolizumab therapy without a defined cause. Conclusion: Treatment failure with mepolizumab may be secondary to exacerbation events that are driven by infection, necessitating the need to characterise exacerbations carefully prior to initiating type-2 monoclonals in severe asthma.