Game Changer: Dupilumab Injections for Uncontrolled Asthma

Dupilumab decreased asthma exacerbations by 50% and increased FEV1 by more than 300 ml. This is truly a game changer in treatment of moderate to severe asthma. The study was published in the "best medical journal in the world", NEJM, the references are below.

Dupilumab is a fully human anti–interleukin-4 receptor α monoclonal antibody that blocks both interleukin-4 and interleukin-13 signaling. The dose of dupilumab, 300 mg, is the same as the improvement in FEV1, 300 ml.

It is administered by patients at home, every 2 weeks. This is different from the other monoclonal antibodies for treatment of asthma which are administered in clinic under physician observation.

Dupilumab is already approved for treatment of atopic dermatitis.

In this trial, patients who received dupilumab had significantly lower rates of severe asthma exacerbation than those who received placebo, as well as better lung function and asthma control. Greater benefits were seen in patients with higher baseline levels of eosinophils. Hypereosinophilia was observed in some patients.

By the end of 2018, there will likely be a change in the stepwise treatment of asthma below:

Asthma Treatment Options (click to enlarge the image).


Dupilumab Efficacy and Safety in Moderate-to-Severe Uncontrolled Asthma | NEJM
Efficacy and Safety of Dupilumab in Glucocorticoid-Dependent Severe Asthma | NEJM
New Biologics for Asthma | NEJM

May 1st is World Asthma Day: use CDC Toolkit to take control of and raise awareness about asthma

Today is World Asthma Day. May is Asthma Awareness Month. You can use CDC Toolkit to take control of and raise awareness about asthma.

Clinical research volunteers share their experiences of living with asthma and participating in NIH studies:

More info:

In memoriam: Dr. Jelks collected daily pollen counts from her home in Sarasota, FL for over 40 years, made an impact

Dr. Mary Jelks passed away on March 27, 2018.

From New College of Florida:

Dr. Mary Jelks earned the nickname "Myakka Mary" for the amount of time and money she has spent in service to the Myakka river and park. In 1961, Dr. Jelks moved to Sarasota with her husband, Allen to start their pediatric allergy practice. In addition to practicing medicine, Dr. Jelks has collected daily pollen counts from her home for over forty years. She founded the Friends of the Myakka in 1993 and has been an active member of many different environmental groups in the area. In 1994 Dr. Jelks and her family formed the Jelks Family Foundation, an organization with a focus on conservation of natural resources, helping the county to purchase the 614-acre Jelks Preserve along the Myakka River. She was deeply committed to Sarasota, which she believed "is a view of paradise."

From Sarasota magazine:

"Every morning, despite rain, arthritis and a broken back, Dr. Mary Jelks, a 74-year-old retired pediatrician, climbs a ladder to the roof of her modest home on Clematis Street to collect samples for meteorologists and universities throughout the state. She also receives samples by mail from Miami and Tallahassee. (“They have tremendously interesting spores up there,” she says.) One of only six certified pollen counters in the state, she’s now training a national network of counters who, she hopes, will be just as dazzled as she is by pollen and mold.

Raised on an Illinois farm surrounded by allergens, Jelks is allergic to nothing. Her passion for spores was born from a pediatric practice fraught with chronically ill, tiny patients."


The VOCs danger: Everyday products such as perfume, skin lotion, hair spray, deodorant, household cleaners are a top source of air pollution

Volatile organic compounds (VOCs) are emitted as gases from certain solids or liquids. VOCs include a variety of chemicals, some of which may have short- and long-term adverse health effects. Concentrations of many VOCs are consistently higher indoors (up to ten times higher) than outdoors. VOCs are emitted by a wide array of products numbering in the thousands.

Everyday products such as perfume, skin lotion, hair spray, deodorant, household cleaners and lawn pesticides are a top source of air pollution, as damaging to air quality as the exhaust from cars and trucks, according to a new report.

Consumer products containing compounds refined from petroleum all release small amounts of smog-producing particles into the air, the researchers explained.

Combined, these products now release as many volatile organic compounds (VOCs) into the atmosphere as vehicle emissions do.

The use of these products emits VOCs in a magnitude that's comparable to what comes out of the tailpipe of your car.

Remember: Consumer products are designed to release VOCs into the air. That's what they do.

Sources of VOCs

Household products, including:

paints, paint strippers and other solvents
wood preservatives
aerosol sprays
cleansers and disinfectants
moth repellents and air fresheners
stored fuels and automotive products
hobby supplies
dry-cleaned clothing

Other products, including:

building materials and furnishings
office equipment such as copiers and printers, correction fluids and carbonless copy paper
graphics and craft materials including glues and adhesives, permanent markers and photographic solutions.

Health Effects from VOCs

Health effects may include:

Eye, nose and throat irritation
Headaches, loss of coordination and nausea
Damage to liver, kidney and central nervous system
Some organics can cause cancer in animals, some are suspected or known to cause cancer in humans.

Key signs or symptoms associated with exposure to VOCs include:

conjunctival irritation
nose and throat discomfort
allergic skin reaction
declines in serum cholinesterase levels

Steps to Reduce Exposure to VOCs

Increase ventilation when using products that emit VOCs.
Meet or exceed any label precautions.
Do not store opened containers of unused paints and similar materials within the school.
Formaldehyde, one of the best known VOCs, is one of the few indoor air pollutants that can be readily measured.
Identify, and if possible, remove the source.
If not possible to remove, reduce exposure by using a sealant on all exposed surfaces of paneling and other furnishings.
Use integrated pest management techniques to reduce the need for pesticides.
Use household products according to manufacturer's directions.
Make sure you provide plenty of fresh air when using these products.
Throw away unused or little-used containers safely; buy in quantities that you will use soon.
Keep out of reach of children and pets.
Never mix household care products unless directed on the label.


Household Products May Pollute the Air as Much as Your Car Does: Study. WebMD,
Volatile Organic Compounds' Impact on Indoor Air Quality | US EPA

Preschool Recurrent Wheezing and Asthma

This is Twitter summary from the 2018 WSAAI meeting. This summary was compiled from the tweets posted by @MatthewBowdish, an allergist/immunologist, who attended the 2018 Western Society of Allergy, Asthma and Immunology (WSAAI) meeting. The tweets were labeled #WSAAI. The text was edited and modified by me.

Leonard Bacharier presented on Management of Preschool Recurrent Wheezing and Asthma.

One of the big challenges for pediatricians has been determining which preschool kids who wheeze go on to develop asthma and who don't.

Estimated prevalence of wheezing identified by latent class analysis:

Modified Asthma Predictive Index (API) (click to enlarge the image).

mAPI: High risk children ages 2-3 include 4 wheezing episodes in the past year PLUS one major criterion (pt w/MD asthma, MD atopic derm, aeroallergen sensitivity) OR two minor criteria (food sens, peripheral eos >4%, non-infectious wheeze).

Stepwise pharmacologic approach for children younger than 5yo with wheezing:

Reviewing results of Individualized therapy for asthma in toddlers (INFANT) study - Fitzpatrick AM et al JACI 2016;138:1608. Differential response between at least two treatments was observed in 75% of children. Take-homes from INFANT: 1) In kids w/aeroallergen sensitivity or eosinophilia, start ICS first. In kids who are not sensitized to aeroallergens or without eosinophilia, you can choose any of the treatments (ICS, prn daily ICS or daily LTRA).

Subgroup analysis of kids w/intermittent asthma or viral-triggered wheezing showed reduced risk of exacerbation w/preemptive high-dose intermittent ICS compared w/placebo (Kaiser SV, Pediatr 2016;137.

Azithro started at the earliest signs of RTIs was effective in reducing the risk of experiencing episodes of severe lower respiratory tract illness. (JAMA 2015;314(19):2034). There was no difference in response by API status, and azithro was well-tolerated with low rates of adverse effects.

Putting these together in an approach that we may be able to use in the clinic:

Research also suggests that if a child does not respond to a given controller, explore other Step 2 therapies before moving on to Step 3 therapies.

Summary slide: