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

Claire A. Butler, Alan J. Mcmichael, Kirsty Honeyford, Louise Wright, Jayne Logan, Joshua Holmes, John Busby, Catherine E. Hanratty, Freda Yang, Steven J. Smith, Kirsty Murray, Rekha Chaudhuri, Liam G. Heaney

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Rationale: The utility of fractional exhaled nitric oxide (FENO) 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 FENO 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 FENO 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 FENO between post-suppression test and follow-up (median, 33 (IQR 25–55) versus 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” FENO, 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.
Original languageEnglish
Article number00273-2021
Pages (from-to)1-10
Number of pages10
JournalERJ Open Research
Issue number3
Publication statusPublished (in print/issue) - 8 Jul 2021


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