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

Rationale: The utility of fractional exhaled nitric oxide (F-ENO) 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 F-ENO 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 F-ENO 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 F-ENO 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 F-ENO, predicts a subgroup of patients in whom asthma control is preserved with adherence to high-dose ICS/long-acting beta 2 agonist and who can be discharged from specialist care.

Automated summary

The FeNOSuppT test can help predict whether asthma patients will progress to needing biologic agents or being discharged from specialist care. Patients with a positive FeNOSuppT, who maintain optimized F-ENO levels, can maintain asthma control with high-dose ICS/long-acting beta 2 agonist and be discharged from specialist care.