Using fractional exhaled nitric oxide to guide step-down treatment decisions in patients with asthma: A systematic review and individual patient data meta-analysis

Kay Wang, Jan Y. Verbakel, Jason Oke, Alexander Fleming-Nouri, Josh Brewin, Nia Roberts, Norihiro Harada, Ryo Atsuta, Kazuhisa Takahashi, Kazutaka Mori, Tomoyuki Fujisawa, Toshihiro Shirai, Tomotaka Kawayama, Hiromasa Inoue, Stephen Lazarus, Stanley Szefler, Fernando Martinez, Dominick Shaw, Ian D. Pavord, Mike Thomas

Research output: Contribution to journalReview articlepeer-review

4 Scopus citations

Abstract

Background: High exhaled nitric oxide fraction (FENO) levels are associated with greater risk of asthma exacerbation. However, it is not clear how FENO can be used to guide safe reductions in inhaled corticosteroid (ICS) doses in asthma patients. This study assesses the ability of FENO to guide ICS reductions. Methods: Systematic searching of electronic databases identified prospective observational studies and randomised controlled trials which recruited participants with mild-to-moderate asthma aged ≽12 years and measured FENO before reducing ICS. We performed multilevel mixed-effects logistic regression in relation to acute exacerbations and estimated each participant's exacerbation risk using our logistic regression model. Results: We included data from seven out of eight eligible studies, representing 384 participants. ICS doses were halved in four studies and withdrawn in three studies. A baseline FENO measurement of ≽50 ppb was associated with increased risk of exacerbations (crude OR 3.14, 95% CI 1.41-7.00, p=0.005; adjusted OR 3.08, 95% CI 1.36-6.98, p=0.007) and corresponded to an estimated exacerbation risk cut-off of 15%. Reducing ICS when estimated exacerbation risk was <15% versus <10% would result in fewer patients remaining on the same ICS dose (40 (10.4%) out of 384 versus 141 (36.7%) out of 384), but similar proportions of patients avoiding exacerbations (222 (91.4%) out of 243, 95% CI 87.1-94.6% versus 311 (90.4%) out of 344, 95% CI 86.8-93.3%). Conclusion: In patients with mild-to-moderate asthma, gradual ICS reduction when FENO is <50 ppb may help decrease ICS use without increasing exacerbations. Future research should aim to validate these findings in larger populations.

Original languageEnglish (US)
Article number1902150
JournalEuropean Respiratory Journal
Volume55
Issue number5
DOIs
StatePublished - 2020

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine

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