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Using fractional exhaled nitric oxide to guide asthma therapy: design and methodological issues for ASthma TReatment
1Department of Respiratory and Sleep Medicine, Centre for Asthma and Respiratory Diseases, Hunter Medical Research Institute at John Hunter Hospital, University of Newcastle, Newcastle, Australia. peter.gibson@hnehealth.nsw.gov.au
Summary
Fraction of exhaled nitric oxide (FENO) shows promise for guiding asthma therapy, but mixed trial results highlight the need for improved study design. Future research should focus on clear dose-response relationships and relevant outcome metrics for better treatment personalization.
Area of Science:
- Pulmonology
- Allergy and Immunology
- Clinical Trial Design
Background:
- Current asthma guidelines rely on symptoms and lung function for treatment.
- Noninvasive markers offer potential for personalized asthma therapy and improved treatment titration.
- Fraction of exhaled nitric oxide (FENO) is a promising noninvasive marker for asthma management.
Purpose of the Study:
- To review the methodological and design features of studies investigating noninvasive markers in asthma.
- To identify factors influencing the effectiveness of asthma treatment algorithms guided by noninvasive markers.
Main Methods:
- Systematic assessment of published randomized controlled trials (RCTs) of asthma therapy.
- Focus on trials where treatment was guided by fraction of exhaled nitric oxide (FENO).
Main Results:
- FENO is measurable, reproducible, and responsive to inhaled corticosteroid dose adjustments.
- Five RCTs of FENO-guided therapy yielded mixed results, suggesting methodological limitations.
- Optimal study design requires clear dose-response relationships, population-specific algorithm decision points, and a novel metric (e.g., discordance:concordance ratio) for performance assessment.
Conclusions:
- Future FENO studies require refined design features to improve performance.
- Addressing methodological issues will enhance the estimation of FENO's value in guiding asthma therapy.
- Improved study designs are crucial for realizing the potential of personalized asthma treatment.
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