Phenotyping the responses to systemic corticosteroids in the management of asthma attacks (PRISMA)
C.A. Celis-Preciado, Simon Leclerc, Martine Duval, Dominic O. Cliché, Lucie Brazeau, Felix-Antoine Vézina, Marylène Dussault, Pierre Larivée, Samuel Lemaire-Paquette, Simon Lévesque, Philippe Lachapelle, Simon Couillard
Abstract
Background Asthma attacks are heterogeneous. It is not known whether the response to oral corticosteroids (OCS) in acute asthma varies according to type 2 (T2) inflammatory biomarkers, blood eosinophil count (BEC) and fractional exhaled nitric oxide ( F ENO ). We aimed to explore the relationship between T2 biomarkers and response to OCS in acute asthma. Methods We conducted a longitudinal observational study of people experiencing an asthma attack evaluated before and after a 7-day OCS course. The primary outcome was post-bronchodilator change in forced expiratory volume in 1 s (FEV 1 ) according to ordinal BEC- F ENO three-group categories (T2-Low/Low: BEC <0.15×10 9 cells·L −1 and F ENO <25 ppb; T2-High/High: BEC ≥0.30×10 9 cells·L −1 and F ENO ≥35 ppb; T2-Mid: not meeting Low/Low or High/High criteria). A key secondary outcome was the change in Asthma Control Questionnaire-5 score. Exploratory outcomes included OCS-attributable adverse events. Results 53 people were enrolled, with 16 (30%) T2-Low/Low, 27 (51%) T2-Mid and 10 (19%) T2-High/High asthma attacks. Post-bronchodilator FEV 1 changes increased with combined BEC- F ENO elevation (p for interaction=0.007), peaking in the T2-High/High phenotype (0.390±0.512 L, p for trend<0.0001). Conversely, T2-Low/Low attacks showed nonsignificant FEV 1 changes (0.017±0.153 L). In univariable and multivariable analyses, only ordinal BEC- F ENO stratification, not symptoms nor FEV 1 , predicted subsequent post-bronchodilator FEV 1 improvement. All patients had improved Asthma Control Questionnaire-5 score, numerically peaking in the T2-High/High phenotype (−1.58±0.60, p for trend=0.08). All groups experienced similar OCS-attributable adverse events, with 33 patients (62%) reporting at least one event. Conclusions We found that objective improvement following OCS is confined to T2-High events. As in chronic asthma, greater T2 burden identifies a distinct clinical and therapeutic trajectory, whereas OCS‑related adverse events are uniformly distributed.