title: Management based on exhaled nitric oxide levels adjusted for atopy reduces asthma exacerbations in children: A dual centre randomized controlled trial.
abstract: While several randomized control trials (RCTs) have evaluated the use of fractional exhaled nitric oxide (FeNO) to improve asthma outcomes, none used FeNO cut-offs adjusted for atopy, a determinant of FeNO levels. In a dual center RCT, we assessed whether a treatment strategy based on FeNO levels, adjusted for atopy, reduces asthma exacerbations compared with the symptoms-based management (controls). Children with asthma from hospital clinics of two hospitals were randomly allocated to receive an a-priori determined treatment hierarchy based on symptoms or FeNO levels. There was a 2-week run-in period and they were then reviewed 10 times over 12-months. The primary outcome was the number of children with exacerbations over 12-months. Sixty-three children were randomized (FeNO = 31, controls = 32); 55 (86%) completed the study. Although we did achieve our planned sample size, significantly fewer children in the FeNO group (6 of 27) had an asthma exacerbation compared to controls (15 of 28), P = 0.021; number to treat for benefit = 4 (95% CI 3-24). There was no difference between groups for any secondary outcomes (quality of life, symptoms, FEV1 ). The final daily inhaled corticosteroids (ICS) dose was significantly (P = 0.037) higher in the FeNO group (median 400 µg, IQR 250-600) compared to the controls (200, IQR100-400). Taking atopy into account when using FeNO to tailor asthma medications is likely beneficial in reducing the number of children with severe exacerbations at the expense of increased ICS use. However, the strategy is unlikely beneficial for improving asthma control. A larger study is required to confirm or refute our findings.
authors.affiliation: Queensland Children's Medical Research Institute, Queensland University of Technology, Herston, Australia.
authors.forename: Helen L
authors.initials: HL
authors.lastname: Petsky
authors.affiliation: Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Albert M
authors.initials: AM
authors.lastname: Li
authors.affiliation: Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Chun T
authors.initials: CT
authors.lastname: Au
authors.affiliation: General Paediatrician, Royal Children's Hospital, Herston, Brisbane, Queensland, Australia.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Kynaston
authors.affiliation: School of Nursing & Midwifery, The University of Queensland, Brisbane, Queensland, Australia.
authors.forename: Catherine
authors.initials: C
authors.lastname: Turner
authors.affiliation: Queensland Children's Medical Research Institute, Queensland University of Technology, Herston, Australia.|Child Health Division, Menzies School of Health, Darwin, Northern Territory, Australia.
authors.forename: Anne B
authors.initials: AB
authors.lastname: Chang
mesh_terms: D000293:Adolescent; D001249:Asthma / Q000175:diagnosis / Q000188:drug therapy*; D001944:Breath Tests; D001993:Bronchodilator Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D019819:Budesonide / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D045853:Exhalation; D005260:Female; D000068298:Fluticasone / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D009569:Nitric Oxide / Q000032:analysis*; D011788:Quality of Life; D016896:Treatment Outcome
chemical_list: D001993:Bronchodilator Agents; D009569:Nitric Oxide; D019819:Budesonide; D000068298:Fluticasone
keywords: FeNO; asthma; atopy; pediatrics