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Better asthma management with FeNO testing
Why improve asthma management?
The consequences of poorly controlled asthma can be serious, with 50% of patients experiencing an exacerbation in the preceding 12 months and globally, 1,000 deaths a day.1,2 Many patients remain symptomatic despite treatment and are at greater risk of exacerbations.
The Global Initiative for Asthma (GINA) describes the goals of asthma management as risk reduction and symptom control, with the aim of relieving the burden on the patient. Risks include exacerbations, airway remodelling, the side-effects of medication and asthma-related death.3
Reducing exacerbations is the top priority
In the short term, symptomatic patients face the immediate threat of hospitalisation and death due to potentially severe exacerbations. Patients can also experience reduced quality of life, from missed days of work or school to forced exclusion from sport, a lack of regular exercise and difficulty with daily activities.3
Asthma can also cause long-term problems. Repeated exacerbations can lead to detrimental airway remodelling and significant loss of lung function. Decline in lung function has been shown to be twice as fast in patients with frequent exacerbations.4 Untreated exacerbation risks also adversely affect healthcare budgets with the cost of unscheduled appointments and hospitalisation.
One size doesn't fit all
Uncontrolled asthma is the main risk factor for exacerbations.3 But each patient also has their own set of modifiable risks, such as high airway inflammation, reduced lung function, high SABA usage, poor adherence to ICS or inadequate inhaler technique.3
A tailored approach to managing personal risk factors is essential to improve patient outcomes.5 Targeting and treating airway inflammation, a key characteristic of asthma, has been proven to be effective in reducing the risk of exacerbations.6
FeNO is the most convenient biomarker of airway inflammation. FeNO levels are elevated in asthma and reduced with steroid therapy, making FeNO testing a helpful tool when personalising asthma care for each individual.
FeNO, the asthma risk estimator
Regular monitoring of asthma is crucial to keep a close eye on the patient's future risk. It takes less than two minutes to perform a FeNO test and see the results at the point-of-care, and it can be repeated at each visit.
Elevated FeNO values are associated with 3.2x greater risk of exacerbations when compared to low FeNO levels.7
In addition, half of patients with high FeNO could suffer from airway remodelling, despite asthma being controlled.8
FeNO-guided management
Tracking patient FeNO levels with regular testing enables physicians to address airway inflammation through optimised treatment.
FeNO values can indicate whether inhaled corticosteroids (ICS) may be stepped up or down as appropriate.9 FeNO also helps monitor patient compliance.10
Optimising therapy and adherence with FeNO testing has been proven to reduce exacerbations by up to 50%.6
Up to 50% fewer
exacerbations
with FeNO-guided asthma management for both adults and children
FeNO for treatment optimisation
FeNO testing can directly alter treatment decisions.9 Titrating medication according to the level of airway inflammation will help gain control of the disease and reduce the risk of exacerbation.6
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Studies have shown that performing FeNO testing led physicians to optimise treatment titration in up to a third of patients. 90% of those changes affected ICS dosage.9,13
Physicians may consider stepping up ICS dosage in patients with high FeNO levels. Once asthma is controlled, FeNO can help safely step down ICS therapy. Regular FeNO monitoring will then highlight any future loss of control and predict asthma relapse.14 FeNO testing also allows physicians to limit the use of high-dose ICS and avoid the long-term consequences of steroid intake.
Patients who remain symptomatic despite low FeNO may be part of the small proportion of asthmatics who are unlikely to respond to ICS, so physicians may want to consider alternative treatment.15,16
FeNO for adherence
Non-compliance is a major problem in asthma management and could be responsible for up to 75% of asthma costs.11,12 FeNO can help identify patients who are non-adherent to their ICS medication.10
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Up to 80% of patients are not adherent to their controller medication, which may lead to a loss of control of airway inflammation and increased risk of exacerbations.3,11 Non-adherence can happen by missing doses or incorrect inhaler technique. FeNO levels are usually higher in non-adherent patients.10
A FeNO suppression test can help identify patients who may be non-adherent. Usually performed over five to seven days, a reduction in FeNO levels through the test period suggests a case of non-compliance. Indeed, FeNO levels will reduce by approximately half within four days with directly observed ICS treatment.10
FeNO for patient education
Listen to Dr Richard Russell as he explains how patients who track their FeNO levels with their physician over time have shown great interest in reducing the value to improve their symptoms and asthma control.
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FeNO by NIOX VERO®
Learn more about the gold standard FeNO testing device.17
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References
1. Centers for Disease Control and Prevention (CDC). Vital signs: asthma prevalence, disease characteristics, and self-management education-United States, 2001-2009. MMWR Morb Mortal Weekly Rep. 2011;60(17): 547-552. 2. Global Asthma Network. The Global Asthma Report. 2018. 3. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2021 update. 4. Bai TR et al. Severe exacerbations predict excess lung function decline in asthma. Eur Respir J. 2007;30(3):452-6. 5. McDonald VM et al:. Treatable traits: a new paradigm for 21st century management of chronic airway diseases (Treatable traits down under international workshop report). Eur Respir J. 2019;53(5):1802058. 6. Petsky HL et al. Tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils): a systematic review and meta-analysis. Thorax. 2018;73(12):1110-9. 7. Busse, W.W et al. Baseline FeNO as a prognostic biomarker for subsequent severe asthma exacerbations in patients with uncontrolled, moderate-to-severe asthma receiving placebo in the LIBERTY ASTHMA QUEST study: a post-hoc analysis. The Lancet Respir Med. 2021:9(10): pp.1165-1173. 8. Matsunaga K et al. Persistently high exhaled nitric oxide and loss of lung function in controlled asthma. Allergol Int. 2016;65(3):266-71. 9. Hanania NA et al. Measurement of fractional exhaled nitric oxide in real-world clinical practice alters asthma treatment decisions. Ann Allergy Asthma Immunol. 2018;120(4):414-418. 10 Heaney LG et al. Medical Research Council UK Refractory Asthma Stratification Programme (RASP-UK). Remotely monitored therapy and nitric oxide suppression identifies nonadherence in severe asthma. Am J Respir Crit Care Med. 2019;199(4):454-464. 11. Rifaat N et al. The golden factor in adherence to inhaled corticosteroid in asthma patients. Egypt J Chest Dis Tuberc. 2013;62:371-376. 12. Apter AJ. Enhancing patients adherence to asthma therapy. Up to Date. Last updated 2021. 13. LaForce C et al. Impact of exhaled nitric oxide measurements on treatment decisions in an asthma specialty clinic. Ann Allergy Asthma Immunol. 2014;113(6):619-23. 14. Wang K et al. Using fractional exhaled nitric oxide to guide step-down treatment decisions in patients with asthma: a systematic review and individual patient data meta-analysis. Eur Respir J. 2020;55(5):1902150. 15. Dweik RA et al. An official ATS clinical practice guideline: interpretation of exhaled nitric oxide levels (FeNO) for clinical applications. Am J Respir Crit Care Med. 2011;184(5):602-15. 16. Heaney LG et al. Eosinophilic and noneosinophilic asthma: an expert consensus framework to characterize phenotypes in a global real-life severe asthma cohort. Chest. 2021;160(3):814-830. 17.NIOX®. Data on File; MKT-DOF-007. 2023.