Management Case Study - Escalating Treatment in Moderate Persistent Asthma Using FeNO

Patient profile

Gender/Age: Female in their 50’s
History: Adult-onset asthma, nasal polyps, allergic rhinitis, and gastroesophageal reflux disease (GERD)

Symptoms

Poor asthma control
two exacerbations in the past year requiring oral corticosteroids (OCS)

Management Approach:

Asthma Control Test (ACT): Score of 13 (indicating poor control) Lung Function: Reduced but reversible; 78% predicted Eosinophils: 250/µL Total IgE: 40 kU/L

The elevated FeNO and eosinophil count indicated Type 2 inflammation. The patient had persistent inflammation despite moderate treatment, suggesting a need for more intensive therapy.

FeNO Test: 55 ppb, indicating ongoing airway inflammation

Treatment Plan:

Inhaled Corticosteroid (ICS): The patient’s ICS dose was increased to high-dose ICS-LABA to better control her asthma.
Addition of LAMA: A long-acting antimuscarinic (LAMA) was added to her therapy, putting her on triple inhaled therapy (ICS, LABA, and LAMA).
Monitoring: Close monitoring of her symptoms, lung function, and FeNO levels was scheduled to assess the treatment’s effectiveness.

Outcome:

After the treatment adjustment, her ACT improved to 16, and she had no further exacerbations at this point. FeNO: Reduced to 25 ppb, showing improved control.
Eosinophils: Increased to 350/µL, and IgE remained stable at 35 kU/L.

Given the persistent inflammation and elevated eosinophils despite high-dose therapy, biologic therapy was considered. FeNO and eosinophil levels were used to guide the decision on which biologic treatment would be most appropriate.

Clinical Takeaway:

FeNO testing provided important information about ongoing inflammation in this patient, prompting an increase in ICS dose and the addition of a LAMA. When standard therapies weren’t fully effective, biomarkers like FeNO and eosinophils indicated the need for biologic therapy, allowing for a more personalised treatment approach.