FeNO-guided treatment makes no difference in children prone to asthma exacerbations

Adding fractional exhaled nitric oxide (FeNO) to symptom-guided asthma treatment does not lead to reduced exacerbations in children, a large UK study suggests.

The trial of more than 500 6-15 year olds who were prescribed inhaled corticosteroids and had received oral steroids for at least one asthma exacerbation in the past year found no real difference in outcomes when FeNO was also used to guide treatment.

Overall the primary outcome of an asthma exacerbation needing oral corticosteroids over 12 months occurred in 48.2% of the intervention group and 51.4% of the standard care group, the researchers report in The Lancet Respiratory Medicine.

They concluded that in this group of children prone to exacerbations, typical of those seen in secondary and tertiary care services in the UK, there was no significant impact of including FeNO in decision making.

The adjusted difference in the percentage of children in the FeNO group who had exacerbations compared with those who received standard care was –3∙1% (–11∙9% to 5∙6%).

And there was no statistically significant difference in the primary outcome for any of the subgroups, the RAACENO study researchers said.

No clear differences were found in secondary outcomes which included FEV1, use of inhaled corticosteroids and asthma control scores, in the study which was done at multiple locations across the country.

They did note that the typical FeNO concentration in the study was a low 21ppb suggesting a limit to what FeNO-guided improvement could be achieved.

In addition, there were marked improvements in outcomes for participants in the standard care group, ‘which made it difficult to detect differences in secondary outcomes between trial groups’, they noted.

‘Asthma symptoms remain the only tool for guiding treatment decisions and objective tests need to be identified and validated,’ they concluded.

Dr Katy Pike, Consultant in Paediatric Respiratory Medicine at Bristol Royal Hospital for Children said the trial was a massive coordinated effort between multiple sites.

‘The finding of reduced asthma attacks in both study arms is not unusual, but underlines the value of regular and systematic review,’ she told the limbic.

‘What is clear is that this using FeNO according to the algorithm used in this study does not reduce asthma attacks in this group of patients which is representative of the vast majority of children followed up in hospital clinics after a previous asthma attack.’

She added that the door remains open to the possibility that FeNO guided algorithms might be beneficial for certain subgroups possibly those with allergic asthma.

‘Moreover, an important limitation might be that FeNO levels were already low at baseline and inhaled steroid doses moderate to high such that there was little room on the dose response curve for inhaled corticosteroid effect upon FeNO to have much impact, particularly as often the treatment decisions were often the same regardless of group allocation.’

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