Letter to the Editor
Severe asthma intervention in adult obese patients
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"apellidos" => "Agostinho Marques" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043720300957?idApp=UINPBA00004E" "url" => "/25310437/0000002600000005/v1_202009020805/S2531043720300957/v1_202009020805/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2531043719302193" "issn" => "25310437" "doi" => "10.1016/j.pulmoe.2019.12.002" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "1432" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Pulmonol. 2020;26:323-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 105 "formatos" => array:3 [ "EPUB" => 18 "HTML" => 39 "PDF" => 48 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Juvenile dermatomyositis and pneumomediastinum: a case of a very rare complication" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "323" "paginaFinal" => "325" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 424 "Ancho" => 1505 "Tamanyo" => 77996 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Gottron´s papules over the elbows (left). Gottron´s papules on the hands (middle). Heliotrope (right).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Renata Lopes Francisco de Andrade, Ana Carolina Lopes Held, Maria Teresa Terreri, Sonia Mayumi Chiba" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Renata Lopes Francisco" "apellidos" => "de Andrade" ] 1 => array:2 [ "nombre" => "Ana Carolina Lopes" "apellidos" => "Held" ] 2 => array:2 [ "nombre" => "Maria Teresa" "apellidos" => "Terreri" ] 3 => array:2 [ "nombre" => "Sonia Mayumi" "apellidos" => "Chiba" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043719302193?idApp=UINPBA00004E" "url" => "/25310437/0000002600000005/v1_202009020805/S2531043719302193/v1_202009020805/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Severe asthma intervention in adult obese patients" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "325" "paginaFinal" => "327" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Serino, M. van Zeller, N. Martins, M. Drummond" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Serino" "email" => array:1 [ 0 => "mariana.serino@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "van Zeller" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "N." "apellidos" => "Martins" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Drummond" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Pulmonology Department, Centro Hospitalar Universitário São João, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Faculty of Medicine, University of Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Institute for Research and Innovation in Health, University of Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 980 "Ancho" => 3167 "Tamanyo" => 97655 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Variation in (A) FEV (%) and weight (kg) and (B) eosinophils count (cells/L) and weight (kg) over time following omalizumab treatment initiation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Obesity and asthma are prevalent disorders, both with an important impact on public health.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> A meta-analysis of seven prospective studies found a relationship between obesity and asthma: incident asthma OR in overweight and obese groups was 1.5 and 1.9, respectively, when compared to the normal weight group.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> In fact, obese patients have an increased risk of asthma, and obese asthmatics have even more symptoms, frequent and severe exacerbations and worse response to asthma-specific therapies.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1–4</span></a> Weight loss has been proposed as essential in these patients, where up to 5–10% of weight loss is associated with improved asthma control and quality of life.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,5</span></a> In this way, bariatric surgery is considered as the key option to promote a substantial weight loss.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6–8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Here, we report the case of an obese adult woman who presented with severe allergic-predominant asthma, who really improved her symptoms and frequency of exacerbations following bariatric surgery. However, she developed a psychiatric disorder due to the non-acceptance of her new body image.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A thirty-eight-year-old woman was referred to a pulmonology department because of severe uncontrolled steroid-dependent asthma. She had frequent cough, shortness of breath, wheezing and recurrent exacerbations. She had other comorbidities, like obesity (BMI 38), gastroesophageal reflux disease (GERD) and chronic rhinosinusitis. The patient's comorbidities, exposure to allergens or other harmful agents, as well as adherence and the appropriate use of current treatment were assessed. After the evaluation, weight loss was proposed and proton pump inhibitors and intranasal corticosteroids were prescribed. Asthma treatment was reviewed and optimized (with reduction of systemic corticosteroids (SC), high-dose inhaled corticosteroids (ICS) and long-acting beta 2-agonists (LABA), long-acting muscarinic antagonists (LAMA), leukotriene receptor antagonists (LTRAs)). However, the patient continued to have uncontrolled asthma.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient had reduced lung function (FEV1 63% pred, Tiffeneau index 61), atopy (skin prick test positive), IgE 454<span class="elsevierStyleHsp" style=""></span>kU/L and blood eosinophils count of 890 cells/l. Based on this, anti-IgE treatment (omalizumab 525<span class="elsevierStyleHsp" style=""></span>mg, SC each 2 weeks) was started.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Over the next four years (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), the patient was asymptomatic, had a total CARAT score of 22 (9<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>13), decreased blood eosinophil count (260 cells/l), improved respiratory function tests (FEV1 87% pred), showed a clear decrease in the number of exacerbations and did not report the need for systemic therapy with corticosteroids. After that, the patient had progressively worse asthma control, despite using specific asthma therapy. Thus, the patient's comorbidities, exposure to allergens, as well as adherence and the appropriate use of current treatment were re-evaluated. The patient gained weight, reaching BMI of 40<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>. She was diagnosed with moderate obstructive sleep apnea (OSA) syndrome (apnea-hypopnea index of 20.3 events/h) and automatic positive airway pressure (APAP) therapy was initiated. Meanwhile, after a psychiatric evaluation, she underwent bariatric surgery. Following bariatric surgery, the patient had a rapid reduction in BMI, 65<span class="elsevierStyleHsp" style=""></span>kg in 6 months. Subsequently, the patient presented a clinical (total CARAT score of 28) and functional improvement and did not require systemic corticosteroids or omalizumab therapy. However, the patient started having depressive symptoms and lack of acceptance of her new body image, being referred for psychiatric re-evaluation. She started drug treatment and cognitive-behavioral therapy, but her weight persistently increased and asthma became uncontrolled. Thus, due to a new severe uncontrolled asthma, anti-IgE treatment was repurposed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In fact, obesity and asthma are prevalent disorders, and there is an association between the two conditions,<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,3,4</span></a> where obesity is both a major risk factor and an asthma modifier. Patients with severe asthma usually have limiting symptoms, exacerbations and side effects of medications, especially with the prolonged and recurrent use of SC.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2,9</span></a> The adverse effects of SC include obesity, diabetes, hypertension and psychological disorders, such as depression and anxiety. Therefore, although asthma in obese patients is more commonly associated with non-type 2 inflammation,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> obese patients with childhood-onset asthma tend to have higher markers of Th2 inflammation and more severe disease among obese asthmatics.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4,9</span></a> Studies have shown that weight loss interventions are associated with better control of asthma and respiratory function,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2,10</span></a> and that bariatric surgery promotes a rapid and sustained weight loss, and is generally associated with significant improvement in both asthma control and quality of life scores, reducing the risk of hospitalizations due to asthma exacerbation,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">7,8,10</span></a> and even triggering a significant decrease in treatment step.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> However, although obese asthmatic patients can be treated with specific asthma therapy and weight loss interventions, some patients still remain uncontrolled.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Obesity and asthma are frequently and independently associated with other conditions, which are also associated with worse asthma control, such as GERD, OSA and mood disorders.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2–4</span></a> Mood disorders, which consisted mainly of anxiety and depression, have been reported to be strongly correlated with asthma symptoms severity.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> Thus, severe asthma management is difficult and needs a careful and multidimensional assessment.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Here we report the case of an obese adult woman who presented with predominant severe allergic asthma, who truly improved her symptoms and exacerbations frequency following specific asthma therapy and bariatric surgery. However, despite all comorbidities and risk factors having been systematically assessed, their management was difficult, never allowing a longstanding asthma control. This may be due to a different type of airway inflammation, mechanical factors and other commodities that are associated with obesity.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Specifically, although the evaluation of all comorbidities is extremely important, it must be emphasized that, in the case of mood disorders evaluation, this can have a negative impact if not appropriately recognized and treated.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> The patient mentioned in this case started unpredictable depressive symptoms and lack of acceptance of her new body image, following a rapid reduction in BMI. Once depression was suspected, the patient was referred for psychiatric evaluation and management. She started drug treatment and cognitive-behavioral therapy, but her weight persistently increased and her asthma became uncontrolled. In conclusion, the management of this patient remains difficult, as the various comorbidities diverge and antagonize each other. Taking this into account, anti-IgE therapy was restarted.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In short, given that obesity is an important risk factor for asthma and asthma-related morbidity, weight loss interventions should be highly encouraged to ensure proper control of asthma, lung function and quality of life. However, although this aspect is extremely important, it is also essential to ensure holistic management with an appropriate approach to all comorbid conditions in obese asthmatic individuals.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 980 "Ancho" => 3167 "Tamanyo" => 97655 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Variation in (A) FEV (%) and weight (kg) and (B) eosinophils count (cells/L) and weight (kg) over time following omalizumab treatment initiation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Obesity and asthma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.A. 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McDonald" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/resp.13134" "Revista" => array:6 [ "tituloSerie" => "Respirology" "fecha" => "2017" "volumen" => "22" "paginaInicial" => "1262" "paginaFinal" => "1275" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28776330" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/25310437/0000002600000005/v1_202009020805/S2531043720300866/v1_202009020805/en/main.assets" "Apartado" => array:4 [ "identificador" => "72880" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/25310437/0000002600000005/v1_202009020805/S2531043720300866/v1_202009020805/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043720300866?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 4 | 12 |
| 2024 October | 31 | 29 | 60 |
| 2024 September | 44 | 27 | 71 |
| 2024 August | 57 | 33 | 90 |
| 2024 July | 45 | 31 | 76 |
| 2024 June | 32 | 30 | 62 |
| 2024 May | 47 | 37 | 84 |
| 2024 April | 36 | 26 | 62 |
| 2024 March | 52 | 26 | 78 |
| 2024 February | 30 | 17 | 47 |
| 2024 January | 24 | 25 | 49 |
| 2023 December | 22 | 24 | 46 |
| 2023 November | 53 | 56 | 109 |
| 2023 October | 36 | 42 | 78 |
| 2023 September | 22 | 37 | 59 |
| 2023 August | 18 | 17 | 35 |
| 2023 July | 30 | 33 | 63 |
| 2023 June | 17 | 20 | 37 |
| 2023 May | 39 | 34 | 73 |
| 2023 April | 22 | 11 | 33 |
| 2023 March | 46 | 20 | 66 |
| 2023 February | 58 | 18 | 76 |
| 2023 January | 18 | 19 | 37 |
| 2022 December | 41 | 22 | 63 |
| 2022 November | 39 | 36 | 75 |
| 2022 October | 56 | 39 | 95 |
| 2022 September | 26 | 38 | 64 |
| 2022 August | 22 | 32 | 54 |
| 2022 July | 36 | 50 | 86 |
| 2022 June | 22 | 34 | 56 |
| 2022 May | 30 | 37 | 67 |
| 2022 April | 26 | 32 | 58 |
| 2022 March | 29 | 54 | 83 |
| 2022 February | 25 | 34 | 59 |
| 2022 January | 38 | 50 | 88 |
| 2021 December | 28 | 38 | 66 |
| 2021 November | 29 | 33 | 62 |
| 2021 October | 57 | 71 | 128 |
| 2021 September | 31 | 43 | 74 |
| 2021 August | 51 | 35 | 86 |
| 2021 July | 33 | 26 | 59 |
| 2021 June | 40 | 28 | 68 |
| 2021 May | 48 | 47 | 95 |
| 2021 April | 106 | 116 | 222 |
| 2021 March | 69 | 55 | 124 |
| 2021 February | 53 | 36 | 89 |
| 2021 January | 32 | 30 | 62 |
| 2020 December | 37 | 17 | 54 |
| 2020 November | 63 | 28 | 91 |
| 2020 October | 110 | 56 | 166 |
| 2020 September | 210 | 114 | 324 |
| 2020 August | 97 | 36 | 133 |
| 2020 July | 73 | 43 | 116 |
| 2020 June | 55 | 27 | 82 |
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