Asthma Phenotypes

Thitima Kantachatvanich, M.D.

Asthma
• Character: “Heterogeneity”
• Cluster analysis  asthma phenotypes
(statistically, molecularly, genetically)
• Link biology to phenotype
• Targeted and personalized approaches to therapy

Asthma phenotypes: the evolution from clinical to molecular approaches : nature medicine VOLUME 18 | NUMBER 5 | MAY 2012
Phenotypes
• The visible characteristics of an organism resulting from the interaction
between its genetic makeup and the environment.1

1.The Encarta World Dictionary, 1st edn. New York: St Martin’s Press; 1999.
Endotypes
• A specific biological pathway is identified that explains the
observable properties of a phenotype

Lötvall, J. et al. Asthma endotypes: a new approach to classification of disease

entities within the asthma syndrome. J. Allergy Clin. Immunol. 127, 355–360 (2011).
Severe Asthma
• International Innovative Medicines Initiative criteria
• Asthma (R/O alternative Dx, compliance, trigger factors, Tx error)
• Poor asthma control or frequent (≥2) severe exacerbations per year
• Despite high-intensity treatment or can only maintain adequate control when taking
systemic corticosteroids and are thereby at risk of serious adverse effects of treatment.
• High intensity asthma Tx:
• 1000 mcg/day fluticasone equivalent combined + LABA or other controllers (adults)
• 500 mcg/day fluticasone equivalent (school-aged children)
• 400 mcg/day budesonide equivalent + oral leukotriene receptor antagonists (pre-school
children)

Elisabeth H Bel, et al.Diagnosis and definition of severe refractory asthma: an international

consensus statement from the Innovative Medicine Initiative (IMI); Thorax 2011;66:910e917.
 GINA Guideline 2018

Asthma that requires GINA

steps 4 to 5 Tx
(high-dose ICS and LABA or LT
modifier/theophylline) for
the previous year or systemic
corticosteroids for ≥50% of
the previous year

“uncontrolled“
despite this therapy

M. Amelink, et al., Severe adult-onset asthma: A distinct phenotype; J Allergy Clin Immunol 2013
Old Asthma Phenotypes Approaches
• Extrinsic (Allergic)
• Atopy
• sIgE to trigger
• Intrinsic (Nonallergic)
• Develop later in life (> 40 years old)
• AERD, etc.
The Umbrella Term ‘Asthma’

Asthma phenotypes: the evolution from clinical to Eosinophilic and Noneosinophilic Asthma:
molecular approaches: nature medicine MAY 2012
AJRCCM Jan 2018
Cluster Analysis
• SARP: Severe Asthma Research Program (by the National Heart, Lung,
and Blood Institute )
• Clinical characteristics of age of asthma onset, lung function, bronchodilator
reversibility, and demographics

• UBIOPRED: Unbiased Biomarkers for the Prediction of Respiratory

Disease Outcome Consortium

• ADEPT: Airways Disease Endotyping for Personalized Therapeutics

Elisabeth H Bel, et al.Diagnosis and definition of severe refractory asthma: an international

consensus statement from the Innovative Medicine Initiative (IMI); Thorax 2011;66:910e917.
 Several endotypes drive the phenotypes present in each cluster.
Cluster Analysis
Eo↑

Elisabeth H Bel, et al.Diagnosis and definition of severe refractory asthma: an international

consensus statement from the Innovative Medicine Initiative (IMI); Thorax 2011;66:910e917.
Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018
 Eosinophilic vs Non-eosinophilic Asthma
• Eosinophilic
• Non-eosinophilic
 Sputum Eo levels > 2 to 3% (of total cells in a
whole expectorate)  Dominant cell: neutrophils,
 BAL Eo > 2%
mixed inflammatory
 No actual cut-off Eo in bronchial wall Bx
*Wenzel, et al.: ≥20 cells/mm2 of tissue (16-31)
granulocytes
 ↑Serum periostin (correlated to AW & sputum
eosinophilia, IL-13 pathway)1
 Or very few inflammatory cells
 DPP-4: IL-13 pathway “paucigranulocytic”
Exhaled nitric oxide
 Respiratory epithelium under control of IL-13
 Often but not always correlated with sputum/blood
Eo (marker of TH2 phenotype)
 Predicts responsiveness to inhaled corticosteroids
Blood Eo: indirect, fluctuating,
may not reflect sputum Eo
(but if extreme(<90, >400) 1.Jia G et al.; Bronchoscopic Exploratory Research Study of Biomarkers in Corticosteroid-refractory Asthma (BOBCAT) Study Group.
: ↑ reflective) Periostin is a systemic biomarker of eosinophilic airway inflammation in asthmatic patients. JACl 2012;130:647–654.e10.
AEC > 300-400 Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018
 Periostin

• Matricellular protein from Eo, MØ,

fibroblasts, epithelial cells
• Eo recruitment
• AW remodeling (TGF-B inducing
protein homoloque)
• Th2 phenotype
• ↑Inflammatory mediators

Wei Li, et al. Periostin: its role in asthma and its potential as a diagnostic or therapeutic target. Respir Res. 2015; 16(1): 57.
Eosinophilic Asthma (EA)
• May be responsive to ICS
• If unresponse to high dose ICS/need systemic steroid
• May be responsive some biologic Tx
• Several endotypes  EA
• IL-4/13: early onset atopic asthma
• IL-5: late onset, less atopic

• Allergic or atopic: Ag specific Th2

• Nonallergic or nonatopic: obesity

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018

Allergic EA: childhood

Asthma phenotypes: the evolution from clinical to molecular approaches : nature medicine VOLUME 18 | NUMBER 5 | MAY 2012
Non-allergic Eosinophilic Asthma
• Non-atopic: less IL-4 for sIgE production
• Innate immune pathway: ILC-2  IL-5, IL-13
• Late onset, severe, relatively steroid insensitive
• Irritants/pollutants and microbes (protease) AW epithelial injury
IL-25, IL-33, and TSLP  stimulate ILC-2, Th2, TSLP-primed DCs, mast
cell

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018

TSLP (thymic stromal lymphopoietin)
• Direct mast cell activation  release of proinflammatory cytokines
and lipid mediators
• Bind to receptor on DC  upregulating CD40, OX40, and CD80
Enhancing Th2 polarization
Not predominant IL-4 production: minimizes B cell
class switching to IgE(Ag specific IgE is not prominent)
IL-25, IL-33: directly on the naïve T cells to promote
Th2 immune deviation
Middleton 8th edition
Non-allergic Eosinophilic Asthma
• Th2, Th17: Dual positive in
some patients
• “Late onset EA”
• IL-6, IL-1b, IL-23
• MEK(MAP-ERK kinase 1)
• IL-1b–mediated inflammation
• Corticosteroid insensitive
• Type 2 cytokine: inh IL-8
(Eo>PMN)
Middleton 8th edition
Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018
 Staphylococcal Enterotoxin: Non-allergic EA
• Superantigen production
• Polyclonal IgE production in the airways
 non-Ag-specific mast cell activation
• Suppression of Treg
• Production of cytotoxic Ab
to epithelial proteins (i.e., cytokeratin-18)
• corticosteroid insensitivity

Middleton 8th edition

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018
↑expressed levels of 15-LOX-1 in Exacerbation-prone asthma
airways of severe asthma patients

Periostin, TGF-B: AW remodeling

Aspergillus protein: processed by DC (HLA-

DR2/DR5) potent T2 inflammation, directly
epithelial cell damage.
Genetic risk: IL-4 receptor, IL-10 promotor,
TLR, surfactant protein A polymorphisms
Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018
 • PGD2: Major mast cell–derived prostanoid, also from
eosinophils
• DP2 also is known as CRTH2 (chemoattractant receptor–like
PGD2 Receptor Type molecule expressed on Th2, ILC2 cells)
• DP2 is preferentially expressed by IL-4+/IL-13+ T cells more
than by interferon (IFN)-γ+ T cells, ↑in severe asthma

Allergic inflammation(↑PDE)

Delays Th2 apoptosis,

Stimulates Th2 to produce IL-4, 5, 13

Middleton 8th edition

Asthma phenotypes: the evolution from clinical to molecular approaches : nature medicine VOLUME 18 | NUMBER 5 | MAY 2012
Anti IL-5: Mepolizumab
• Steroid Reduction with Mepolizumab Study (SIRIUS)1
• Mepolizumab as Adjunctive Therapy in Patients with Severe Asthma
(MENSA)2

• Severe asthma
• AEC ≥ 150 cells/mcL at screening or 300 cells/mcL in last year

1. Bel EH,et al.; Oral glucocorticoid-sparing effect of mepolizumab in eosinophilic asthma. NEJM 2014;371:1189–1197.
2. Ortega HG,et al.; Mepolizumab treatment in patients with severe eosinophilic asthma. NEJM 2014;371:1198–1207.
 • Steroid sparing
• ↓Exacerbation: 1.44/2.12
• ↑QoL, Improve ACQ-5
• (FEV1: nonsignificant diff)

Mepolizumab 100mg sc or placebo was administered subcutaneously once every 4 weeks until week 20
Bel EH,et al.; Oral glucocorticoid-sparing effect of mepolizumab in eosinophilic asthma. NEJM 2014;371:1189–1197.
75mg IV dose or 100mg sc, or placebo every 4 weeks for 32 weeks
• ↓Exacerbation: 0.83/0.93/1.74 per patient per year
• ↑pre BD FEV1 from BL: 100 ml /98 ml compared to placebo
• ↑QoL, improve ACQ-5
Ortega HG,et al.; Mepolizumab treatment in patients with severe eosinophilic asthma. NEJM 2014;371:1198–1207.
 17 countries, 347 centers
Age 12–75 years
IL-5 Receptor Antagonist: Benralizumab 48 weeks add-on Tx
1ry outcome: Annual AE

Benralizumab q 8 wk in Eo≥300: improve ACQ-6

Exacerbations, FEV1 in the benralizumab-treated and placebo cohorts diverged at 4 week
Bleecker ER, et al.; SIROCCO study investigators. Efficacy and safety of benralizumab for patients with severe asthma uncontrolled with highdosage inhaled
corticosteroids and long-acting b2-agonists (SIROCCO): a randomised, multicentre, placebo-controlled phase 3 trial. Lancet 2016;388:2115–2127.
Anti IL-13: 1
Tralokinumab , Lebrikizumab 2

Tralokinumab 300mg sc every 2 or 4 weeks for 52 weeks1

• Not ↓exacerbation rates in severe uncontrolled asthma compared with
placebo,
• Improve FEV1 in Tralokinumab 300mg sc every 2 weeks
• Post-hoc subgroup analysis (Tralokinumab 300mg sc every 2 weeks)
: DPP-4 = improvements in preBD FEV1, ACQ-6, and AQLQ(S)
Periostin = preBD FEV1, ACQ-6, exacerbation rate
Lebrikizumab 250 mg sc every 4 weeks for 6 months2
• Improved lung function (%change of FEV1 from BL)
• Not ↓severe exacerbation rates, ACQ5 score
• Higher pretreatment periostin: greater improve FEV1 with lebrikizumab
• Musculoskeletal side effects (13.2% vs. 5.4%, P = 0.045)
1. Brightling CE, et al. Efficacy and safety of tralokinumab in patients with severe uncontrolled asthma:
a randomised, double-blind, placebo-controlled, phase 2b trial. Lancet Respir Med 2015;3:692–701.
2. Corren J, et al. Lebrikizumab Treatment in Adults with Asthma. N Engl J Med 2011;365:1088-98.
 174 study sites across 16 countries or regions
Adults (aged ≥18 years)
1ry outcome: FEV1 in L change from baseline at 12th week

Anti IL-4/13 : Dupilumab

• Fully human anti-interleukin-4 receptor α monoclonal antibody
• Dupilumab 200 mg or 300 mg sc every 2 weeks or every 4 weeks, or
placebo, over a 24-week period
• Dupilumab 300 mg q 2 weeks: the greatest ↑lung function in the
overall population (also ↑lung function in AEC ≥ 300 ,< 300 subgroup)
• Dupilumab q 2 weeks: the greatest ↓annualised rates of exacerbation
in the overall population (70–70.5%)
• AEC ≥ 300 : 71.2–80.7% In patients with uncontrolled persistent asthma
• AEC < 300 : 59.9–67.6% • ↑lung function in AEC ≥ 300
• ↓severe exacerbations irrespective of baseline AEC
• Favourable safety profile
Wenzel S, et al. Dupilumab efficacy and safety in adults with uncontrolled persistent asthma despite use of medium-to-high-dose inhaled
corticosteroids plus a long-acting b2 agonist: a randomised double-blind placebo-controlled pivotal phase 2b dose-ranging trial. Lancet 2016;388:31–44.
 Single-centre

PGD2 Receptor 2 Antagonist: Fevipiprant 1ry outcome: change in

sputum Eo% from
baseline to 12 weeks

• Persistent, moderate-to-severe asthma and ↑sputum eosinophil

count (≥2%)
• Fevipiprant (225 mg twice per day orally) or placebo for 12 week
• Mean %sputum Eo was reduced by 4.5 times (1.3 times in the
placebo group)
• Difference between groups 3.5 times, 95% CI 1·7–7·0; p=0·0014).

• Favourable safety profile

Gonem S, et al. Fevipiprant, a prostaglandin D2 receptor 2 antagonist, in patients with persistent eosinophilic asthma: a
single-centre, randomised, double-blind, parallel-group, placebo-controlled trial. Lancet Respir Med 2016;4:699–707.
Biologics for EA

For non IL-5 specific EA endotypes (also benefit in NEA)

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018

Non-eosinophilic Asthma
• Sputum Eo < 2%
• Paucigranulocytic: sputum neutrophils < 61%
• Mixed granulocytic, or neutrophilic: sputum neutrophilia >40% or
≥76%

• Neutrophilic asthma
• Obesity-induced asthma
• Paucigranulocytic asthma
• Asthma related to environmental exposures

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018

Neutrophilic asthma
• Older age
• Impaired lung function
• Less bronchodilator reversibility
• Less atopy

• Trigger factors activate TLR4 and CD14 on epithelial cells, MØ

NF-kB activation
↑IL-8 (recruit activated neutrophils into the airways)
• Impaired MØ efferocytosis (phagocytosis of apoptotic cells)
• The p38 kinases(MAPK): induced by environmental triggers
• ↑inflammasome activity
• NK, NKT-like cells: corticosteroid insensitivity

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018

MAPK Family: p38 Kinase
• MAPK: dephosphorylation enz  generally halt prot. activation,
signal amplification (exc. Tyrosine kinase Src)
“p38 kinase: control cell cycle, gene transcription, stress response
• Relevant to asthma and in particular to NEA.
• Inhibition of p38/mitogen-activated protein kinase mitigates
neutrophilic inflammation

Middleton 8th edition

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018
Non-eosinophilic Asthma: Th2/T2 Low
Neutrophilic asthma: clue for chr.subclinical infection1
Th171
• Induced by chr.infection, inhale
exposure
• Neutrophilic, mixed granulocytic
• Severe, frequent exacerbation,
steroid resistance
• Mucus hypersecretion
• SM hypertrophy, AW remodeling

1.Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018

Asthma phenotypes: the evolution from clinical to molecular approaches : nature medicine VOLUME 18 | NUMBER 5 | MAY 2012
Air Pollutant, Smoking, Occupational Asthma
• Smoking: alter histone deacetylase activity  corticosteroid
insensitivity
• HDACs: deacetylate AA of glucocorticoid receptor (activate GR)
• Direct toxic effect from environment pollutants

Middleton 8th edition

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018
Paucigranulocytic Asthma
• 40% NEA
• Well controlled, mild intermittent in SARP cohort
• Some: severe, may not response to ICS
• Dysfunction of AW SM, n., vascular tissues
• AW SM: secrete cytokines, chemokines
• ↑Bronchospasm: muscarinic, adrenergic pathways
• Tx by muscarinic(LAMA), B2 antagonist(↓bronchospasm), bronchial
thermoplasty(↓exacerbation in severe paucigranulocytic asthma)
• Aberrant repair mechanism: AW remodeling

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018

 Obesity Related Asthma (EA, NEA)
• Eosinophilic (Early onset eosinophilic) • Non-eosinophilic (late onset, female
• Metabolic: ↓CD4 effector cell function predominant)
• High fat diet: ↑BM Eo • Neutrophilic, paucigranulocytic
• TNF-α: ↑AW hyperresponsiveness • ↑AW Resistance, easy to closure
• Surfactant protein A lipid: ↑type 2 • Reverse with weight reduction
inflammation • Activated MØ  inflammation in
• Adipokines ex leptin: ↑AW adipose tissue  ↑IL-6, TNFα, leptin
hyperresponsiveness, serum IgE • AW hyperresponsiveness:
(Adiponectin: ↓AW hyperresponsiveness) • O3  ↓lung function, ↑IL-6,
↑AW PMN
• Fat, antioxidants, lycopene consumption
Obese asthma mouse model: hi-fat diet
AW hyperreactive from IL-17A(ILC3)
• Modifying dietary fat intake: important in asthma Mx
Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018
 • Activation of the innate immune response by fatty acids in the
airways
• Modifying dietary fat intake: important in asthma Mx

• Nonobese (BMI < 30 kg/m2) and obese (BMI ≥30 kg/m2)

• Age > 18 years with stable asthma, nonsmokers
• AHF: Asthma high-fat
• AHF-NonO: Asthma high-fat/high energy—nonobese
• AHF-O:Asthma high-fat/high energy—obese ALF
• ALF: Asthma low-fat/low-energy
• HCHF: Healthy controls high-fat
• 4 hours postmeal, AHF-NonO 
• ↑sputum % PMN
• ↑TLR4 mRNA expression
• ↑FEV1/FVC were lower in the high-fat versus low-fat groups.
• After the high-trans fatty acid meal, sputum % neutrophils
were significantly higher than after the non-trans meal
Wood LG, et al. A high-fat challenge increases airway inflammation and impairs
bronchodilator recovery in asthma. J Allergy Clin Immunol 2011;127:1133–1140.
EH: Epoxide hydrolase Lipoxin = endo. Arachidonate
Metabolize lipoxin ↓Eo,PMN trafficking,toxic degranulation

Chronic infection

Viral infection
Tx in NEA(1) No proven targeted biologic, lacking clinical studies

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018

Tx in NEA(2) No proven targeted biologic, lacking clinical studies

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018

Non-pharmacologic Mx in NEA
• Smoking cessation
• Avoidance environmental triggers/pollutants
• Tx comorbid: weight reduction
• Look for chronic subclinical infection
• Dietary modification
• Low fat, low trans fat1
• Adequate antioxidants2
• Lycopene rich supplements2
• Bronchial thermoplasty: paucigranulocytic asthma

Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018

1. Wood LG, et al. A high-fat challenge increases airway inflammation and impairs bronchodilator recovery in asthma. J Allergy Clin Immunol 2011;127:1133–1140.
2. Wood LG, Garg ML, Powell H, Gibson PG. Lycopene-rich treatments modify noneosinophilic airway inflammation in asthma: proof of concept. Free Radic Res
2008;42:94–102.
Precision Medicine in Targeted Therapies for Severe Asthma: Is There Any Place for (Omics) Technology, BioMed Research International, 2018
Tara F. Carr, Eosinophilic and Noneosinophilic Asthma: AJRCCM Jan 2018
Severe Asthma Evaluation
• Age of onset
• Symptom
• Comorbidity: AR, obesity, chronic rhinosinusitis
• Acute exacerbation
• Lung function: fixed/reversible airflow obstruction
• Cellular inflammation
• Treatment response: corticosteroid insensitivity