Role of Epithelial Barrier Integrity in Biologic Treatment Response of Severe Asthmatics With/Out Chronic Rhinosinusitis With Nasal Polyps (CRSwNP).

Study Overview
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Brief Summary
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Advances in understanding the pathophysiology of asthma development and severity have pointed towards a prominent role of the bronchial epithelium, especially in more chronic and severe disease. Studies suggest that airway eosinophilic inflammation in asthma is linked to epithelial injury and structural changes of the airways, co called airway wall remodeling. Together the chronic airway inflammation and remodeling are associated with bronchial hyperresponsiveness, fixed airflow obstruction or progressive loss of lung function and clinical severity of asthma. Chronic rhinosinusitis with nasal polyps (CRSwNP), is another respiratory inflammatory disease often co-existing with severe asthma, sharing similar pathophysiology. The investigators hypothesize that epithelial barrier integrity may play a role in the pathophysiology of severe eosinophilic asthma and nasal polyposis and in response to anti-IL5 therapy of severe asthmatics, and that shedding of epithelial barrier proteins may be used as biomarker in the management of severe asthma. In order to study that, the investigators will conduct a prospective cohort study of adult severe asthmatics with/out CRSwNP, who live on the island of Crete, Greece and who meet the criteria for entering anti-IL5 treatment, as assessed by pulmonologist. The participants will be recruited with a convenience sampling in a period of 2 years, under real life conditions, and will be followed up for 1 year after treatment initiation. A control group of subjects diagnosed with nasal polyposis without severe asthma will be used. Eligible subjects will undergo clinical assessment with radiological (CT) and endoscopic investigations. Samples of serum, sputum, nasal secretions, as well as nasal and bronchial biopsies will be obtain for assessing clinicopathological differences among the 3 groups but also response to anti-IL5 therapy in SEA w/o CRSwNP.

Official Title
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Role of Epithelial Barrier Integrity in Biologic Treatment Response of Severe Asthmatics With/Out Chronic Rhinosinusitis With Nasal Polyps (CRSwNP). Can Shedding of Epithelial Barrier Proteins be Used as Biomarker in Severe Asthma With/Out CRSwNP Management?

Conditions
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Severe Eosinophilic Asthma w/wo CRSwNP

Intervention / Treatment
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* Drug: Mepolizumab 100 MG


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Able to provide informed written consent (study participation informed consent form): Able to give written informed consent prior to participation in the study, which will include the ability to comply with the requirements and restrictions listed in the consent form. Subjects must be able to read, comprehend, and write at a level sufficient to complete study related materials. Anti-IL5/IL5R naïve Confirmed asthma diagnosis and severity and treatment requirements (for severe asthma group see boxes 1-3). For the 2nd control group, patients with CRSwNP must have a diagnosis of mild asthma (GINA steps 1-2) or no asthma by pulmonologist. Polyposis must be bilateral, to be considered as CRSwNP Triggers and relevant co-morbidity have been assessed and are well controlled Triggers such as active or passive smoking, beta-blockers, aspirin/NSAIDs, allergen exposure;Comorbidities such as rhinitis, obesity, GERD, OSA, VCD, depression/anxiety. Age: Adults ≥18 years of age Any smoking status Any ethnicity Be affiliated to or a beneficiary of a social security category and/health insurance. Gender: Male and Eligible Female. To be eligible for entry into the study, females of childbearing potential must commit to consistent and correct use of an acceptable method of birth control for the duration of the follow up (and for 4 months after the last injection administration). A serum pregnancy test is required of all females. This test will be performed at the initial screening visit. In addition, a urine pregnancy test can be offered (optional) for all females during each scheduled treatment visit prior to the infusion of biologic product until the 1-year follow-up visit. Laboratory abnormality: No evidence of clinically significant abnormality (other than those seen in SEA) in the haematological, biochemical or urinalysis screen at Visit 1, as judged by the investigator. Asthma Exacerbation: Subjects with an ongoing asthma exacerbation should have their screening and treatment initiation visit delayed until the investigator considers the subject has returned to their baseline asthma status. If the 4-week screening period (visits 1 and 1a) has elapsed, then the subject should be considered a screening failure. An exacerbation is defined as worsening of asthma requiring the use of systemic CS and/or emergency department visit, or hospitalisation. For subjects on maintenance oral corticosteroids, an exacerbation requiring oral CS is defined as the use of oral/systemic corticosteroids at least double the existing dose for at least 3 days. Maintenance Asthma Therapy: No changes in the dose or regimen of baseline ICS and/or additional controller medication during the screening period (except for treatment of an exacerbation). Maintenance CRSwNP: No changes in the dose or regimen of baseline intranasal CS and/or additional controller medication during the screening period (except for treatment of an exacerbation). Subjects with a previous surgery for the removal of nasal polyps are allowed to participate and will be considered as subjects with CRSwNP (with severe asthma or not). However, any subject who had at least one surgery for removal of nasal polyps, even if at study screening he/she is free of nasal polyps, cannot be considered as a subject without CRSwNP. Severe asthma patients must meet requirements for biologic therapy with anti-IL5 treatment (Mepolizumab) Exclusion Criteria: Pregnancy Current exacerbation at visit 1 (repeat screening when stable). If exacerbation is lasting up until Visit 1a then exclude subject. Cognitive impairment preventing completion of data collection forms People highly dependent on medical care People with significant life limiting co-morbidity Other eosinophilic conditions (eosinophilic granulomatosis polyangiitis (Churg-Strauss syndrome), eosinophilic oesophagitis etc) Unilateral polyposis Primary diagnosis of lung disease other than asthma (chronic obstructive lung disease (COPD), asthma-COPD overlap (ACO), interstitial lung disease, sarcoidosis, bronchiectasis, cystic fibrosis, primary ciliary dyskinesia, active tuberculosis, allergic bronchopulmonary aspergillosis (ABPA)) Current lung cancer or other blood, lymphatic or solid organ malignancy Autoimmune diseases of the skin, muscle-skeletal or gastrointestinal system needing systemic corticosteroids, immunosuppressants or biologic treatment as well as individuals with granulomatosis with polyangiitis (Wegener's granulomatosis) Inability to attend study and treatment visits Inability to understand and speak Greek or English language

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Severe asthma without CRSwNP<br>control group; n 20 of anti-IL5 naïve severe asthmatics | Drug: Mepolizumab 100 MG<br>* Patients with SEA eligible to receive anti-IL5 treatment, which is a biologic treatment for SEA<br>|
| Severe asthma with CRSwNP<br>n 40 of anti-IL5 naïve severe asthmatics | Drug: Mepolizumab 100 MG<br>* Patients with SEA eligible to receive anti-IL5 treatment, which is a biologic treatment for SEA<br>|
| subjects CRSwNP with mild or no asthma<br> 25;2nd control group | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Differences in sputum columnar epithelial cells (CEPs) among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in sputum CEPs in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | We will employ flow cytometry on freshly isolated sputum cell suspensions from participants to measure CEPs proportion and count. Previously proposed cut-off value for normal range sputum CEP proportion (CEP % high = ≥11%) or number (CEP count high = ≥18.1 × 10^4/mL) may be considered. | Baseline and 1 year | 
| Differences in E-cadherin protein level in sputum and nasal secretions among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in E-cadherin protein level in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | Soluble E-cadherin in sputum and nasal secretions measured with ELISA. Data will be expressed as nanograms per milliliter in original sputum/secretion. Cell surface expression of E-cadherin on columnar epithelial cells may be analyzed by flow cytometry. | Baseline and 1 year | 
| Differences in nasal and bronchial epithelial thickness among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in epithelial thickness in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | Epithelial thickness will be determined in biopsies by dividing the epithelial surface area by the basement membrane (BM) length | Baseline and 1 year | 
| Differences in nasal and bronchial epithelial integrity among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in epithelial integrity in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | Epithelial integrity will be assessed in biopsy sections and expressed as percentage (%) of BM covered with normal epithelium (a layer of basal and ciliated columnar epithelial cells without detachment from the BM) | Baseline and 1 year | 
| Differences in nasal and bronchial epithelial E-cadherin expression among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in protein expression in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | Epithelial E-cadherin expression in biopsies will be measure with immonohistochemistry and expressed as the percentage of BM covered with E-cadherin-positive intact epithelium and/or as strong, moderate and weak epithelial E-cadherin staining | Baseline and 1 year | 
| Differences in nasal and bronchial basement membrane thickness (BM) among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in Basement membrane thickness in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | BM thickness in biopsies will be expressed as BM surface area divided by BM length | Baseline and 1 year | 
| Differences in CT-assessed airway wall thickness (WT) among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in WT in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | We will use high resolution computer tomography of the chest to measureairway wall thickness (WT). Airway dimensions will be measured at on contiguous slices of the right apical segmental bronchus and right posterior basal segmental bronchus, from which tangential views of the bronchi can be obtained. The averaged values of the 2 bronchi will be used for analysis | Baseline and 1 year | 
| Differences in CRSwNP stage among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in CRSwNP stage in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | The Lund-Mackay score is widely used in radiological staging of chronic rhinosinusitis. Although there are many scoring systems in place for sinonasal computed tomography (CT) analysis, the Lund-Mackay system has the best inter- and intraob-server agreement. In LMK scoring, the sinuses (maxillary, anterior/posterior ethmoid, sphenoid, and frontal) are each scored on a scale of 0-2 opacification (0, normal; 1, partial opacification; 2, total opacification). The ostiomeatal complex is scored on a two-point scale of 0 and 2 (0, not occluded; 2, occluded). The scores on each side ranged from 0 (complete translucency of all sinuses) to 12 (complete opacity of all sinuses), leading to a total LMK score of 24 for both sides.Of note, an aplastic (absent) frontal sinus receives a score of 0. | Baseline and 1 year | 
| Differences in exacerbation rate among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in exacerbation rate in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | Number of exacerbation in the past 12 months. An exacerbation is defined as worsening of asthma requiring the use of systemic CS and/or emergency department visit, or hospitalisation. For subjects on maintenance oral corticosteroids, an exacerbation requiring oral CS is defined as the use of oral/systemic corticosteroids at least double the existing dose for at least 3 days | Baseline and 1 year | 
| Differences in lung function among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in lung function in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | FEV1 (liters and %predicted), FVC (liters and %predicted, FEV1/FVC (%) including pre and post bronchodilator test | Baseline and 1 year | 
| Differences in need for sinus surgery among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in need for sinus surgery in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | Number (%) of participants with a reduced need for sinus surgery at 1 year. Surgery will be deemed required with an ENP score of >=3, or an ENP score of 2 and a TNSS score of >7. Polyp (ENP) score: 0=No polyps,1=Small polyps in the middle meatus not reaching below the inferior border of the middle turbinate, 2=Polyps reaching below the lower border of the middle turbinate, 3=Large polyps reaching the lower border of the inferior turbinate or polyps medial to the middle turbinate, 4=Large polyps causing complete obstruction of the inferior nasal cavity. The higher of the two nostril scores will be derived and used for the analysis. With a VAS (0 to 10 cm) the severity of 4 nasal polyposis symptoms (one VAS for each symptom): rhinorrhea; mucus in the throat; nasal blockage; loss of smell, and for total nasal symptom score (TNSS). The left-hand side of the scale (0) represents not troublesome, and the right-hand side of the scale (10) represents worst possible troublesome. | Baseline and 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Differences in total IgE among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in total IgE in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | Total serum IgE (UI/ml) | Baseline and 1 year | 
| Differences in blood eosinophil count among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in blood eosninophil count in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | Blood eosinophil differential counts (number and percentage) | Baseline and 1 year | 
| Differences in sputum eosinophil count among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in sputum eosinophil count in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | Eosinophils count (number x10^4/mL and %) in a differential cell count obtained from induced sputum | Baseline and 1 year | 
| Differences in FeNO among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in FeNO in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | Fractional Exhaled Nitric Oxide (FeNO in parts per billion) | Baseline and 1 year | 
| Differences in Asthma Control Test (ACT) among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in asthma control in1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | ACT includes 5 items, with 4-week recall (on symptoms and daily functioning). More specifically, ACT assesses the frequency of shortness of breath and general asthma symptoms, use of rescue medications, the effect of asthma on daily functioning, and overall self-assessment of asthma control. There is 5-point scale (for symptoms and activities: 1=all the time to 5= not at all; for asthma control rating: 1=not controlled at all to 5=completely controlled).The scores range from 5 (poor control of asthma) to 25 (complete control of asthma), with higher scores reflecting greater asthma control. An ACT score >19 indicates well-controlled asthma. | Baseline and 1 year | 
| Differences in quality of life among 3 groups (SEA w/o CRSwNP and CRSwNP with mild or no asthma) at baseline, and change in quality of life in 1-year post anti-IL5 treatment initiation in SEA w/o CRSwNP | With the Asthma Quality of Life Questionnaire (AQLQ) we will assess quality of life and psychological morbidity. The Asthma Quality of Life Questionnaire (AQLQ) is a 32-item questionnaire used to assess the physical, occupational, emotional, and social qualities of adults aged 17 to 70 years with asthma (Juniper et al, 2005). The AQLQ has 4 domains: symptoms (12 items), activity limitation (6 generic and 5 patient-specific items), emotional function (5 items), and environmental stimuli (4 items). The AQLQ was developed for patients exhibiting mild to moderate asthma (Aburuz et al, 2007). The AQLQ items are each scored on a 7-point Likert scale, with 1 representing maximal impairment and 7 representing no impairment. The original AQLQ includes 5 patient-specific questions in the activity limitation domain. As part of the initial interview, the patient indicates 5 activity limitations due to asthma. These 5 activity limitations are used for the remaining follow-up visits. | Baseline and 1 year |