Exploring the long-term utility of remotely monitored FeNO suppression testing in severe asthma

John Busby; Joshua Holmes; Mohammed Almutairi; Irene Berrar-Torre; Claire Butler; Christabelle Chen; Gráinne  d'Ancona; Paddy Dennison; Sharron Gilbey; David J Jackson; Sumita Kerley; Sukeshi Makhecha; Adel Mansur; Anna-Louise Nichols; Pujan H. Patel; Paul E. Pfeffer; Hitasha Rupani; Joan Sweeney; Liam G. Heaney

doi:10.1016/j.jaip.2025.04.036

Exploring the long-term utility of remotely monitored FeNO suppression testing in severe asthma

John Busby
, Joshua Holmes
, Mohammed Almutairi
, Irene Berrar-Torre
, Claire Butler
, Christabelle Chen
, Gráinne d'Ancona
, Paddy Dennison
, Sharron Gilbey
, David J Jackson
, Sumita Kerley
, Sukeshi Makhecha
, Adel Mansur
, Anna-Louise Nichols
, Pujan H. Patel
, Paul E. Pfeffer
, Hitasha Rupani
, Joan Sweeney
, Liam G. Heaney^*

^*Corresponding author for this work

School of Medicine, Dentistry and Biomedical Sciences

Research output: Contribution to journal › Article › peer-review

1 Citation (Scopus)

14 Downloads (Pure)

Abstract

Background
Confirmation of optimal inhaled corticosteroid use is essential before initiating biologic therapy. Fractional exhaled nitric oxide (FeNO) suppression testing (FeNOSuppT) is a proven phenotyping technique; however, its long-term effect on clinical outcomes remains unclear.

Objectives
To assess the real-world feasibility of delivering FeNOSuppT alongside digital inhaler monitoring and to examine its effect on biologic initiation and clinical outcomes.

Methods
Prospective cohort study within 7 U.K. severe asthma centers. Patients received a sensor-enabled inhaled corticosteroid/long-acting β-agonist (ICS/LABA) inhaler during an initial appointment between July 2020 and June 2022. A positive FeNOSuppT was defined as greater than 42% FeNO reduction at short-term follow-up (typically 1–3 mo postbaseline). Biologic initiation and clinical outcomes were compared at short-term and long-term (typically 12 mo postbaseline) follow-up.

Results
Of 353 included patients, 257 (72.8%) completed the FeNOSuppT and 140 (54.5%) were positive. A positive FeNOSuppT was associated with greater improvements in the % predicted short-term forced expiratory volume in 1 second (FEV₁%; 8.6% vs –0.3; P < .001) and the 6-Item Asthma Control Questionnaire (ACQ6; 0.7 vs 0.3; P = .001) compared with a negative test. Of 168 patients eligible for biologics who completed the FeNOSuppT, those with a positive result initiated biologics less often (48.2% vs 65.2%; P = .035). Despite this, there was a greater improvement in FEV₁ (11.0% vs 2.3%; P = .016), and a similar reduction in both asthma symptoms (ACQ6 0.7 vs 0.8; P = .623) and exacerbations (66.7% vs 66.7%; P = .349) at long-term follow-up when compared with those with a negative FeNOSuppT.

Conclusions
Delivering FeNOSuppT aligned with digital monitoring is feasible within routine care. A positive FeNOSuppT was associated with lower rates of biologic initiation, with similar clinical outcomes.

Original language	English
Pages (from-to)	1816-1823
Number of pages	8
Journal	Journal of Allergy and Clinical Immunology: In Practice
Volume	13
Issue number	7
DOIs	https://doi.org/10.1016/j.jaip.2025.04.036
Publication status	Published - 07 Jul 2025

Keywords

adult
aged
female
humans
male
middle aged
administration, inhalation
adrenal cortex hormones/therapeutic use
anti-asthmatic agents/therapeutic use
asthma/drug therapy
fractional exhaled nitric oxide testing/methods
nitric oxide/analysis
prospective studies

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10.1016/j.jaip.2025.04.036Licence: CC BY

Exploring the long-term utility of remotely monitored FeNO suppression testing in severe asthma
Copyright 2025 The Authors. This is an open access article published under a Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium, provided the author and source are cited.
Final published version, 704 KBLicence: CC BY

Cite this

Busby, J., Holmes, J., Almutairi, M., Berrar-Torre, I., Butler, C., Chen, C., d'Ancona, G., Dennison, P., Gilbey, S., Jackson, D. J., Kerley, S., Makhecha, S., Mansur, A., Nichols, A.-L., Patel, P. H., Pfeffer, P. E., Rupani, H., Sweeney, J., & Heaney, L. G. (2025). Exploring the long-term utility of remotely monitored FeNO suppression testing in severe asthma. Journal of Allergy and Clinical Immunology: In Practice, 13(7), 1816-1823. https://doi.org/10.1016/j.jaip.2025.04.036

@article{63b4f9d373754dd284915e7e815c3192,

title = "Exploring the long-term utility of remotely monitored FeNO suppression testing in severe asthma",

abstract = "Background Confirmation of optimal inhaled corticosteroid use is essential before initiating biologic therapy. Fractional exhaled nitric oxide (FeNO) suppression testing (FeNOSuppT) is a proven phenotyping technique; however, its long-term effect on clinical outcomes remains unclear. Objectives To assess the real-world feasibility of delivering FeNOSuppT alongside digital inhaler monitoring and to examine its effect on biologic initiation and clinical outcomes. Methods Prospective cohort study within 7 U.K. severe asthma centers. Patients received a sensor-enabled inhaled corticosteroid/long-acting β-agonist (ICS/LABA) inhaler during an initial appointment between July 2020 and June 2022. A positive FeNOSuppT was defined as greater than 42\% FeNO reduction at short-term follow-up (typically 1–3 mo postbaseline). Biologic initiation and clinical outcomes were compared at short-term and long-term (typically 12 mo postbaseline) follow-up. Results Of 353 included patients, 257 (72.8\%) completed the FeNOSuppT and 140 (54.5\%) were positive. A positive FeNOSuppT was associated with greater improvements in the \% predicted short-term forced expiratory volume in 1 second (FEV1\%; 8.6\% vs –0.3; P < .001) and the 6-Item Asthma Control Questionnaire (ACQ6; 0.7 vs 0.3; P = .001) compared with a negative test. Of 168 patients eligible for biologics who completed the FeNOSuppT, those with a positive result initiated biologics less often (48.2\% vs 65.2\%; P = .035). Despite this, there was a greater improvement in FEV1 (11.0\% vs 2.3\%; P = .016), and a similar reduction in both asthma symptoms (ACQ6 0.7 vs 0.8; P = .623) and exacerbations (66.7\% vs 66.7\%; P = .349) at long-term follow-up when compared with those with a negative FeNOSuppT. Conclusions Delivering FeNOSuppT aligned with digital monitoring is feasible within routine care. A positive FeNOSuppT was associated with lower rates of biologic initiation, with similar clinical outcomes. ",

keywords = "adult, aged, female, humans, male, middle aged, administration, inhalation, adrenal cortex hormones/therapeutic use, anti-asthmatic agents/therapeutic use, asthma/drug therapy, fractional exhaled nitric oxide testing/methods, nitric oxide/analysis, prospective studies",

author = "John Busby and Joshua Holmes and Mohammed Almutairi and Irene Berrar-Torre and Claire Butler and Christabelle Chen and Gr{\'a}inne d'Ancona and Paddy Dennison and Sharron Gilbey and Jackson, \{David J\} and Sumita Kerley and Sukeshi Makhecha and Adel Mansur and Anna-Louise Nichols and Patel, \{Pujan H.\} and Pfeffer, \{Paul E.\} and Hitasha Rupani and Joan Sweeney and Heaney, \{Liam G.\}",

year = "2025",

month = jul,

day = "7",

doi = "10.1016/j.jaip.2025.04.036",

language = "English",

volume = "13",

pages = "1816--1823",

journal = "Journal of Allergy and Clinical Immunology: In Practice",

issn = "2213-2198",

publisher = "American Academy of Allergy, Asthma and Immunology",

number = "7",

}

Busby, J, Holmes, J, Almutairi, M, Berrar-Torre, I, Butler, C, Chen, C, d'Ancona, G, Dennison, P, Gilbey, S, Jackson, DJ, Kerley, S, Makhecha, S, Mansur, A, Nichols, A-L, Patel, PH, Pfeffer, PE, Rupani, H, Sweeney, J & Heaney, LG 2025, 'Exploring the long-term utility of remotely monitored FeNO suppression testing in severe asthma', Journal of Allergy and Clinical Immunology: In Practice, vol. 13, no. 7, pp. 1816-1823. https://doi.org/10.1016/j.jaip.2025.04.036

TY - JOUR

T1 - Exploring the long-term utility of remotely monitored FeNO suppression testing in severe asthma

AU - Busby, John

AU - Holmes, Joshua

AU - Almutairi, Mohammed

AU - Berrar-Torre, Irene

AU - Butler, Claire

AU - Chen, Christabelle

AU - d'Ancona, Gráinne

AU - Dennison, Paddy

AU - Gilbey, Sharron

AU - Jackson, David J

AU - Kerley, Sumita

AU - Makhecha, Sukeshi

AU - Mansur, Adel

AU - Nichols, Anna-Louise

AU - Patel, Pujan H.

AU - Pfeffer, Paul E.

AU - Rupani, Hitasha

AU - Sweeney, Joan

AU - Heaney, Liam G.

PY - 2025/7/7

Y1 - 2025/7/7

N2 - Background Confirmation of optimal inhaled corticosteroid use is essential before initiating biologic therapy. Fractional exhaled nitric oxide (FeNO) suppression testing (FeNOSuppT) is a proven phenotyping technique; however, its long-term effect on clinical outcomes remains unclear. Objectives To assess the real-world feasibility of delivering FeNOSuppT alongside digital inhaler monitoring and to examine its effect on biologic initiation and clinical outcomes. Methods Prospective cohort study within 7 U.K. severe asthma centers. Patients received a sensor-enabled inhaled corticosteroid/long-acting β-agonist (ICS/LABA) inhaler during an initial appointment between July 2020 and June 2022. A positive FeNOSuppT was defined as greater than 42% FeNO reduction at short-term follow-up (typically 1–3 mo postbaseline). Biologic initiation and clinical outcomes were compared at short-term and long-term (typically 12 mo postbaseline) follow-up. Results Of 353 included patients, 257 (72.8%) completed the FeNOSuppT and 140 (54.5%) were positive. A positive FeNOSuppT was associated with greater improvements in the % predicted short-term forced expiratory volume in 1 second (FEV1%; 8.6% vs –0.3; P < .001) and the 6-Item Asthma Control Questionnaire (ACQ6; 0.7 vs 0.3; P = .001) compared with a negative test. Of 168 patients eligible for biologics who completed the FeNOSuppT, those with a positive result initiated biologics less often (48.2% vs 65.2%; P = .035). Despite this, there was a greater improvement in FEV1 (11.0% vs 2.3%; P = .016), and a similar reduction in both asthma symptoms (ACQ6 0.7 vs 0.8; P = .623) and exacerbations (66.7% vs 66.7%; P = .349) at long-term follow-up when compared with those with a negative FeNOSuppT. Conclusions Delivering FeNOSuppT aligned with digital monitoring is feasible within routine care. A positive FeNOSuppT was associated with lower rates of biologic initiation, with similar clinical outcomes.

AB - Background Confirmation of optimal inhaled corticosteroid use is essential before initiating biologic therapy. Fractional exhaled nitric oxide (FeNO) suppression testing (FeNOSuppT) is a proven phenotyping technique; however, its long-term effect on clinical outcomes remains unclear. Objectives To assess the real-world feasibility of delivering FeNOSuppT alongside digital inhaler monitoring and to examine its effect on biologic initiation and clinical outcomes. Methods Prospective cohort study within 7 U.K. severe asthma centers. Patients received a sensor-enabled inhaled corticosteroid/long-acting β-agonist (ICS/LABA) inhaler during an initial appointment between July 2020 and June 2022. A positive FeNOSuppT was defined as greater than 42% FeNO reduction at short-term follow-up (typically 1–3 mo postbaseline). Biologic initiation and clinical outcomes were compared at short-term and long-term (typically 12 mo postbaseline) follow-up. Results Of 353 included patients, 257 (72.8%) completed the FeNOSuppT and 140 (54.5%) were positive. A positive FeNOSuppT was associated with greater improvements in the % predicted short-term forced expiratory volume in 1 second (FEV1%; 8.6% vs –0.3; P < .001) and the 6-Item Asthma Control Questionnaire (ACQ6; 0.7 vs 0.3; P = .001) compared with a negative test. Of 168 patients eligible for biologics who completed the FeNOSuppT, those with a positive result initiated biologics less often (48.2% vs 65.2%; P = .035). Despite this, there was a greater improvement in FEV1 (11.0% vs 2.3%; P = .016), and a similar reduction in both asthma symptoms (ACQ6 0.7 vs 0.8; P = .623) and exacerbations (66.7% vs 66.7%; P = .349) at long-term follow-up when compared with those with a negative FeNOSuppT. Conclusions Delivering FeNOSuppT aligned with digital monitoring is feasible within routine care. A positive FeNOSuppT was associated with lower rates of biologic initiation, with similar clinical outcomes.

KW - adult

KW - aged

KW - female

KW - humans

KW - male

KW - middle aged

KW - administration, inhalation

KW - adrenal cortex hormones/therapeutic use

KW - anti-asthmatic agents/therapeutic use

KW - asthma/drug therapy

KW - fractional exhaled nitric oxide testing/methods

KW - nitric oxide/analysis

KW - prospective studies

U2 - 10.1016/j.jaip.2025.04.036

DO - 10.1016/j.jaip.2025.04.036

M3 - Article

C2 - 40316253

SN - 2213-2198

VL - 13

SP - 1816

EP - 1823

JO - Journal of Allergy and Clinical Immunology: In Practice

JF - Journal of Allergy and Clinical Immunology: In Practice

IS - 7

ER -

Exploring the long-term utility of remotely monitored FeNO suppression testing in severe asthma

Abstract

Keywords

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