A breath of fresh air
Asthma and allergy research at Dundee

In October this year, the University of Dundee was blown into the international spotlight as a team from the Asthma and Allergy Research Group published one of the world's first medical reports on the effects of the smoking ban, introduced in Scotland in March.

The findings, published by the Journal of the American Medical Association, showed that the smoking ban in Scotland had an immediate and positive impact on the health of bar workers, and has the potential to influence political decisions around the globe as governments consider whether they should follow Scotland's lead and also implement a ban.

Research into the effects of the smoking ban is just one of many projects being undertaken by the small University team who are making a big impact in improving the lives of people with asthma and allergies.

Asthma is caused when the airways become inflamed, making it difficult to breath. Even though as many as one in ten people in Scotland are believed to suffer from the condition, the reason for airway inflammation is not known, although certain triggers, such as allergies, viruses and chemicals are known to aggravate the disorder.

Inhaled corticosteroids are the usual first-line of defence offered to asthma sufferers to ease the condition but they can have some unpleasant side effects ranging from oral thrush to suppression of the adrenal glands, osteoporosis, skin bruising and growth retardation in children.

The Asthma and Allergy Research Group was launched a decade ago by Dr Brian Lipworth, who heads the group, to research ways to improve the quality of life for people with asthma and allergies of the airways.

Evaluating the safety and effectiveness of various corticosteroids and finding treatments that will ease the symptoms of asthma without causing other side effects is one of the main research streams of the group.

"Despite the proven effectiveness of inhaled corticosteroids in the treatment and prevention of airway inflammation and asthma symptoms, their more widespread use has been limited by short and long term safety concerns," Professor Lipworth said.

"There is a pressing need for the development of a treatment that is safer, but still as effective."

Dr Lipworth and his team are closely looking at novel inhaled steroids to see if claims about superior safety profiles are true as compared to older drugs. Moreover they are looking to see if non steroidal anti-inflammatory agents could allow the use of lower doses of inhaled steroids, without compromising asthma control or worsening inflammation. Because there is a close link between allergic inflammation in the nose (allergic rhinitis) and the lungs (asthma) the group are also looking to see what downstream effects treating the nose has on asthma control.

As well as improving medicines for asthma, the team are also focused on developing better mechanisms for getting the medicine into the airway passages where it is needed and have been involved in close collaboration with industry to evaluate the use of novel inhalers in comparison with more conventional devices.

"Conventional metered-dose (i.e. press and breathe type) inhalers are typically recommended for people with asthma, but have their limitations. Aside from issues of poor coordination with these devices, a large proportion of the drug from metered-dose inhalers impacts in the throat and voice box and doesn't get into the lungs where it is most needed," Dr Lipworth said.

The group are currently evaluating ways to improve delivery of the drug to the lungs and reduce mouth deposition using novel inhalers which have a modified actuator in the mouthpiece of the inhaler. This device is portable, cheap and much easier to use than conventional metered-dose inhalers and a lot more convenient than the larger plastic spacer attachments which most asthmatics presently use.

As well as investigating ways to improve current treatment methods, the group is also conducting research to identify biological markers that could be used to identify underlying inflammation in the airways so that treatment can be given before symptoms get worse.

Dr Lipworth and his team collaborated with industry to evaluate a novel test that involves the inhalation of manntiol dry powder through a simple inhaler. This works osmotically by zapping inflammatory cells in the patient's lungs to produce a controlled inflammatory response, which is simply measured using a standard assessment of lung volume. Results of the test provide a reliable measure of hyper-responsiveness in the airways, one of the key hallmarks of asthma. This test is simple, relatively inexpensive and rapid to perform and is applicable to being used by nurses in the community.

A large-scale community based study is currently underway to determine whether the mannitol challenge test is a better way to adjust and decide on the right dose of asthma medication than those currently recommended by British Society Guidelines.

Dr Lipworth said, "If our hypothesis is correct this test could fundamentally change the way we monitor asthma in primary care, and also give us a deeper understanding of the role of inflammation in asthma and how best to treat it."

The team are also looking at a novel portable asthma 'breathalyser' machine which measures the amount of nitric oxide (produced by inflammation in the lung) in exhaled breath.

"For the first time this portable, relatively inexpensive machine will hopefully allow us to measure asthmatic inflammation in primary care," Dr Lipworth said.

"Colleagues in General Practice including Dr Cathy Jackson are evaluating the new portable machine (MINO) in a number of GP practices to see how the readings relate to other asthma control outcomes and to exacerbations. We are also using MINO in conjunction with the mannitol test in the community to see how the two tests are related. This is a good example of how collaboration between academics in primary and secondary care settings will hopefully improve the way we manage our patients," said Dr Lipworth.

The team have also been trying to identify ways of tailoring treatment based on the patient's genetic make up. This could mean that in the future we will more easily identify who will benefit from certain drugs and who may get worse.

Along with their extensive research program in the laboratory, the Asthma and Allergy Research Group play a leading role in Scotland in the advancement of knowledge of these conditions through regular public awareness initiatives, education and research.

The smoking ban study is one example of research that reaches into the community and gives people a clear picture of the actual physical benefits to their health as a result of the ban.

The team were also responsible for Britain's first mobile asthma unit, which takes asthma testing to the community. On World Asthma Day this year, the researchers could be found in the Overgate Centre offering free asthma tests to the passing shoppers.

The Asthma and Allergy Research Group is a relatively small team of 12 people including doctors, nurses, technicians and scientists. Their research is based at Ninewells Hospital and the new satellite unit at Perth Royal Infirmary.

The University recently took over two vacant wards at the hospital and plans to transform them into a £5 million Perth Clinical Research Centre which will focus on chronic diseases including asthma and allergies and will support Professor Lipworth and other researchers, including child health expert Dr Somnath Mukhopadhyay, to further advance our understanding and treatment of these conditions.

"Scotland has the highest prevalence rates in the world for childhood asthma symptoms and the third highest for adults - about one in 12 has the disease," Dr Lipworth said.

"We are proud of our wide ranging research program that reaches into and engages with the public to improve the diagnosis and treatment of asthma."