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Rationale:  The utility of fractional exhaled nitric oxide ( F  ENO ) suppression (FeNOSuppT) to identify non-adherence to inhaled corticosteroid (ICS) treatment has previously been reported, but whether it can predict clinical outcome remains unclear.    Objectives:  We examined the utility of FeNOSuppT in prediction of progression to biologic agents or discharge from specialist care.    Methods:  FeNOSuppT was measured at home using remote monitoring technology of inhaler use alongside daily  F  ENO  measurement over 7 days. Long-term clinical outcomes in terms of progression to biologic agent or discharge from specialist care were compared for non-suppressors and suppressors.    Measurements and main results:  Of the 162 subjects, 135 successfully completed the test with 81 (60%) positive  F  ENO  suppression tests. Subjects with a negative FeNOSuppT were more likely to proceed to biologic therapy (39 of 54 patients, 72%) compared to those with a positive FeNOSuppT (35 of 81 patients, 43%, p=0.001). In subjects with a positive FeNOSuppT, predictors of progression to biologic therapy included higher dose of maintenance steroid at initial assessment and prior intensive care unit admission. These subjects had a significant rise in  F  ENO  between post-suppression test and follow-up (median, 33 (IQR 25–55)  versus  71 (IQR 24–114); p=0.009), which was not explained by altered corticosteroid dose.    Conclusions:  A negative FeNOSuppT correlates with progression to biologic therapy. A positive FeNOSuppT, with subsequent maintenance of “optimised”  F  ENO , predicts a subgroup of patients in whom asthma control is preserved with adherence to high-dose ICS/long-acting β2 agonist and who can be discharged from specialist care.

Utility of fractional exhaled nitric oxide suppression as a prediction tool for progression to biologic therapy