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Journal articleWang M, He Y, Hu H, et al., 2026,
Protective role of fatty acid oxidation against epithelial barrier dysfunction in allergic asthma.
, Redox Rep, Vol: 31BACKGROUND: Fatty acid oxidation (FAO) is implicated in lung diseases, but its role in bronchial asthma is not fully understood. We investigated its effect on airway epithelial barrier integrity. METHODS: Using a house dust mite (HDM)-induced murine asthma model and HDM, IL-4, IL-13, or TNF-α stimulated human primary bronchial epithelial cells (BECs) and bronchial epithelial (Beas-2b) cells, we modulated FAO with L-carnitine (agonist) and Etomoxir (inhibitor). BECs and Beas-2b cells were infected with lentivirus-mediated CPT1A shRNA prior to stimulation. Barrier function, mitochondrial oxidative stress, inflammation, and metabolism were assessed. RESULTS: FAO level in lungs negatively correlated with increased inflammation and tissue injury in HDM-induced asthmatic mice (all p < 0.05), while positively regulating tight junction protein expression. In BECs and Beas-2b cells, Etomoxir treatment and CPT1A knockdown exacerbated the impairment of FAO caused by various stimulants (all p < 0.05). Furthermore, FAO negatively regulated HDM/cytokine-induced epithelial barrier damage, hyperactive inflammatory response, and mitochondrial dysfunction in Beas-2b cells (all p < 0.05). In contrast, treatment with L-carnitine significantly alleviated these pathophysiological features in both in vivo and in vitro models. CONCLUSION: FAO plays a protective role in the occurrence and development of asthma by maintaining airway epithelial cell homeostasis and barrier function.
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Journal articleDevulder J, 2026,
Extracellular Vesicle microRNAs From Small Airways Promote Senescence and Fibrosis in COPD
, ERJ Open Research, ISSN: 2312-0541 -
Journal articleHopkinson N, 2026,
The ethics of tobacco control -"good people doing good things"
, Tobacco Control, ISSN: 0964-4563A richer understanding of the ethical basis for ending the tobacco epidemic has the potential to strengthen the case for change. This paper first addresses the way that the two key moral goods of wellbeing and freedom, elements of a “good life”, are limited by tobacco dependence. The limited negative view of freedom as a lack of prohibition is rejected in favour of a view of freedom as capability – what individuals can actually do. Second, arguments around tobacco control are considered through the long-established medical ethics framework of Principlism – an approach that weighs decisions according to their respect for beneficence, non-maleficence, autonomy, and distributive justice. The ethical responsibilities of healthcare and other organisations, as well as government are considered. As are the ethics of the tobacco industry itself, whose products drastically limit human wellbeing and freedom, yet uses moral arguments to promote itself through corporate social responsibility, are considered.The enormous impact of smoking on both wellbeing and freedom, combined with the existence of effective means to end these harms, provides a moral imperative to pursue the Tobacco Endgame.
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Journal articlePan Z, Du Z, Layhadi JA, et al., 2026,
A Novel Phenotype of Mugwort-Associated Delayed Gastrointestinal-Onset Anaphylaxis With Nasal-Ocular Involvement.
, Allergy -
Journal articleAlferes de Lima Headley D, Richardson H, Hennayake C, et al., 2026,
Sputum and oral microbiota profiles are associated with long COVID severity and phenotype post-hospitalisation: a UK multicentre, prospective cohort study.
, Eur Respir JBACKGROUND: Acute COVID-19 alters the airway microbiota. Whether these changes persist post-COVID-19 and contribute to long COVID is unknown. We aimed to describe the microbiota by long COVID severity and subtype, and identify links with inflammation. METHODS: Adults were prospectively recruited to the longitudinal UK Post-hospitalisation COVID-19 study (PHOSP-COVID). Patients were grouped by previously described "severity clusters" (of ongoing health impairments) and symptom subgroups. Oral and sputum microbiota (at 6 months post-discharge) were characterised through 16S ribosomal RNA gene amplicon sequencing, and microbiota diversity was assessed. Co-occurrence network analysis identified keystone taxa. Associations between keystone taxa and plasma inflammatory proteins were assessed through Spearman's rank correlations. RESULTS: 771 participants had their microbiota assessed. Of participants with oral rinses and "severity cluster" assignment (mean age 57.5 years), 278 out of 722 (38.5%) were women. The "very severe" cluster, in which disease was predominantly pulmonary in nature, was associated with a distinct microbiota profile post-COVID-19. Reduced lung function was associated with a distinct oral microbiota profile. Persistent neurocognitive symptoms were associated with a distinct oral microbiota profile, while gastrointestinal symptoms were associated with a distinct sputum microbiota profile. Microbiota keystone taxa shifted to a higher prevalence of lactic acid bacteria associated with worse health outcomes. Lactic acid bacteria abundance was associated with elevated blood inflammatory proteins. CONCLUSION: Distinct oral and sputum microbiota profiles were associated with pulmonary function and with neurocognitive and gastrointestinal symptoms in long COVID. Shifts in keystone microbiota taxa linked with inflammation, based on worse health outcomes, suggest a potential role change for lactic acid bacteria, which may be a
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Journal articleHine J, Bush A, De Simoni A, et al., 2026,
Experiences of financial incentives to improve medication adherence for children and young people with asthma: a qualitative study.
, Arch Dis Child -
Journal articleHasegawa T, Yang F, Kermani N, et al., 2026,
Sputum eosinophil and neutrophil activation biomarkers in severe asthma
, ERJ Open Research, Pages: 00602-2026<jats:sec> <jats:title>Background</jats:title> <jats:p>Asthma is characterized by different inflammatory phenotypes. We hypothesized that sputum eosinophil-derived neurotoxin (EDN), and myeloperoxidase (MPO) or interleukin-8 (IL-8) levels improves the granulocytic characterization of asthma compared to sputum granulocyte counts.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>EDN, IL-8 and MPO were assayed in induced sputum supernatants from patients with severe and mild-to-moderate asthma, and healthy controls. Elevated cut-off values were determined using Youden Index. Asthma patients were stratified in four subgroups based on EDN and IL8 or MPO levels.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p> Sputum EDN, IL-8 and MPO levels were higher in severe asthma (n=193) than in controls (n=40). Optimal cut-offs were 103.5 ng·mL <jats:sup>−1</jats:sup> for EDN, 1150.7 pg·mL <jats:sup>−1</jats:sup> for IL-8 and 220 ng·mL <jats:sup>−1</jats:sup> for MPO. 53 patients (23%) were EDN <jats:sup>High</jats:sup> IL-8 <jats:sup>Low</jats:sup> , 16 (7%) EDN <jats:sup>Low</jats:sup> IL-8 <jats:sup>High</jats:sup> , 112 (49%) EDN <jats:sup>High</jats:sup> IL-8
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Journal articleKlimek L, Torres MJ, Bousquet J, et al., 2026,
Natural Diversity of Grass Pollen in Europe-An EAACI Perspective.
, AllergyGrass pollen, the most clinically relevant outdoor aeroallergen in Europe and worldwide, presents a complex challenge due to the diverse nature of its subspecies. This diversity complicates the interpretation of their contribution to the overall pollen burden during the grass pollen season and the selection of the appropriate allergen immunotherapy. Almost all species of the Pooideae subfamily share important major allergens, namely the allergens of Group 1 and 5, leading to a high level of cross-reactivity at the IgE level. However, the presence of a multitude of additional minor allergens and species-specific epitopes adds to the complexity. Timothy (Phleum pratense), previously considered the most relevant allergen source among grass species, is found during the late-blooming grass pollen season, while symptom severity and pollen concentrations already show several peaks during the early-blooming grass and main grass pollen seasons. Current data suggest a limited regional relevance of timothy grass during the natural grass pollen season in southern Europe from both the aerobiology and allergy perspectives. This review aims to discuss the latest evidence supporting a broad-spectrum approach to best reflect natural grass pollen exposure in allergen immunotherapy, presenting a complex but crucial aspect of allergology.
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Journal articleHine J, Bush A, De Simoni A, et al., 2026,
Financial INcentives to improve Asthma (FINA): a pilot RCT to improve medication adherence for children and young people with asthma.
, Arch Dis ChildOBJECTIVE: To assess effectiveness and feasibility of financial incentives to improve medication adherence for children and young people (CYP) with asthma. DESIGN: Pilot randomised controlled trial measuring adherence in CYP using an electronic monitoring device (EMD) with twice-daily reminders; design supported by patient and public involvement. SETTING: CYP were recruited between 2 and 12 weeks after attendance at an emergency department (ED) following a severe asthma exacerbation. PATIENTS: CYP aged 11-17 years old with asthma, who were prescribed inhaled corticosteroids for at least 6 months prior to their exacerbation, owned their own smartphone and understood verbal and written English. INTERVENTIONS: Intervention CYP received £1 per complete morning/£1 per complete evening inhaler dose(s) for 12 weeks (max £168). Controls received usual care (with EMD and reminder use) with no financial incentives. MAIN OUTCOME MEASURES: adherence, asthma control and psychological outcomes. Feasibility assessed by recruitment, randomisation and intervention delivery indicators. RESULTS: 32 CYP (mean age: 13.4 years (±1.64, SD); 65.6% male) were enrolled; 16 randomised to intervention. After 12 weeks, those who received financial incentives had higher median adherence (73.0%, range: 23.0-89.0%), compared with control (56.0%, range: 7.0-87.0%); this did not reach significance (p=0.077). During follow-up, intervention and control adherence significantly decreased (to 39.0%, range: 0.0-72.0%, p=0.012 and 31.5%, range: 3.0-62.0%, p=0.002, respectively). Study implementation was challenging due to slow recruitment and technological issues. CONCLUSIONS: In this small pilot study, financial incentives were not effective in sustaining adherence. Improved technology is necessary for a definitive study. Future work could explore individual characteristics that contribute to successful financial incentive use in CYP. TRIAL REGISTRATION
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Journal articleHatziagorou E, Bush A, 2026,
Home spirometry in bronchiectasis: when does a measurement become medicine?
, Thorax -
Journal articleYang F, Marshall DC, Howell I, et al., 2026,
Exacerbation trajectories in biologic-eligible severe asthma patients.
, ChestBACKGROUND: Asthma biologics are highly effective in reducing exacerbations. Improvement in exacerbations after biologic initiation is often attributed to treatment effect. RESEARCH QUESTION: What proportion of biologic-eligible severe asthma patients improve without biologic therapy, and what characterises those who remain frequent exacerbators? STUDY DESIGN AND METHODS: Biologic-naïve adults with severe asthma were identified in nationwide UK electronic medical records. Year 0 was defined as the first year patients met severe asthma criteria with ≥3 systemic corticosteroid-treated exacerbations (biologic-eligible). Post-eligibility exacerbation trajectories were identified using longitudinal k-means. Sensitivity analyses included alternative k and a lower exacerbation threshold (≥2/year). Covariates included the highest blood eosinophil count, inhaled corticosteroid (ICS) dose and comorbidities. RESULTS: Among 10,078 biologic-eligible adults (median age 51 years; 71% female), we identified three exacerbation trajectories: (1) Remitting-stable (70%, n=7,091), with sustained improvement to <3 exacerbations/year even though ICS reduced after peak exacerbation year; (2) Chronic-frequent (20%, n=1,969), with persistently frequent exacerbations (median 5/year); (3) Refractory-frequent (10%, n=1,018), with high ongoing oral corticosteroid exposure (median >10 courses/year). Results were consistent across sensitivity analyses. Remitting-stable patients were least likely to have bronchiectasis but were otherwise similar in demographics and allergic comorbidities. Blood eosinophil count was higher in the chronic-frequent group (Year 0 median 0.30×109/L) compared with remitting-stable (0.23×109/L) and refractory-frequent groups (0.21×109/L, p<0.001); this was evident several years before meeting biologic exacerbation criteria. INTERPRETATION: Over two-thirds of biologic-eligible patients improved with standard care alone. Chronic-frequen
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Journal articleDinh CT, Chuang HC, Tran HM, et al., 2026,
Short-Term Effects of PM2.5 Exposure on Hematological and Biochemical Blood Indices in the Middle-Aged and Elderly
, Aerosol and Air Quality Research, Vol: 26, ISSN: 1680-8584Air pollution has been associated with respiratory and cardiovascular diseases; however, its effects on routinely measured blood indices remain incompletely understood. This study examined associations between short-term particulate matter with an aerodynamic diameter of 2.5 μm or less (PM<inf>2.5</inf>) and hematological and biochemical indices in middle-aged and older adults. A study involving 989 adults aged 40 years and older, recruited from the community in Taiwan from 2018 to 2022, assessed hematological (erythrocyte, leukocyte, and thrombocyte) and biochemical (electrolyte levels, renal function, glycemic control, hepatobiliary function, lipid profile, and iron status) indices. PM<inf>2.5</inf> exposure over 1-day, 7-day, and 1-month periods was estimated to evaluate both immediate and lagged effects. Associations between PM<inf>2.5</inf> and blood indices were explored employing linear regression models, adjusted by age, sex, body mass index, smoking status, vegetarian diet, relative humidity, temperature, work status, exercise habits, and comorbidities. Higher PM<inf>2.5</inf> exposure was associated with changes in several hematological and biochemical indices, including lower hematocrit, mean platelet volume, sodium, calcium, magnesium, creatinine, albumin, and iron, and higher mean corpuscular hemoglobin concentration, red cell distribution width, monocytes, and total bilirubin. The magnitude of the effects increased as the exposure period lengthened. Associations were generally more frequent among participants without baseline anemia. Although these modest changes should be interpreted as subclinical biomarker alterations rather than clinical endpoints, they may help characterize early systemic responses to short-term PM<inf>2.5</inf> exposure in community settings.
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Journal articleKhor YH, Luppi F, Adegunsoye A, et al., 2026,
Acute exacerbation in fibrotic interstitial lung disease: an international working group report.
, Am J Respir Crit Care Med, Vol: 212, Pages: 2358-2385Acute exacerbations (AEs) occur both in patients with idiopathic pulmonary fibrosis (IPF) and those with non-IPF fibrotic interstitial lung disease (fILD). These events confer high morbidity and mortality, with a lack of proven effective therapeutic interventions. The objective of this state-of-the-art document is to summarize latest evidence since the 2016 International Working Group Report on AE-IPF, expanding it across the spectrum of all fILDs. A comprehensive literature review on the epidemiology, associated and risk factors, prognosis, and management of AE-fILD is summarized. In addition to revising the AE definition and diagnostic criteria for broad application across different fILDs, a conceptual framework for acute respiratory worsening (ARW) has been proposed to encompass a variety of acute respiratory deteriorations, both related and unrelated to AEs. This allows structured evaluation in both clinical and research settings. The proposed revised definition for AE-fILD is an acute respiratory event characterized by increased respiratory symptoms or signs and associated with radiologic or histologic features consistent with diffuse alveolar damage (with or without superimposed organizing pneumonia) in a patient with known or newly diagnosed fILD. On the other hand, ARW refers to a heterogeneous group of clinical events with acute symptom worsening not attributable to diffuse alveolar damage in patients with fILD, such as pulmonary edema, bronchitis, and pneumonia, although severe pneumonia can trigger AE-fILD. Additionally, we discuss considerations for inclusion of AE as a clinical trial endpoint, as well as research priorities for advancing knowledge on the pathogenic mechanisms, event prediction, risk stratification, and development of drugs and supportive treatments.
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Journal articleSilva AE, Ferrante G, Silveyra P, et al., 2026,
Peripubertal changes in asthma.
, Am J Respir Crit Care Med, Vol: 212, Pages: 2592-2606Asthma is a heterogeneous disease affecting nearly 300 million people around the world. It is the most common chronic respiratory disease of childhood. There are significant sex differences in asthma incidence, severity, and morbidity around the time of puberty. The reasons for these peripubertal changes are still not fully understood, but they are likely multifactorial. In this review, we will discuss several proposed contributing mechanisms, including sex differences in anatomy and development, the effects of sex hormones on airway inflammation and reactivity, the immunomodulatory effects of sex hormones, differences in mucociliary function, and sex differences in genetic and epigenetic factors.
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Journal articleBush A, Ramsey B, 2026,
Cystic fibrosis in 2026: game over, or game on? Introduction to an AJRCCM special section on cystic fibrosis.
, Am J Respir Crit Care Med, Vol: 212, Pages: 2518-2519 -
Journal articlePugashetti JV, Jee AS, Yu AR, et al., 2026,
Mycophenolate and azathioprine in fibrotic interstitial lung disease
, American Journal of Respiratory and Critical Care Medicine, Vol: 212, Pages: 2493-2503, ISSN: 1073-449XRationaleImmunosuppression is routinely used for non–idiopathic pulmonary fibrosis (IPF) interstitial lung diseases (ILDs), despite limited trial evidence and unclear impact on long-term outcomes.ObjectivesTo evaluate whether mycophenolate or azathioprine improves 3-year transplant-free survival and lung function trajectory in fibrotic ILD, including non-IPF idiopathic interstitial pneumonia (IIP), fibrotic hypersensitivity pneumonitis (fHP), and connective tissue disease (CTD)–associated ILD.MethodsWe employed a clone-censor-weighting framework to emulate a randomized controlled trial in this multicenter retrospective study. Each patient was cloned and assigned to immunosuppression initiation within 6 months of enrollment or no initiation strategies and censored when the assigned strategy deviated from observed treatment. Stabilized inverse probability treatment and censoring weights were used.MeasurementsThe primary endpoint was 3-year transplant-free survival assessed with weighted Cox models across treatment strategies. Weighted generalized estimating equations were used to model lung function trajectory.Main resultsAmong 2270 included patients, 18% (186/1022) with non-IPF IIP, 30% (162/544) with fHP, and 31% (221/704) with CTD-ILD were initiated on immunosuppression within 6 months. Immunosuppression was not associated with improved survival within any ILD subtype but was associated with worse survival in non-IPF IIP (hazard ratio [HR] = 1.38; 95% CI, 1.04-1.84) and fHP (HR = 1.62; 95% CI, 1.09-2.40). Immunosuppression was not associated with differential lung function trajectory within any ILD subtype.ConclusionsIn this study, immunosuppression initiation showed no evidence of benefit for 3-year transplant-free survival or lung function and was associated with higher mortality in select fibrotic ILD subtypes. Prospective randomized controlled trials are needed to inform patient care.
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Journal articleWu Z, Yazbeck L, Smith DJF, et al., 2026,
Characterizing Cough and Its Response to Therapy in Hypersensitivity Pneumonitis.
, Chest, Vol: 170, Pages: 1105-1113BACKGROUND: Hypersensitivity pneumonitis (HP) is an immune-mediated interstitial lung disease driven by repeated antigen exposure in susceptible individuals. Cough is a prominent but poorly characterized symptom, especially in relationship to objective measures and treatment response. RESEARCH QUESTION: What are the clinical predictors of cough severity in HP, and how does cough respond to corticosteroid therapy based on subjective and objective assessments? STUDY DESIGN AND METHODS: A prospective cohort of patients with fibrotic HP diagnosed per American Thoracic Society/Japanese Respiratory Society/Asociación Latinoamericana del Tórax guidelines was recruited. Baseline assessments included cough visual analog scale (VAS) and Leicester Cough Questionnaire (LCQ) score. Cough frequency was assessed using the VitaloJAK (Vitalograph) cough monitor in a subset of patients. Multivariable models evaluated predictors of cough severity, and in incident cases, changes in cough outcomes were evaluated after 3 months of corticosteroid therapy. RESULTS: A total of 101 patients were recruited (41 male patients; mean age, 65 years). The median cough VAS was 35 mm (interquartile range [IQR], 14-50 mm) and the median LCQ score was 15.2 (IQR, 13.2-17.4). The median cough count was 8.7/h (range, 0.2-32.1/h; n = 28). Subjective cough scores correlated with objective cough frequency (cough VAS, ρ = 0.69 [P < .001] and LCQ score, ρ = -0.555 [P = .002]). Female sex, reduced FVC, and higher bronchoalveloar lavage lymphocyte fractions were independent predictors of worse cough severity, as measured by cough VAS. Corticosteroids significantly improved cough subjectively (cough VAS, -13.7 mm [P = .002] and LCQ score, +1.9 [P < .001]; n = 44), but did not significantly reduce objective cough frequency (n = 16). Lung function remained unchanged at 3 months. INTERPRETATION: Our results show that cough is a major symptom for patients with HP. Although corticosteroids
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Journal articleLele S, Pillai A, Quayum M, et al., 2026,
Combined Large and Small Airway Obstruction Is Associated With Increased Exacerbation Frequency and Poorer Symptom Control in Persistent Asthma.
, J Allergy Clin Immunol Pract, Vol: 14, Pages: 2348-2355.e3BACKGROUND: Spirometry remains central to the assessment of asthma but may fail to detect small airways dysfunction (SAD), which contributes to considerable symptoms and exacerbation risk. OBJECTIVE: We investigated whether integrating oscillometry with spirometry improves physiological phenotyping and risk stratification in asthma. METHODS: In this retrospective, multicenter study, data from 1497 adults with asthma were analyzed from the Oscillometry Asthma Registry. SAD was defined using the ratio of resistance heterogeneity between 5 and 20 Hz to resistance at 5 Hz ≥19% and airflow obstruction as forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) <70%. Participants were categorized into 4 mutually exclusive groups: (1) group 1-normal oscillometry and normal spirometry, (2) group 2-abnormal oscillometry with normal spirometry, (3) group 3-normal oscillometry with abnormal spirometry, and (4) group 4-abnormal oscillometry and abnormal spirometry. Associations with symptom control, exacerbations, and type 2 inflammatory biomarkers were assessed using multivariable logistic regression. RESULTS: For ≥1 exacerbation, the adjusted odds ratios (aORs) (95% confidence intervals) for group 4 were as follows: versus group 1, 3.19 (2.31, 4.42); versus group 2, 1.99 (1.46, 2.74); and versus group 3, 1.59 (1.07, 2.37). Corresponding aOR values for group 3 were as follows: versus group 2, 1.26 (0.85, 1.86), and versus group 1, 2.01 (1.37, 2.94). The aOR for ≥1 exacerbation for group 2 versus group 1 was 1.60 (1.18, 2.16). Results were similar when using FEV1/FVC <lower limit of normal instead of traditional predicted values. CONCLUSIONS: The combined use of oscillometry and spirometry identifies distinct physiological phenotypes of asthma with clinically meaningful differences in symptom burden and exacerbation risk.
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Journal articleCecchi L, Annesi-Maesano I, Biagioni B, et al., 2026,
EAACI Guidelines on Environmental Science for Allergy and Asthma-Evidence-Based Recommendations for Prevention and Public Health Action to Mitigate the Impact of Pollen Exposure on Respiratory Allergy.
, Allergy, Vol: 81, Pages: 3414-3438Developed using the GRADE methodology, these EAACI guidelines provide evidence-based recommendations on the effectiveness of pollen reduction/avoidance strategies for allergic rhinitis (AR) and asthma, the utility of biomarkers for monitoring pollen-induced asthma and the efficiency of mitigation measures and of public health strategies. Systematic and narrative reviews and health economic analysis support the recommendations. According to GRADE, the certainty of evidence was moderate to very low, therefore conditional recommendations are provided to guide healthcare professionals, patients, and policymakers in developing personalized, preventive, and scalable interventions. Reducing/avoiding exposure to pollen should be recommended to reduce the risk of severe asthma exacerbations. Lung function decrease and exhaled nitric oxide increase may be predictive for pollen-induced asthma exacerbations. Real-time pollen monitoring and pollen concentration-based forecast may be recommended for managing pollen-induced AR and/or asthma. Pollutant information should be included in pollen information systems. Combined forecast (weather, pollen, pollutants) and warning systems might reduce the impact of thunderstorm asthma (TA). Emergency department/asthma-related services should be strengthened during pollen season and in TA. Personalized frameworks covering the types and allergenic potential of pollen, the coaggressors and the vulnerability of each patient are needed in daily practice. The fundamental role of prevention should be further prioritized.
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Journal articleGonzalez-Matamala MF, Patel N, Kahn-Santoro D, et al., 2026,
International survey of parental and patient perspectives on emerging adrenaline devices for community-based management of anaphylaxis: An EAACI task force report.
, Pediatr Allergy Immunol, Vol: 37INTRODUCTION: Intranasal adrenaline has been approved in multiple countries for anaphylaxis treatment, based primarily on pharmacokinetic/pharmacodynamic comparisons to adrenaline autoinjectors (AAIs). AIM: To assess patient and caregiver perspectives regarding emerging non-injectable adrenaline routes. METHODS: Online survey of adults and caregivers of children with food allergy prescribed AAIs, with international dissemination supported by the European Academy of Allergy and Clinical Immunology (February-April 2025). RESULTS: We analyzed 542 responses from caregivers and 224 from adults with food allergy. Effectiveness of adrenaline nasal spray (ANS) compared to AAI was rated "extremely important" by 78% of caregivers and 71% of adults. 48% of caregivers and 42% of adults were "extremely worried" that ANS may not work as well as AAI, and 50% and 44% (respectively) that it may not work well enough. Compared with AAI, respondents were less worried about ANS being painful or difficult to carry, and about fear/embarrassment around use, but more worried about side effects and knowing how to use it. Most anticipated being more comfortable using ANS than AAI, and over half anticipated earlier use during anaphylaxis. Only 17.2% of caregivers and 23.2% of adults preferred to be prescribed ANS only. There was interest in sublingual adrenaline due to portability and reduced needle-related burden, but confidence depended on comparable speed/effectiveness and feasibility during reactions. CONCLUSIONS: Non-injectable adrenaline is attractive to caregivers and adults, and may improve willingness to carry and use adrenaline. However, demand for evidence of effectiveness, safety, and real-world feasibility is high, highlighting important information needs for shared decision-making.
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