[Relationship between comorbidity and asthma control]

A cross-sectional study to evaluate utility measure and health-related quality of life (HRQoL) among patients with severe uncontrolled asthma in Spain

BACKGROUND AND PURPOSE OF THE STUDY

The utility measure is a method to quantify health-related quality of life according to the preference values that patients attach to their health status. This study aimed to estimate the utility measure of patients with controlled and uncontrolled severe asthma (SA) in Spain, separately. Additionally, other characteristics (sociodemographic, clinical, and healthcare resource use [HCRU]) were also assessed for both SA populations.

METHODS

This cross-sectional study included 159 patients with SA in Spain. Data were collected from medical records and directly from the patients during the study visit. Asthma Control Questionnaire (ACQ)-5 was used to classify patients with controlled and uncontrolled SA.

RESULTS

Most of the patients were female (72.0% uncontrolled SA and 63.6% controlled SA). The mean (SD) EuroQol-5D (EQ-5D-5L) score was 0.88 (0.14) and 0.70 (0.25) in controlled and uncontrolled SA, respectively. The mean (SD) Asthma Quality-of-Life-5D (AQL-5D) score was 0.93 (0.09) and 0.85 (0.09) in controlled and uncontrolled SA, respectively. Emergency visits (19.2 vs. 2.7%) and hospitalizations (7.7% vs. no hospitalization) were more common among uncontrolled SA than controlled SA. Mean (SD) number of visits to primary care and pneumologists in uncontrolled SA vs. controlled SA was 4.1 (2.8) vs. 2.5 (3.0) and 3.7 (3.5) vs. 2.8 (2.2), respectively.

CONCLUSION

The study provides data on utility measures among patients with SA in Spain for the first time. Patients with uncontrolled SA had lower HRQoL and higher HCRU than patients with controlled SA. Therefore, the implementation of measures that improve HRQoL among patients with uncontrolled SA is highly recommended.

Phenotype-Guided Asthma Therapy: An Alternative Approach to Guidelines

Despite recent advances in therapy, a substantial proportion of asthmatics remain not well controlled. The classical stepwise approach to pharmacological therapy in adult asthma recommends that treatment is progressively stepped up by increasing the inhaled corticosteroid (ICS) dose or by adding another controller medication- to achieve symptom control and reduce the risk of exacerbations, and stepped down after a period of control. In general, asthma guideline recommendations do not reflect that there are significant differences between ICS in terms of potency. Moreover, they do not consider efficacy and safety separately, incorrectly assuming that "low" and "high" dose categories inevitably correspond with low and high risk of systemic effects. Another point of criticism is the fact that guidelines do not take into account the inflammatory profile of the patient, although substantial groups of patients with mild and moderate asthma have little evidence of "T2-high" inflammation, and by extension are likely to show a poor response to ICS treatment. On the other hand, the latest version of the Global Initiative for Asthma (GINA) equally recommends regular ICS and ICS/formoterol as needed to prevent exacerbations in step 2 patients, without taking into consideration that the therapeutic objectives (exacerbations, symptoms) may differ between individual patients and that different goals may warrant distinct treatment strategies. In this review, we bring to the table several controversial issues concerning asthma treatment and suggest an alternative proposal that takes into consideration the potential side effects of high ICS doses, the patient's inflammatory profile and the therapeutic goals to be achieved.

A Proposed Approach to Chronic Airway Disease (CAD) Using Therapeutic Goals and Treatable Traits: A Look to the Future

Chronic airflow obstruction affects a wide range of airway diseases, the most frequent of which are asthma, COPD, and bronchiectasis; they are clearly identifiable in their extremes, but quite frequently overlap in some of their pathophysiological and clinical characteristics. This has generated the description of new mixed or overlapping disease phenotypes with no clear biological grounds. In this special article, a group of experts provides their perspective and proposes approaching the treatment of chronic airway disease (CAD) through the identification of a series of therapeutic goals (TG) linked to treatable traits (TT) - understood as clinical, physiological, or biological characteristics that are quantifiable using biomarkers. This therapeutic approach needs validating in a clinical trial with the strategy of identification of TG and treatment according to TT for each patient independently of their prior diagnosis.

Oral health and risk of pneumonia in asthmatic pacients with inhaled treatment

INTRODUCTION AND OBJECTIVE

Asthma is a chronic disease requiring inhaled treatment and in addition it is a risk factor (RF) of pneumonia. In the oropharyngeal cavity there are numerous species of bacteria that could be dragged to the bronco-alveolar level.

OBJECTIVE

to decide whether oral health is a community acquired pneumonia (CAP) RF in asthmatic patients who are taking inhaled treatment, and determining whether the frequency of use of inhalation devices and the type of inhaled drug are CAP RF.

PATIENTS AND METHOD

Case-control study in asthmatic population with inhaled treatment. We recruited 126 asthmatic patients diagnosed with pneumonia by clinical and radiological criteria (cases) and 252 asthmatics not diagnosed with pneumonia during the last year (controls), matched by age. The main factor of study was the General Oral Health Assessment Index (GOHAI) score.

RESULTS

Bivariated analysis showed a statistically significant association of CAP with a GOHAI score≤57 points (poor oral health) (OR 1.69), anticholinergic treatment (OR 2.41), 6 or more inhalations (3.23), chamber use (OR 1.62), FEV₁ (OR 0.98), altered functionality (OR 2.08) and psychiatric disorders or depression (OR 0.41). The multivariated analysis shows an independent association of performing 6 or more inhalations per day (OR 2.74) and functional impairment (OR 1.67).

CONCLUSIONS

The results suggest that poor oral health may be a CAP RF.

Excess medical costs in patients with asthma and the role of comorbidity

Asthmatic patients frequently have comorbidities, but the role of comorbidities in the economic burden of asthma is unclear. We examined the excess direct medical costs, including asthma- and comorbidity-related costs, in patients with asthma.We created a propensity score-matched cohort of patients newly diagnosed with asthma and non-asthmatic comparison subjects, both aged 5-55 years, from health administrative data (1997-2012) in British Columbia, Canada. Health services use records were categorised into 16 major disease categories based on International Classification of Diseases codes. Excess costs (in 2013 Canadian dollars ($)) were estimated as the adjusted difference in direct medical costs between the two groups.Average overall excess costs were estimated at $1058/person-year (95% CI 1006-1110), of which $134 (95% CI 132-136) was attributable to asthma and $689 (95% CI 649-730) to major comorbidity classes. Psychiatric disorders were the largest component of excess comorbidity costs, followed by digestive disorders, diseases of the nervous system, and respiratory diseases other than asthma. Comorbidity-attributable excess costs greatly increased with age but did not increase over the time course of asthma.These findings suggest that both asthma and comorbidity-related outcomes should be considered in formulating evidence-based policies and guidelines for asthma management.

The added effect of comorbidity on health-related quality of life in patients with asthma

PURPOSE

To examine the effect of comorbidities on health-related quality of life (HRQoL) and their interaction with asthma control.

METHODS

In a random sample of adults with asthma, we measured generic (EQ5D) and disease-specific (AQ5D) utility scores. Asthma symptom control was determined using the 2014 Global Initiative for Asthma Management Strategy. Comorbidity scores were calculated using a validated questionnaire. We used two-part regression models to measure the adjusted difference in utility across levels of symptom control and comorbidity scores and to examine the relative role of symptom control and comorbidity in explaining the variation in HRQoL.

RESULTS

A total of 2,299 observations from 460 adult patients (mean age 52 years, 67 % women) were included. Compared to controlled asthma, uncontrolled asthma was associated with -0.018 reduction (95 % CI -0.028, -0.009) in EQ5D and -0.076 reduction (95 % CI -0.115, -0.052) in AQ5D utilities. An increase by one standard deviation in comorbidity score relative to the mean was associated with a change of -0.029 (95 % CI -0.043, -0.016) in EQ5D and -0.010 (95 % CI -0.020, -0.004) in AQLQ utilities. The impact of comorbidity was greater than asthma symptom control in explaining EQ5D variance (12 vs. 1 %) but smaller in explaining AQ5D variance (3 vs. 12 %).

CONCLUSIONS

Generic and disease-specific HRQoL instruments differentially capture the impact of symptom control and comorbidity in asthma. The selection of HRQoL instruments for asthma studies should depend on the prevalence of comorbidity in the target population and the impact of interventions on asthma control and comorbidity.

[Advances in asthma: review of publications in Archivos de Bronconeumología in the last year]

Interest in asthma research among Spanish pneumologists is increasing. In the last year, 22 articles on asthma have been published in Archivos de Bronconeumología, six more than in the previous year. Furthermore, 56 communications were presented at the National Congress of the Spanish Society of Pneumology and Thoracic Surgery and were published in a supplement of the journal, representing 60% more than in the previous year's congress. A critical review of all these articles is provided. The original articles contribute further knowledge on epidemiological and clinical aspects of the disease and basic research. A notable contribution is the publication of two clinical practice guidelines, the Spanish Guideline for the Management of Asthma 2009 and the ALERTA-2 Guideline for the Management of Asthma Exacerbations. These two guidelines represent not only an update but also a change in the methodology used in their drafting, thus improving their scientific quality.

"Causes of death in asthma, COPD and non-respiratory hospitalized patients: a multicentric study"

BACKGROUND

There is limited information on the causes of death in asthma patients.To determine the causes of death in hospitalized asthmatic patients and to compare with those observed in COPD patients and non-respiratory individuals, with a particular interest in associations with previous cardiovascular disease.

METHODS

Retrospective case-control study which analyzed the deaths of all hospitalized patients admitted for any reason during January, April, July and October of 2008 in 13 Spanish centers. Medical records of deceased patients were reviewed, and demographic and clinical data were collected.

RESULTS

A total of 2,826 deaths (mean age 75 years, 56% men) were included in the analysis, of which 82 (2.9%) were of patients with asthma and 283 (10%) with COPD.The most common causes of death in asthma patients were cardiovascular diseases (29.3%), malignancies (20.7%) and infections (14.6%); in COPD patients they were malignancies (26.5%), acute respiratory failure (25.8%) and cardiovascular diseases (21.6%). Asthma, compared to COPD patients, died significantly less frequently from acute respiratory failure and lung cancer. A multivariate logistic regression analysis failed to associate asthma with cardiovascular deaths.

CONCLUSIONS

Cardiovascular disease is the most frequent cause of death among hospitalized asthma patients. The specific causes of death differ between asthma and COPD patients.

Nasal nitric oxide is a marker of poor asthma control

Asthma control, evaluated by symptoms, exacerbations rate and lung function may be greatly influenced by comorbidities, particularly chronic rhinosinusitis (CRS). Measurement of nasal nitric oxide (nNO) is a simple way to assess the severity of CRS. We aimed to analyze the relationship between asthma control and nasal NO. All patients with moderate-to-severe asthma on regular follow-up at our Outpatients' Clinic between November 2009 and April 2010 were included into the study. All patients were evaluated for asthma control by asthma control questionnaire (ACQ) and comorbidities (rhinitis, chronic rhinosinusitis with (CRSwNP) or without nasal polyps, obesity). Exhaled nitric oxide and nNO were obtained in all patients. Eighty-two patients were enrolled (mean age: 48 years, range: 21-80; 42 females). According to ACQ, 53 patients (64.6%) reported controlled asthma. Patients with uncontrolled asthma had lower nNO and higher prevalence of CRSwNP, with a significant correlation between nNO and ACQ. nNO is a biomarker negatively related to asthma control. As low nNO values were associated to CRSwNP, our results indicate that asthma control is highly influenced by this comorbidity.

[Asthma control and obesity: a solid link]

BACKGROUND AND OBJECTIVE

An epidemiological association between obesity and asthma has been confirmed, but its possible link to disease control is controversial. The aim of this study was to investigate if asthma control was related with obesity.

PATIENTS AND METHODS

Asthmatics adult outpatients with good compliance on therapy and correct inhalation technique were included. An Asthma Control Test validated for Spanish population was used to measure asthma control and it was related with: age, sex, forced expiratory volume in one second, smoking, atopy, body mass index (BMI), rhinitis, anxiety and/or depression, bronchiectasis and gastroesophageal reflux. For statistical analysis chi square distribution, Student test and a logistic regression analysis were used.

RESULTS

One hundred and ten patients were included, of whom 41 (37.3%) had BMI ≥ 30 kg/m(2). Poor asthma control was associated, in the bivariate analysis, with: BMI, rhinitis, anxiety-depressive disorders and female sex. In the multivariate analysis, it remained independently associated with: BMI (odds ratio [OR] 3.66, 95% confidence interval [95% CI] 1.49-8.92), rhinitis (OR 2.87, 95% CI 1.18-6.99 and anxiety-depressive disorder (OR 6.45, 95% CI 2.10-20).

CONCLUSIONS

We conclude that there is a link between obesity and poorly controlled asthma, hence weight loss may have major clinical implications.

[A female patient with asthma in the emergency room]

A 20-year-old woman, with intolerance to non-steroid anti-inflammatory drugs (NSAIDs) who was diagnosed of asthma 2 years earlier. Both her mother and brother were asthmatic. Non-smoker. Anosmia and rhinosinusitis symptoms. Several hospitalizations for asthmatic attacks, the last one, one month before in the ICU that did not require mechanical ventilation. Skin tests negative to aeroallergens. Better personal PEF: 450 l/min. Previous treatment: salmeterol/fluticasone 50/500 1 inh/12h. and formoterol p.r.n. She came to the emergency room by ambulance due to evolution of fever, expectoration and headache after having gone to her physician, who had prescribed metamizole and azithromycin. She returned at one hour due to difficult breathing and Sat O(2) 89%. The physical examination showed abdominal breathing, 40 rpm and Sat O(2) 92% with nebulizer at 6 bpm, PEF: 180 l/min, tachycardia at 150 bpm, generalized wheezing. Hemodynamically stable. Blood gases with O(2) to 6 bpm: 7.28 pH, 45 pCO(2), 66pO(2), 21.1 HCO(3), Chest X-ray: no consolidations.

Relationship between gastro-oesophageal reflux and airway diseases: the airway reflux paradigm

Our understanding of the relationship between gastro-oesophageal reflux and respiratory disease has recently undergone important changes. The previous paradigm of airway reflux as synonymous with the classic gastro-oesophageal reflux disease (GORD) causing heartburn has been overturned. Numerous epidemiological studies have shown a highly significant association of the acid, liquid, and gaseous reflux of GORD with conditions such as laryngeal diseases, chronic rhinosinusitis, treatment resistant asthma, COPD and even idiopathic pulmonary fibrosis. However, it has become clear from studies on cough hypersensitivity syndrome that much reflux of importance in the airways has been missed, since it is either non- or weakly acid and gaseous in composition. The evidence for such a relationship relies on the clinical history pointing to symptom associations with known precipitants of reflux. The tools for the diagnosis of extra-oesophageal reflux, in contrast to the oesophageal reflux of GORD, lack sensitivity and reproducibility. Unfortunately, methodology for detecting such reflux is only just becoming available and much additional work is required to properly delineate its role.