1
|
Pfeffer PE, Brown T, Chaudhuri R, Faruqi S, Gore R, Heaney LG, Mansur AH, Pantin T, Patel M, Rupani H, Siddiqui S, Vyas A, Busby J. Impact of comorbidities on EQ-5D quality-of-life index in severe asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100286. [PMID: 39071731 PMCID: PMC11277382 DOI: 10.1016/j.jacig.2024.100286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/10/2024] [Accepted: 04/05/2024] [Indexed: 07/30/2024]
Abstract
Background Severe asthma pathology encompasses a wide range of pulmonary and extrapulmonary treatable traits with a high prevalence of comorbidities. Although asthma-specific health-related quality-of-life measures are most sensitive to changes in asthma control, generic measures, such as EQ-5D-5L (EuroQol 5-Dimension 5-Level questionnaire), are potentially better for capturing the impact of comorbidities. Objective We sought to examine the impact of pulmonary and extrapulmonary treatable traits on quality of life at initial severe asthma assessment, and to compare the characteristics of those patients whose quality of life does and does not improve during follow-up at severe asthma centers. Methods Patients' characteristics at baseline assessment within the UK Severe Asthma Registry were compared by EQ-5D-5L utility index quartile. Patients with follow-up review data were stratified by change in EQ-5D-5L utility index from baseline to follow-up, and characteristics similarly examined. Results Patients in the quartiles with worst dysutility at baseline were observed to exhibit more treatable traits and in particular extrapulmonary traits associated with cumulative systemic corticosteroids, including obesity, anxiety/depression, and osteoporosis. In those patients whose quality of life improved over follow-up, a reduction in exacerbations, uncontrolled symptoms, and requirement for maintenance oral corticosteroids were observed. Conclusions Both pulmonary and extrapulmonary treatable traits are important determinants of quality of life in severe asthma. Comorbidities associated with cumulative systemic corticosteroid exposure are particularly associated with worse quality of life, emphasizing the importance of early identification and management of severe asthma before comorbidities develop.
Collapse
Affiliation(s)
- Paul E. Pfeffer
- Barts Health NHS Trust, London, United Kingdom
- Queen Mary University of London, London, United Kingdom
| | - Thomas Brown
- Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
| | - Rekha Chaudhuri
- Gartnavel General Hospital and University of Glasgow, Glasgow, United Kingdom
| | - Shoaib Faruqi
- Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | - Robin Gore
- Addenbrookes Hospital, Cambridge, United Kingdom
| | | | - Adel H. Mansur
- University Hospitals Birmingham NHS Trust, Birmingham, United Kingdom
- University of Birmingham, Birmingham, United Kingdom
| | | | | | - Hitasha Rupani
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Salman Siddiqui
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Aashish Vyas
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - John Busby
- Centre for Public Health, Queen’s University Belfast, Belfast, United Kingdom
| |
Collapse
|
2
|
Tattersall MC, Jarjour NN, Busse PJ. Systemic Inflammation in Asthma: What Are the Risks and Impacts Outside the Airway? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:849-862. [PMID: 38355013 PMCID: PMC11219096 DOI: 10.1016/j.jaip.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/19/2024] [Accepted: 02/02/2024] [Indexed: 02/16/2024]
Abstract
Airway inflammation in asthma has been well recognized for several decades, with general agreement on its role in asthma pathogenesis, symptoms, propensity toward exacerbation, and decline in lung function. This has led to universal recommendation in asthma management guidelines to incorporate the use of inhaled corticosteroid as an anti-inflammatory therapy for all patients with persistent asthma symptoms. However, there has been limited attention paid to the presence and potential impact of systemic inflammation in asthma. Accumulating evidence from epidemiological observations and cohort studies points to a host of downstream organ dysfunction in asthma especially among patients with longstanding or more severe disease, frequent exacerbations, and underlying risk factors for organ dysfunction. Most studies to date have focused on cognitive impairment, depression/anxiety, metabolic syndrome, and cardiovascular abnormalities. In this review, we summarize some of the evidence demonstrating these abnormalities and highlight the proposed mechanisms and potential benefits of treatment in limiting these extrapulmonary abnormalities in patients with asthma. The goal of this commentary is to raise awareness of the importance of recognizing potential extrapulmonary conditions associated with systemic inflammation of asthma. This area of treatment of patients with asthma is a large unmet need.
Collapse
Affiliation(s)
- Matthew C Tattersall
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Paula J Busse
- Department of Medicine, Division of Clinical Immunology, Icahn School of Medicine at Mount Sinai School of Medicine, New York, NY
| |
Collapse
|
3
|
Busse WW, Chupp G, Corbridge T, Stach-Klysh A, Oppenheimer J. Targeting Asthma Remission as the Next Therapeutic Step Toward Improving Disease Control. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:894-903. [PMID: 38320720 DOI: 10.1016/j.jaip.2024.01.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/10/2024] [Accepted: 01/25/2024] [Indexed: 03/09/2024]
Abstract
The long-term goal of asthma management is to achieve disease control, comprising the assessment of 2 main domains: (1) symptom control and (2) future risk of adverse outcomes. Decades of progress in asthma management have correlated with increasingly ambitious disease control targets. Moreover, the introduction of precision medicines, such as biologics, has further expanded the limits of what can be achieved in terms of disease control. It is now believed that clinical remission, a term rarely associated with asthma, may be an achievable treatment goal. An expert framework published in 2020 took the first step toward developing a commonly accepted definition of clinical remission in asthma. However, there remains a widespread discussion about the clinical parameters and thresholds that should be included in a standardized definition of clinical remission. This review aims to discuss on-treatment clinical remission as an aspirational outcome in asthma management, drawing on experiences from other chronic diseases where remission has long been a goal. We also highlight the integral role of shared decision-making between patients and health care professionals and the need for a common understanding of the individual patient journey to remission as foundational elements in reducing disease burden and improving outcomes for patients with asthma.
Collapse
Affiliation(s)
- William W Busse
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin, Madison, Wis
| | - Geoffrey Chupp
- Yale Center for Asthma and Airways Disease (YCAAD), Yale School of Medicine, New Haven, Conn
| | | | | | - John Oppenheimer
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ.
| |
Collapse
|
4
|
McDonald VM, Holland AE. Treatable traits models of care. Respirology 2024; 29:24-35. [PMID: 38087840 DOI: 10.1111/resp.14644] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/22/2023] [Indexed: 12/22/2023]
Abstract
Treatable traits is a personalized approach to the management of respiratory disease. The approach involves a multidimensional assessment to understand the traits present in individual patients. Traits are phenotypic and endotypic characteristics that can be identified, are clinically relevant and can be successfully treated by therapy to improve clinical outcomes. Identification of traits is followed by individualized and targeted treatment to those traits. First proposed for the management of asthma and chronic obstructive pulmonary disease (COPD) the approach is recommended in many other areas of respiratory and now immunology medicine. Models of care for treatable traits have been proposed in different diseases and health care setting. In asthma and COPD traits are identified in three domains including pulmonary, extrapulmonary and behavioural/lifestyle/risk-factors. In bronchiectasis and interstitial lung disease, a fourth domain of aetiological traits has been proposed. As the core of treatable traits is personalized and individualized medicine; there are several key aspects to treatable traits models of care that should be considered in the delivery of care. These include person centredness, consideration of patients' values, needs and preferences, health literacy and engagement. We review the models of care that have been proposed and provide guidance on the engagement of patients in this approach to care.
Collapse
Affiliation(s)
- Vanessa M McDonald
- Centre of Excellence in Treatable Traits, National Health and Medical Research Council, Newcastle, New South Wales, Australia
- School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Anne E Holland
- Centre of Excellence in Treatable Traits, National Health and Medical Research Council, Newcastle, New South Wales, Australia
- Department of Immunology, Respiratory Research@Alfred, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Melbourne, Victoria, Australia
- Physiotherapy, Alfred Health, Melbourne, Victoria, Australia
| |
Collapse
|
5
|
Crawford AL, Setty N, Kyle B, Baumwol K, Blakey JD. Untangling asthma, inducible laryngeal obstruction, and dysfunctional breathing in a competitive sportsperson. Respirol Case Rep 2024; 12:e01282. [PMID: 38269313 PMCID: PMC10807984 DOI: 10.1002/rcr2.1282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 01/09/2024] [Indexed: 01/26/2024] Open
Abstract
A young woman with historically mild asthma experienced worsening breathlessness and cough with competitive ice skating. Despite optimizing and escalating treatment for her eosinophilic asthma, and addressing known exacerbating factors, her symptoms remained uncontrolled and refractory to bronchodilators and oral corticosteroids. Objective testing suggested her presentation was out of keeping with asthma alone, and she was suspected to have comorbid dysfunctional breathing and/or inducible laryngeal obstruction. Evidence was required to confirm the diagnoses, assess each condition's contribution to her symptom burden, and guide therapy. As exercise was a predominant trigger, she proceeded to cardiopulmonary exercise test with continuous laryngoscopy during exercise (CPET-CLE). Testing confirmed the presence of two forms of inducible laryngeal obstruction and evidence of hyperventilation predominant dysfunctional breathing. This case highlights the importance of identifying coexisting conditions in difficult-to-treat asthma, and the value of structured multidisciplinary assessment in referral centres for such individuals.
Collapse
Affiliation(s)
- Alice L. Crawford
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
- Medical SchoolCurtin UniversityPerthWestern AustraliaAustralia
| | - Niranjan Setty
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Brooke Kyle
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Kate Baumwol
- Department of Speech PathologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - John D. Blakey
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
- Medical SchoolCurtin UniversityPerthWestern AustraliaAustralia
| |
Collapse
|
6
|
Lewthwaite H, Byrne A, Brew B, Gibson PG. Treatable traits for long COVID. Respirology 2023; 28:1005-1022. [PMID: 37715729 DOI: 10.1111/resp.14596] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/31/2023] [Indexed: 09/18/2023]
Abstract
Long COVID, or post-acute COVID-19 sequelae, is experienced by an estimated one in eight adults following acute COVID-19. Long COVID is a new and complex chronic health condition that typically includes multiple symptoms that cross organ systems and fluctuate over time; a one-size-fits-all approach is, therefore, not likely to be appropriate nor relevant for long COVID treatment. 'Treatable Traits' is a personalized medicine approach, purpose-built to address the complexity and heterogeneity of complex chronic conditions. This comprehensive review aimed to understand how a treatable traits approach could be applied to long COVID, by first identifying the most prevalent long COVID treatable traits and then the available evidence for strategies to target these traits. An umbrella review of 22 systematic reviews identified 34 symptoms and complications common with long COVID, grouped into eight long COVID treatable trait clusters: neurological, chest, psychological, pain, fatigue, sleep impairment, functional impairment and other. A systematic review of randomized control trials identified 18 studies that explored different intervention approaches for long COVID prevention (k = 4) or management (k = 14). While a single study reported metformin as effective for long COVID prevention, the findings need to be replicated and consensus is required around how to define long COVID as a clinical trial endpoint. For long COVID management, current evidence supports exercise training or respiratory muscle training for long COVID treatable traits in the chest and functional limitation clusters. While there are studies exploring interventions targeting other long COVID treatable traits, further high-quality RCTs are needed, particularly targeting treatable traits in the clusters of fatigue, psychological, pain and sleep impairment.
Collapse
Affiliation(s)
- Hayley Lewthwaite
- Centre of Research Excellence Treatable Traits, College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia
- Asthma and Breathing Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Anthony Byrne
- Heart Lung Clinic, Department of Thoracic Medicine St Vincent's Hospital and Clinical School University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Bruce Brew
- Peter Duncan Neuroscience Research Unit, St. Vincent's Centre for Applied Medical Research, Darlinghurst, New South Wales, Australia
- Department of Neurology and Immunology, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Faculty of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Peter G Gibson
- Centre of Research Excellence Treatable Traits, College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia
- Asthma and Breathing Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| |
Collapse
|
7
|
Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
Collapse
Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
| | | |
Collapse
|
8
|
Pfeffer PE, Rupani H, De Simoni A. Bringing the treatable traits approach to primary care asthma management. FRONTIERS IN ALLERGY 2023; 4:1240375. [PMID: 37799134 PMCID: PMC10548136 DOI: 10.3389/falgy.2023.1240375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023] Open
Abstract
Asthma continues to be a major cause of illness with a significant mortality, despite its increasing range of treatments. Adoption of a treatable traits approach in specialist centres has led to improvements in control of asthma and reduced exacerbations in patients with severe asthma. However, most patients with this illness, particularly those with mild-to-moderate asthma, are cared for in primary care according to guidelines that emphasise the use of pharmacotherapeutic ladders uniformly implemented across all patients. These pharmacotherapeutic ladders are more consistent with a "one-size-fits-all" approach than the treatable traits approach. This can be harmful, especially in patients whose symptoms and airway inflammation are discordant, and extra-pulmonary treatable traits are often overlooked. Primary care has extensive experience in patient-centred holistic care, and many aspects of the treatable traits approach could be rapidly implemented in primary care. Blood eosinophil counts, as a biomarker of the treatable trait of eosinophilia, are already included in routine haematology tests and could be used in primary care to guide titration of inhaled corticosteroids. Similarly, poor inhaler adherence could be further assessed and managed in primary care. However, further research is needed to guide how some treatable traits could feasibly be assessed and/or managed in primary care, for example, how to best manage patients in primary care, who are likely suffering from breathing pattern disorders and extra-pulmonary treatable traits, with frequent use of their reliever inhaler in the absence of raised T2 biomarkers. Implementation of the treatable traits approach across the disease severity spectrum will improve the quality of life of patients with asthma but will take time and research to embed across care settings.
Collapse
Affiliation(s)
- Paul E. Pfeffer
- Department of Respiratory Medicine, Barts Health NHS Trust, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Hitasha Rupani
- Department of Respiratory Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Anna De Simoni
- Wolfson Institute of Population Health and Asthma UK Centre for Applied Research, Queen Mary University of London, London, United Kingdom
| |
Collapse
|
9
|
Gibson PG, McDonald VM, Thomas D. Treatable traits, combination inhaler therapy and the future of asthma management. Respirology 2023; 28:828-840. [PMID: 37518933 DOI: 10.1111/resp.14556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023]
Abstract
The landscape of asthma has considerably changed in the last decade. Effective medications and inhaler devices have been developed and integrated into the asthma pharmacopoeia, but unfortunately, the proportion of uncontrolled patients remains unacceptably high. This is now recognized to be mainly due to the inappropriate use of medications or inhaler devices, heterogeneity of the disease or other factors contributing to the disease. Currently, inhaled corticosteroids (ICS), with or without long-acting beta agonists (LABA), are the cornerstone of asthma management, and recently international guidelines recognized the importance of combination inhaler therapy (ICS/LABA) even in mild asthma. In future, ultra-long-acting personalized medications and smart inhalers will complement combination inhaler therapy in order to effectively addresses issues such as adherence, inhaler technique and polypharmacy (both of drugs and devices). Asthma is now acknowledged as a multifaceted cluster of disorders and the treatment model has evolved from one-size-fits-all to precision medicine approaches such as treatable traits (TTs, defined as measurable and treatable clinically important factors) which encourages the quality use of medications and identification and management of all underlying behavioural and biological treatable risk factors. TT requires research and validation in a clinical context and the implementation strategies and efficacy in various settings (primary/secondary/tertiary care, low-middle income countries) and populations (mild/moderate/severe asthma) are currently evolving. Combination inhaler therapy and the TTs approach are complementary treatment approaches. This review examines the current status of personalized medicine and combination inhaler therapy, and describes futuristic views for these two strategies.
Collapse
Affiliation(s)
- Peter G Gibson
- Centre of Excellence in Treatable Traits, College of Health, Medicine and Wellbeing, University of Newcastle, Hunter Medical Research Institute Asthma and Breathing Program, Newcastle, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Vanessa M McDonald
- Centre of Excellence in Treatable Traits, College of Health, Medicine and Wellbeing, University of Newcastle, Hunter Medical Research Institute Asthma and Breathing Program, Newcastle, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Dennis Thomas
- Centre of Excellence in Treatable Traits, College of Health, Medicine and Wellbeing, University of Newcastle, Hunter Medical Research Institute Asthma and Breathing Program, Newcastle, New South Wales, Australia
| |
Collapse
|
10
|
Khan J, Moran B, McCarthy C, Butler MW, Franciosi AN. Management of comorbidities in difficult and severe asthma. Breathe (Sheff) 2023; 19:230133. [PMID: 38020342 PMCID: PMC10644109 DOI: 10.1183/20734735.0133-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Difficult-to-treat and severe asthma are challenging clinical entities. In the face of suboptimal asthma control, the temptation for clinicians is to reflexively escalate asthma-directed therapy, including increasing exposure to corticosteroids and commencement of costly but potent biologic therapies. However, asthma control is objectively and subjectively assessed based on measurable parameters (such as exacerbations or variability in pulmonary physiology), symptoms and patient histories. Crucially, these features can be confounded by common untreated comorbidities, affecting clinicians' assessment of asthma treatment efficacy.
Collapse
Affiliation(s)
- Jehangir Khan
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
- Shared first authorship
| | - Barry Moran
- St Vincent's University Hospital, Dublin, Ireland
- Shared first authorship
| | - Cormac McCarthy
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
| | - Marcus W. Butler
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
- Shared senior authorship
| | - Alessandro N. Franciosi
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
- Shared senior authorship
| |
Collapse
|
11
|
Climente-Martí M, Alvarado-Arenas M, Ausín-Herrero P, Benito-Bernáldez C, Carballo-Martínez N, Delgado-Romero J. Advances in the work of multidisciplinary teams for the care of patients with severe uncontrolled asthma. A post-COVID vision (TEAM 2.0 project). FARMACIA HOSPITALARIA 2023; 47:168-174. [PMID: 37268480 DOI: 10.1016/j.farma.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 01/26/2023] [Accepted: 03/06/2023] [Indexed: 06/04/2023] Open
Abstract
Asthma is a chronic respiratory disease with a high health, social and economic impact, particularly in the case of Severe Uncontrolled Asthma (SUA). For this reason, new strategies are especially necessary to improve its approach, with a personalized approach to each patient and from a multidisciplinary perspective, in addition to integrating the new telemedicine and telepharmacy practices promoted as a result of the COVID-19 pandemic. In this context, the TEAM 2.0 project ("Work in Multidisciplinary Asthma Teams") has been developed, following the TEAM project carried out in 2019, with the aim of updating and prioritizing good multidisciplinary work practices in SUA in a post pandemic context and analyze the progress made. A coordinating group, made up of eight multidisciplinary teams of hospital pharmacists, pulmonologists, and allergists, carried out an updated bibliographic review, sharing of good multidisciplinary practices, and analysis of advances. Through five regional meetings with other experts with experience in SUA, the good practices identified were shared and subjected to debate, evaluation and prioritization. In total, 23 good multidisciplinary work practices in SUA, grouped into five work areas: 1) Organization of work in multidisciplinary teams, 2) Patient education, self-management and adherence, 3) Health results, data monitoring and persistence, 4) Telepharmacy and experiences implemented during the COVID-19 pandemic and 5) Training and research, were evaluated and prioritized by 57 professionals from the field of Hospital Pharmacy, Pulmonology, Allergology and Nursing. This work has made it possible to update the roadmap of priority actions to continue advancing in optimal models of care for patients with AGNC in a post-COVID-19 context.
Collapse
Affiliation(s)
- Mónica Climente-Martí
- Servicio de Farmacia Hospitalaria, Hospital Universitario Doctor Peset, Valencia, España.
| | | | | | | | | | - Julio Delgado-Romero
- Servicio de Alergología, Hospital Universitario Virgen Macarena, Sevilla, España
| |
Collapse
|
12
|
Climente-Martí M, Alvarado-Arenas M, Ausín-Herrero P, Benito-Bernáldez C, Carballo-Martínez N, Delgado-Romero J. [Translated article] Advances in the work of multidisciplinary teams for the care of patients with severe uncontrolled asthma. A post-COVID vision (TEAM 2.0 project). FARMACIA HOSPITALARIA 2023; 47:T168-T174. [PMID: 37453918 DOI: 10.1016/j.farma.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 01/26/2023] [Accepted: 03/06/2023] [Indexed: 07/18/2023] Open
Abstract
Asthma is a chronic respiratory disease with a high health, social and economic impact, particularly in the case of Severe Uncontrolled Asthma (SUA). For this reason, new strategies are especially necessary to improve its approach, with a personalized approach to each patient and from a multidisciplinary perspective, in addition to integrating the new telemedicine and telepharmacy practices promoted as a result of the COVID-19 pandemic. In this context, the TEAM 2.0 project ("Work in Multidisciplinary Asthma Teams") has been developed, following the TEAM project carried out in 2019, with the aim of updating and prioritizing good multidisciplinary work practices in SUA in a post pandemic context and analyze the progress made. A coordinating group, made up of eight multidisciplinary teams of hospital pharmacists, pulmonologists, and allergists, carried out an updated bibliographic review, sharing of good multidisciplinary practices, and analysis of advances. Through five regional meetings with other experts with experience in SUA, the good practices identified were shared and subjected to debate, evaluation and prioritization. In total, 23 good multidisciplinary work practices in SUA, grouped into five work areas: 1) Organization of work in multidisciplinary teams, 2) Patient education, self-management and adherence, 3) Health results, data monitoring and persistence, 4) Telepharmacy and experiences implemented during the COVID-19 pandemic and 5) Training and research, were evaluated and prioritized by 57 professionals from the field of Hospital Pharmacy, Pulmonology, Allergology and Nursing. This work has made it possible to update the roadmap of priority actions to continue advancing in optimal models of care for patients with AGNC in a post-COVID-19 context.
Collapse
Affiliation(s)
- Mónica Climente-Martí
- Servicio de Farmacia Hospitalaria, Hospital Universitario Doctor Peset, Valencia, Spain.
| | | | | | | | | | | |
Collapse
|
13
|
Janssen SMJ, van Helvoort HAC, Tjalma TA, Antons JC, Djamin RS, Simons SO, Spruit MA, van 't Hul AJ. Impact of Treatable Traits on Asthma Control and Quality of Life. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1823-1833.e4. [PMID: 36893847 DOI: 10.1016/j.jaip.2023.02.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 12/08/2022] [Accepted: 02/26/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Many adult patients with asthma have uncontrolled disease and impaired quality of life, despite current asthma-specific drug therapies. OBJECTIVE This study aimed to investigate the prevalence of 9 traits in patients with asthma, their associations with disease control and quality of life, and referral rates to nonmedical health care professionals. METHODS Retrospectively, data from patients with asthma were collected in 2 Dutch hospitals (Amphia Breda and RadboudUMC Nijmegen). Adult patients without exacerbation <3 months who were referred for a first-ever elective, outpatient, hospital-based diagnostic pathway were deemed eligible. Nine traits were assessed: dyspnea, fatigue, depression, overweight, exercise intolerance, physical inactivity, smoking, hyperventilation, and frequent exacerbations. To assess the likelihood of having poor disease control or decreased quality of life, the odds ratio (OR) was calculated per trait. Referral rates were assessed by checking patients' files. RESULTS A total of 444 adults with asthma were studied (57% women, age: 48 ± 16 years, forced expiratory volume in 1 second: 88% ± 17% predicted). Most patients (53%) were found to have uncontrolled asthma (Asthma Control Questionnaire ≥1.5 points) and decreased quality of life (Asthma Quality of Life Questionnaire <6 points). Generally, patients had 3.0 ± 1.8 traits. Severe fatigue was most prevalent (60%) and significantly increased the likelihood of having uncontrolled asthma (OR: 3.0, 95% confidence interval [CI]: 1.9-4.7) and decreased quality of life (OR: 4.6, 95% CI: 2.7-7.9). Referrals to nonmedical health care professionals were low; most referrals were to a respiratory-specialized nurse (33%). CONCLUSION Adult patients with asthma with a first-ever referral to a pulmonologist frequently exhibit traits justifying the deployment of nonpharmacological interventions, especially in those with uncontrolled asthma. However, referrals to appropriate interventions appeared infrequent.
Collapse
Affiliation(s)
- Steffi M J Janssen
- Basalt Rehabilitation Centre, Department of Pulmonary Rehabilitation, Leiden, the Netherlands; Department of Pulmonary Diseases, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+) NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, the Netherlands.
| | - Hanneke A C van Helvoort
- Department of Pulmonary Diseases, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tjitske A Tjalma
- Department of Pulmonary Diseases, Amphia Hospital, Breda, the Netherlands
| | - Jeanine C Antons
- Department of Pulmonary Diseases, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Remco S Djamin
- Department of Pulmonary Diseases, Amphia Hospital, Breda, the Netherlands
| | - Sami O Simons
- Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+) NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, the Netherlands
| | - Martijn A Spruit
- Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+) NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, the Netherlands; Department of Research and Development, CIRO, Horn, the Netherlands
| | - Alex J van 't Hul
- Department of Pulmonary Diseases, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
14
|
Simões Cunha M, Amaral R, Pereira AM, Almeida R, Alves-Correia M, Loureiro CC, Lopes C, Carvalho J, Ribeiro C, Vidal C, Antolín-Amérigo D, Pinto D, Ferreira-Magalhães M, Vasconcelos MJ, Lozoya C, Santos N, Cardia F, Taborda-Barata L, Ferreira R, Morais Silva P, Ferreira TM, Câmara R, Silva E, Bordalo D, Guimarães C, Calix MJ, da Silva S, Marques ML, Morete A, Nunes C, Vieira C, Páscoa R, Alves A, Marques JV, Reis B, Monteiro L, Monteiro R, Cepa M, Valentim B, Coelho DS, Fernandes S, Meireles P, Aguiar MA, Mourão AR, Fonseca JA, Jácome C. Symptoms of anxiety and depression in patients with persistent asthma: a cross-sectional analysis of the INSPIRERS studies. BMJ Open 2023; 13:e068725. [PMID: 37147092 PMCID: PMC10163458 DOI: 10.1136/bmjopen-2022-068725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES Anxiety and depression are relevant comorbidities in asthma, but, in Portugal and Spain, data on this topic are scarce. We assessed, in patients with asthma, the frequency of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) and the European Quality of Life Five Dimension Questionnaire (EQ-5D); the level of agreement between these questionnaires, and the factors associated with these symptoms. METHODS This is a secondary analysis of the INSPIRERS studies. A total of 614 adolescents and adults with persistent asthma (32.6±16.9 years, 64.7% female) were recruited from 30 primary care centres and 32 allergy, pulmonology and paediatric clinics. Demographic and clinical characteristics, HADS and EQ-5D were collected. A score ≥8 on Hospital Anxiety and Depression Scale-Anxiety/Hospital Anxiety and Depression Scale-Depression or a positive answer to EQ-5D item 5 indicated the presence of these symptoms. Agreement was determined by Cohen's kappa. Two multivariable logistic regressions were built. RESULTS According to HADS, 36% of the participants had symptoms of anxiety and 12% of depression. According to EQ-5D, 36% of the participants had anxiety/depression. The agreement between questionnaires in identifying anxiety/depression was moderate (k=0.55, 95% CI 0.48 to 0.62). Late asthma diagnosis, comorbidities and female gender were predictors of anxiety/depression, while better asthma control, health-related quality of life and perception of health were associated with lower odds for anxiety/depression. CONCLUSION At least 1/3 of the patients with persistent asthma experience symptoms of anxiety/depression, showing the relevance of screening these disorders in patients with asthma. EQ-5D and HADS questionnaires showed a moderate agreement in the identification of anxiety/depression symptoms. The identified associated factors need to be further investigated in long-term studies.
Collapse
Affiliation(s)
- Mafalda Simões Cunha
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rita Amaral
- Allergy Unit, Instituto and Hospital CUF, Porto, Portugal
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Cardiovascular and Respiratory Sciences, Porto Health School, Polytechnic Institute of Porto, Porto, Portugal
- Department of Women's and Children's Health, Paediatric Research, Uppsala University, Uppsala, Sweden
| | - Ana Margarida Pereira
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Allergy Unit, Instituto and Hospital CUF, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Rute Almeida
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Magna Alves-Correia
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Allergy Unit, Instituto and Hospital CUF, Porto, Portugal
| | - Cláudia Chaves Loureiro
- Pulmonology Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristina Lopes
- Basic and Clinic Immunology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Immuno-allergology, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
| | - Joana Carvalho
- Serviço de Pediatria, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
| | - Carmelita Ribeiro
- Serviço de Imunoalergologia, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carmen Vidal
- Servicio de Alergia, Complejo Hospitalario Universitario de Santiago, Santiago de Compostella, Spain
| | - Dario Antolín-Amérigo
- Servicio de Alergia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Diana Pinto
- Serviço de Pediatria, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Manuel Ferreira-Magalhães
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
- Serviço de Pediatria, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Maria João Vasconcelos
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Carlos Lozoya
- Allergy, Hospital Amato Lusitano, Unidade Local de Saúde de Castelo Branco, Castelo Branco, Portugal
| | - Natacha Santos
- Serviço de Imunoalergologia, Centro Hospitalar Universitário do Algarve, Portimão, Portugal
| | - Francisca Cardia
- Unidade de Saúde Familiar Terras de Azurara, Agrupamento de Centros de Saúde Dão Lafões, Mangualde, Portugal
| | - Luís Taborda-Barata
- CICS-UBI Centro de Investigação em Ciências da Saúde - Health Sciences Research Centre & UBIAir - Clinical & Experimental Lung Centre, University of Beira Interior, Covilha, Portugal
- Department of Allergy & Clinical Immunology, Cova da Beira University Hospital Centre, Covilhã, Portugal
| | - Rosário Ferreira
- Departamento de Pediatria, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Lisboa, Portugal
| | | | - Tania Monteiro Ferreira
- Unidade de Saúde Familiar Progresso e Saúde, Agrupamento de Centros de Saúde Baixo Mondego, Tocha, Portugal
| | - Raquel Câmara
- Serviço de Pneumologia, Hospital Nossa Senhora do Rosário, Centro Hospitalar Barreiro Montijo, Barreiro, Portugal
| | - Eurico Silva
- Unidade de Saúde Familiar João Semana, Agrupamento de Centros de Saúde de Baixo Vouga, Ovar, Portugal
| | - Diana Bordalo
- Serviço de Pediatria, Unidade Hospitalar de Famalicão, Centro Hospitalar do Médio Ave, Vila Nova de Famalicão, Portugal
| | - Cristina Guimarães
- Unidade de Cuidados de Saúde Personalizados Norte (Arnaldo Sampaio), Agrupamento de Centros de Saúde Pinhal Litoral, Monte Redondo, Portugal
| | - Maria José Calix
- Serviço de Pediatria, Hospital de São Teotónio, Centro Hospitalar Tondela Viseu, Viseu, Portugal
| | - Sofia da Silva
- Unidade de Saúde Familiar Cuidarte, Unidade Local de Saúde do Alto Minho, Portuzelo, Portugal
| | - Maria Luís Marques
- Serviço de Imunoalergologia, Hospital da Senhora da Oliveira, Guimarães, Guimaraes, Portugal
| | - Ana Morete
- Allergy Unit, Instituto and Hospital CUF, Porto, Portugal
- Serviço de Imunoalergologia, Hospital Infante D Pedro, Centro Hospitalar Baixo Vouga, Aveiro, Portugal
| | - Carlos Nunes
- Centro de Imunoalergologia do Algarve, Portimão, Portugal
| | - Cláudia Vieira
- Unidade de Saúde Familiar Corgo, Agrupamento de Centros de Saúde Douro I - Marão e Douro Norte, Vila Real, Portugal
| | - Rosália Páscoa
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, Porto, Portugal
- Unidade de Saúde Familiar Homem do Leme, ACeS Porto Ocidental, Porto, Portugal
| | - Adelaide Alves
- Serviço de Pneumologia, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - José Varanda Marques
- Unidade de Saúde Familiar Viseu-Cidade, Agrupamento de Centros de Saúde do Dão Lafões, Viseu, Portugal
| | - Bruno Reis
- Unidade de Cuidados Saúde Personalizados Sicó, Agrupamento de Centros de Saúde Pinhal Litoral, Leiria, Portugal
| | - Luís Monteiro
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- USF Esgueira +, ACES Baixo Vouga, Esgueira, Portugal
| | - Rosário Monteiro
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
- Unidade de Saúde Familiar Homem do Leme, ACeS Porto Ocidental, Porto, Portugal
| | - Margarida Cepa
- Unidade de Saúde Familiar Marquês, ACES Pinhal Litoral, Pombal, Portugal
| | - Bruno Valentim
- Unidade de Saúde Familiar Condeixa, ACES Baixo Mondego, Condeixa-a-Nova, Portugal
| | - Daniela Sousa Coelho
- Unidade de Cuidados de Saúde Personalizados de Amarante, ACES Tâmega I - Baixo Tâmega, Amarante, Portugal
| | - Sara Fernandes
- Unidade de Saúde Familiar Bracara Augusta, ACES Cávado I, Braga, Portugal
| | - Patrícia Meireles
- Unidade de Saúde Familiar Almedina, ACES Douro II - Douro Sul, Lamego, Portugal
| | - Margarida Abreu Aguiar
- Unidade de Saúde Familiar Valongo, ACES Grande Porto III - Maia / Valongo, Valongo, Portugal
| | - Ana Rita Mourão
- Unidade de Saúde Familiar Canelas, ACES Grande Porto VIII - Espinho / Gaia, Vila Nova de Gaia, Portugal
| | - Joao A Fonseca
- Allergy Unit, Instituto and Hospital CUF, Porto, Portugal
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
- MEDIDA - Medicina, Educação, Investigação, Desenvolvimento e Avaliação, Porto, Portugal
| | - Cristina Jácome
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
| |
Collapse
|
15
|
Agusti A, Gibson PG, McDonald VM. Treatable Traits in Airway Disease: From Theory to Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:713-723. [PMID: 36737342 DOI: 10.1016/j.jaip.2023.01.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/16/2022] [Accepted: 01/03/2023] [Indexed: 02/04/2023]
Abstract
Chronic airway diseases such as asthma and chronic obstructive pulmonary disease are prevalent and complex conditions that often coexist in the same patient. To address this complexity in clinical practice, and to move forward toward personalized and precision medicine of airway diseases, a strategy based on the identification and treatment of so-called "treatable traits" (TTs) has been proposed. A TT is a recognizable phenotypic or endotypic characteristic that can be assessed and successfully targeted by therapy to improve a clinical outcome in a patient with airway disease. Importantly, TTs can coexist in the same patient, so they are not mutually exclusive. The TT strategy proposes to investigate in each individual patient with chronic airway disease the number and type of TTs present and to treat each of them according to guideline recommendations. This strategy is agnostic (ie, independent) to the traditional diagnostic labels (asthma, chronic obstructive pulmonary disease), so it can be applied to any patient with airway disease. Currently, there is firm evidence supporting the adequacy and validity of the TT strategy. Here, we review the current state of the art of this topic, first by presenting its theoretical background and then by discussing how to best implement it in clinical practice.
Collapse
Affiliation(s)
- Alvar Agusti
- Respiratory Institute, Hospital Clinic, Universitat de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
| | - Peter G Gibson
- Centre of Excellence in Treatable Traits, College of Health, Medicine and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Vanessa M McDonald
- Centre of Excellence in Treatable Traits, College of Health, Medicine and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
| |
Collapse
|
16
|
Almonacid C, Fitas E, Sánchez-Covisa J, Gutiérrez H, Rebollo P. Geographical differences in the use of oral corticosteroids in patients with severe asthma in Spain: heat map based on existing databases analyses. BMC Pulm Med 2023; 23:3. [PMID: 36600236 PMCID: PMC9812540 DOI: 10.1186/s12890-022-02295-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 12/22/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Although there are currently alternative treatments to the long-term use of oral corticosteroids (OCS) in severe asthma, recent studies show excessive use depending on geography and differences in medical practice. The objective of the study was to describe the differences in OCS use for severe asthma across the Spanish geography. METHODS This is a real-world study using existing databases (year 2019): longitudinal patient database (EMR), based on electronic medical records, and database of pharmacological consumption (Sell-in) in basic healthcare areas. With EMR, the percentage of OCS prescriptions corresponding to patients with severe asthma (ICD-9 "asthma" and prescription of biological treatment and/or high dose of inhaled corticosteroids/long-acting inhaled β2 agonists) was calculated. This percentage was transferred to the OCS consumption of each basic healthcare area as reported in the Sell-in database and a national heat map was created. The estimation of OCS use in patients with severe asthma per 100,000 inhabitants for each region was calculated by grouping basic healthcare areas and the mean OCS use per patient for different regions in Spain was also estimated. RESULTS Patients with severe asthma in Spain were mostly female (69.6%), with a mean age (SD) of 57.6 years (18.01). Median time (Pc25-Pc75) since asthma diagnosis was 83.1 months (34.65-131.56). Of all patients with OCS prescriptions in 2019 identified in EMR, 4.4% corresponded to patients with severe asthma. Regions with the highest OCS use were Asturias, Andalucía, and Galicia, whereas those with the lowest use were Navarra, Baleares, Madrid and País Vasco. The mean OCS use per patient with severe asthma in 2019 throughout Spain was 1099.85 mg per patient, ranging from 782.99 mg in Navarra to 1432.64 in Asturias. CONCLUSIONS There are geographical differences between Spanish regions with respect to the use of OCS in patients with severe asthma. The national mean consumption of OCS per patient with severe asthma and year is above the limits that indicate good asthma control.
Collapse
Affiliation(s)
- Carlos Almonacid
- grid.418888.50000 0004 1766 1075Pulmonology Unit, Complejo Hospitalario de Toledo, Av. del Río Guadiana, 45007 Toledo, Spain
| | | | | | | | | |
Collapse
|
17
|
Ryu HJ, Lee S, Chung JH. Association between asthma and generalized anxiety disorder-7 (GAD-7) in Korean adolescents. J Asthma 2023; 60:123-129. [PMID: 35060429 DOI: 10.1080/02770903.2022.2032137] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Asthma is known to be associated with a variety of psychological disorders, such as anxiety, but the association between adolescent asthma and anxiety has not been investigated in detail. METHODS We analyzed 2,322 physician-diagnosed adolescent asthma patients and 38,696 non-asthmatic adolescent participants from the 2020 Korean Youth Risk Behavior self-administered Survey. Anxiety status was assessed using the Generalized Anxiety Disorder-7 (GAD-7) questionnaires. Multiple logistic regression analyses with complex sampling was performed with adjustments for multiple confounding variables (socioeconomic, health behavior, and psychological factors) to explore the association between GAD-7 scores and adolescent asthma. RESULTS The asthma group had higher rates of anxiety (GAD-7 score ≥ 10) than the non-asthma group (5.0% and 6.7%, respectively; p < 0.001). After adjustment for multiple confounders, asthma was significantly associated with an increased risk of anxiety (GAD-7 score ≥ 10) (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.06-1.12). CONCLUSION Asthma is associated with an increased prevalence of anxiety in Korean adolescents.
Collapse
Affiliation(s)
- Han Jak Ryu
- Department of Medicine, Catholic Kwandong Graduate School, Gangneung-si, Republic of Korea
| | - Sujin Lee
- Department of Neurology, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea
| | - Jae Ho Chung
- Department of Internal Medicine, International St. Mary's Hospital, Incheon, Republic of Korea
| |
Collapse
|
18
|
Licari A, Andrenacci B, Di Cicco ME, Leone M, Marseglia GL, Tosca M. Respiratory comorbidities in severe asthma: focus on the pediatric age. Expert Rev Respir Med 2023; 17:1-13. [PMID: 36631726 DOI: 10.1080/17476348.2023.2168261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Asthma comorbidities are a frequent cause of adverse outcomes, such as poor asthma control, frequent asthma attacks, reduced quality of life, and higher healthcare costs. Comorbidities are well-known treatable traits whose proper management can help achieve optimal asthma control. Although multimorbidity is frequent among asthmatics, comorbidities are still a potential cause of misdiagnosis and under or over treatments, and little is known about their impact on severe pediatric asthma. AREAS COVERED We provided a comprehensive, 5-year updated review focusing on the main respiratory comorbidities in severe asthma, particularly in epidemiology, pathogenesis, and current and future therapies. EXPERT OPINION Respiratory comorbidities have unique characteristics in childhood. Their management must be multidisciplinary, age-specific, and integrated. Further longitudinal studies are needed to understand better the mutual interrelation and synergistic effect between asthma and its respiratory comorbidities, the identification of common, treatable risk factors leading to potential asthma prevention, the effectiveness of actual and future target-therapies, and the correlation between long-lasting respiratory comorbidities and poor lung function trajectories.
Collapse
Affiliation(s)
- Amelia Licari
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Beatrice Andrenacci
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Maria Elisa Di Cicco
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pavia, Italy
| | | | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mariangela Tosca
- Allergy Centre, IRCCS G. Gaslini Pediatric Hospital, Genova, Italy
| |
Collapse
|
19
|
Abstract
Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.
Collapse
|
20
|
McDonald VM, Gibson PG. Multidisciplinary care in chronic airway diseases: the Newcastle model. ERJ Open Res 2022; 8:00215-2022. [PMID: 35983538 PMCID: PMC9379354 DOI: 10.1183/23120541.00215-2022] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/10/2022] [Indexed: 11/05/2022] Open
Abstract
Chronic airway diseases including, asthma and chronic obstructive pulmonary disease (COPD) are prevalent and high burden conditions with the majority of patients successfully managed in the primary care setting. However, some patients with more complex disease such as difficult-to-treat or severe asthma, or complex COPD, tertiary care is required. This review provides an overview of the successful tertiary care multidisciplinary respiratory service that operates in Newcastle, New South Wales, Australia, which has been integrated into the tertiary care outpatient clinics for almost three decades. The service is multifaceted in terms of the clinical care it provides, and includes an “Inpatient service”, “Asthma Management Service”, “Difficult Airway Clinic”, “Drug Administration Clinic”, “Rapid Access Clinic”, “Pulmonary Rehabilitation” and has an integrated research programme. The core of the multidisciplinary approach to airway diseases is a person-centred model of care, the “Treatable Traits” approach. The staffing of this service comprises of consultant physicians, respiratory advanced trainees, respiratory scientists, physiotherapists, speech pathologists, nurse specialists and a nurse consultant. Patients that present to this service undergo an initial assessment and clinical review by team members, synthesis of relevant data, and development of a diagnosis and management plan. Based on this review specific interventions are determined according to the traits identified. Overtime the service has evolved to accommodate the increasing numbers of patients requiring access to the “Difficult Airways Clinic” assessment and therapies. This has been facilitated by partnered with the Centres of Excellence in Severe Asthma and Treatable Traits to develop educational and practice management tools.
Collapse
|
21
|
Majellano EC, Clark VL, McLoughlin RF, Gibson PG, McDonald VM. Using a knowledge translation framework to identify health care professionals’ perceived barriers and enablers for personalised severe asthma care. PLoS One 2022; 17:e0269038. [PMID: 35671262 PMCID: PMC9173624 DOI: 10.1371/journal.pone.0269038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/12/2022] [Indexed: 01/29/2023] Open
Abstract
Background Whilst multidimensional assessment enables the detection of treatable traits in severe asthma and has the potential to improve patient outcomes, healthcare disparities exist, and little is known about the factors influencing optimal management in severe asthma. This study aimed to explore perceived barriers, and enablers to implementing personalised care in severe asthma, from the healthcare professionals’ perspective. Methods A descriptive, qualitative study involving a single focus group (n = 7) and semi-structured interviews (n = 33) with multidisciplinary healthcare professionals involved in severe asthma care was conducted. A hybrid thematic and content analysis was undertaken to identify themes, which were then deductively mapped to the Theoretical Domains Framework (TDF). Results Overall, three emergent themes were identified: (1) Barriers- (2) Enablers- to optimal management; (3) Desired model of care. Across all TDF domains, 6 constructs influenced development and implementation of optimal care: (1) belief about consequences, (2) environmental context and resources, (3) belief about capabilities, (4) social/professional role and identity, (5) goals and (6) knowledge. Conclusion Implementation of personalised care in severe asthma is complex and non-linear. The use of a theory-based approach effectively demonstrated how a variety of behaviours could be targeted to optimise and promote personalised care in different clinical setting.
Collapse
Affiliation(s)
- Eleanor C. Majellano
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, New South Wales, Australia
- School of Nursing and Midwifery, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Vanessa L. Clark
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, New South Wales, Australia
- School of Nursing and Midwifery, The University of Newcastle, Newcastle, New South Wales, Australia
- National Health and Medical Research Council Centre for Research Excellence in Treatable Traits, New Lambton Heights, New South Wales, Australia
| | - Rebecca F. McLoughlin
- School of Nursing and Midwifery, The University of Newcastle, Newcastle, New South Wales, Australia
- National Health and Medical Research Council Centre for Research Excellence in Treatable Traits, New Lambton Heights, New South Wales, Australia
| | - Peter G. Gibson
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, New South Wales, Australia
- National Health and Medical Research Council Centre for Research Excellence in Treatable Traits, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Vanessa M. McDonald
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, New South Wales, Australia
- School of Nursing and Midwifery, The University of Newcastle, Newcastle, New South Wales, Australia
- National Health and Medical Research Council Centre for Research Excellence in Treatable Traits, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
- * E-mail:
| |
Collapse
|
22
|
Cherukupalli A, Yong M, Chan Y, Desrosiers M, Thamboo A. Identifying barriers to care for complex airway disease and multidisciplinary solutions to optimize therapy in Canada. J Otolaryngol Head Neck Surg 2022; 51:15. [PMID: 35428368 PMCID: PMC9012057 DOI: 10.1186/s40463-022-00576-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/07/2022] [Indexed: 11/21/2022] Open
Abstract
Background Complex airway disease such as Chronic Rhinosinusitis with Asthma or Aspirin Exacerbated Respiratory Disease requires a multidisciplinary approach to management and treatment. Many centers in the USA have created collaborative multidisciplinary clinics to support the management of these patients; however, similar structures do not appear to exist in Canada. Methods This mixed methods study used a combination of structured interviews and a cross-sectional national survey. Interviewees included members of the Canadian Rhinology Working Group and survey participants were a combination of academic and community Rhinologists, Respirologists and Allergists. All participation was voluntary and selection criteria was based on their involvement in treating complex airway disease. Our objective was to identify the current state of diagnosis and treatment of complex airway patients in Canada between Rhinology, Respirology and Allergy and understand the barriers, challenges and propose solutions to establishing a multidisciplinary airway clinic in Canada. Results Four Rhinologists participated in qualitative interviews and a convenience sample of 42 specialists through our known network responded to our quantitative survey. From our survey, 54.8% believed multidisciplinary clinics were necessary in the management of complex airway disease, providing better outcomes and cost-savings (69%, 45.2%). Most specialties agreed that history, physical, pulmonary function and skin prick testing was important for diagnosis (92.9%, 92.9%, 88.1%). If clinicians were to participate in a multidisciplinary clinic, they would be willing to forego an average of 14.2% of their mean daily income for that clinic. The ideal clinic location was split between a neutral shared location vs. a Rhinology clinic space (38.1%, 45.2%). Conclusions Complex airway diseases are currently managed in subspecialty silos resulting in fragmented care. Our study highlights gaps in management, areas for improvement and support for establishing multidisciplinary complex airway disease clinics in Canada to better treat this population.
Collapse
Affiliation(s)
- A Cherukupalli
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, Diamond Healthcare Center, University of British Columbia, 4th Floor, 2775 Laurel St., Vancouver, BC, V5Z 1M9, Canada.
| | - M Yong
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, Diamond Healthcare Center, University of British Columbia, 4th Floor, 2775 Laurel St., Vancouver, BC, V5Z 1M9, Canada
| | - Y Chan
- Department of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - M Desrosiers
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - A Thamboo
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, Diamond Healthcare Center, University of British Columbia, 4th Floor, 2775 Laurel St., Vancouver, BC, V5Z 1M9, Canada
| |
Collapse
|
23
|
McLoughlin RF, McDonald VM. The Management of Extrapulmonary Comorbidities and Treatable Traits; Obesity, Physical Inactivity, Anxiety, and Depression, in Adults With Asthma. FRONTIERS IN ALLERGY 2022; 2:735030. [PMID: 35387051 PMCID: PMC8974714 DOI: 10.3389/falgy.2021.735030] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/19/2021] [Indexed: 12/31/2022] Open
Abstract
Asthma is a complex and heterogenous disease characterized by variability in disease expression and severity. Multiple extrapulmonary comorbidities and treatable traits are common in people with asthma, and there is an increasing appreciation of how these may complicate asthma management. This review will discuss the prevalence and impact of extrapulmonary comorbidities/risk factors or "traits," which have been found to co-exist in asthma (obesity, symptoms of depression and/or anxiety and physical inactivity), the impact these traits have on future outcomes (including exacerbation risk and quality of life) and asthma management, and how we should target treatment in asthma when these extrapulmonary traits are present.
Collapse
Affiliation(s)
- Rebecca F McLoughlin
- National Health and Medical Research Council, Centre of Excellence in Treatable Traits, New Lambton Heights, NSW, Australia.,School of Nursing and Midwifery, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
| | - Vanessa M McDonald
- National Health and Medical Research Council, Centre of Excellence in Treatable Traits, New Lambton Heights, NSW, Australia.,School of Nursing and Midwifery, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
| |
Collapse
|
24
|
Fieten KB, Drijver‐Messelink MT, Cogo A, Charpin D, Sokolowska M, Agache I, Taborda‐Barata LM, Eguiluz‐Gracia I, Braunstahl GJ, Seys SF, den Berge M, Bloch KE, Ulrich S, Cardoso‐Vigueros C, Kappen JH, Brinke AT, Koch M, Traidl‐Hoffmann C, da Mata P, Prins DJ, Pasmans SGMA, Bendien S, Rukhadze M, Shamji MH, Couto M, Oude Elberink H, Peroni DG, Piacentini G, Weersink EJM, Bonini M, Rijssenbeek‐Nouwens LHM, Akdis CA. Alpine altitude climate treatment for severe and uncontrolled asthma: An EAACI position paper. Allergy 2022; 77:1991-2024. [PMID: 35113452 PMCID: PMC9305916 DOI: 10.1111/all.15242] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/14/2022] [Accepted: 01/30/2022] [Indexed: 12/30/2022]
Abstract
Currently available European Alpine Altitude Climate Treatment (AACT) programs combine the physical characteristics of altitude with the avoidance of environmental triggers in the alpine climate and a personalized multidisciplinary pulmonary rehabilitation approach. The reduced barometric pressure, oxygen pressure, and air density, the relatively low temperature and humidity, and the increased UV radiation at moderate altitude induce several physiological and immunological adaptation responses. The environmental characteristics of the alpine climate include reduced aeroallergens such as house dust mites (HDM), pollen, fungi, and less air pollution. These combined factors seem to have immunomodulatory effects controlling pathogenic inflammatory responses and favoring less neuro‐immune stress in patients with different asthma phenotypes. The extensive multidisciplinary treatment program may further contribute to the observed clinical improvement by AACT in asthma control and quality of life, fewer exacerbations and hospitalizations, reduced need for oral corticosteroids (OCS), improved lung function, decreased airway hyperresponsiveness (AHR), improved exercise tolerance, and improved sinonasal outcomes. Based on observational studies and expert opinion, AACT represents a valuable therapy for those patients irrespective of their asthma phenotype, who cannot achieve optimal control of their complex condition despite all the advances in medical science and treatment according to guidelines, and therefore run the risk of falling into a downward spiral of loss of physical and mental health. In the light of the observed rapid decrease in inflammation and immunomodulatory effects, AACT can be considered as a natural treatment that targets biological pathways.
Collapse
|
25
|
Senna G, Micheletto C, Piacentini G, Schiappoli M, Girolomoni G, Sala G, Allievi EG, Stassaldi A. Multidisciplinary management in type 2 inflammatory disease. Multidiscip Respir Med 2022; 17:813. [PMID: 35127078 PMCID: PMC8791023 DOI: 10.4081/mrm.2022.813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/04/2021] [Indexed: 11/22/2022] Open
Abstract
Greater understanding of molecular pathophysiology has led to the recognition that an excessive type 2 inflammatory response is at the basis of the pathophysiology of several inflammatory diseases including atopic dermatitis (AD), asthma, and chronic rhinosinusitis with nasal polyps (CRSwNP). Given the availability of biological agents that can permit management of specific disease endotypes, this reinforces the need for detailed characterization of these diseases through a multidisciplinary approach. Herein, these three conditions are briefly overviewed and practical guidance for a multidisciplinary approach to management is presented. Since type 2 inflammation is suppressed by steroids, drugs such as glucocorticoids have long been the workhorse of medical therapy. However, steroids have well-known local and systemic adverse effects, especially when used at high doses over prolonged periods of time, which is problematic when treating chronic diseases such as AD, asthma, and CRSwNP. Moreover, a substantial proportion of patients remain refractive to therapy. In the attempt to overcome these limitations, greater understanding of the molecular mechanisms of type 2 inflammation have led to the development of targeted biological drugs such as dupilumab, a fully human monoclonal antibody that targets the α chain of the IL-4 receptor. Dupilumab represents a unique therapy for type 2 inflammatory diseases and to date is the only therapy approved for AD, asthma, and CRSwNP. In terms of multidisciplinary management of type 2 inflammatory conditions, the main healthcare professionals involved include a dermatologist, pneumologist or allergologist, and ENT specialist. The model proposed herein takes into account the complex management of patients with type 2 inflammatory conditions and the new biological agents available. A multidisciplinary team can provide a central point for patient management, improve outcomes and specialist referrals, reduce costs, and guarantee that the most appropriate therapeutic decisions are made, as well as aid in management of adverse events. The multidisciplinary model should be structured and dedicated, but at the same time simple and flexible in order to not risk slowing down the patient's care. At present, it is believed that a structured multidisciplinary approach is currently the best means to optimize care of patients with type 2 inflammatory conditions.
Collapse
|
26
|
de Carvalho-Pinto RM, Cançado JED, Pizzichini MMM, Fiterman J, Rubin AS, Cerci A, Cruz ÁA, Fernandes ALG, Araujo AMS, Blanco DC, Cordeiro G, Caetano LSB, Rabahi MF, de Menezes MB, de Oliveira MA, Lima MA, Pitrez PM. 2021 Brazilian Thoracic Association recommendations for the management of severe asthma. J Bras Pneumol 2021; 47:e20210273. [PMID: 34932721 PMCID: PMC8836628 DOI: 10.36416/1806-3756/e20210273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/05/2021] [Indexed: 12/20/2022] Open
Abstract
Advances in the understanding that severe asthma is a complex and heterogeneous disease and in the knowledge of the pathophysiology of asthma, with the identification of different phenotypes and endotypes, have allowed new approaches for the diagnosis and characterization of the disease and have resulted in relevant changes in pharmacological management. In this context, the definition of severe asthma has been established, being differentiated from difficult-to-control asthma. These recommendations address this topic and review advances in phenotyping, use of biomarkers, and new treatments for severe asthma. Emphasis is given to topics regarding personalized management of the patient and selection of biologicals, as well as the importance of evaluating the response to treatment. These recommendations apply to adults and children with severe asthma and are targeted at physicians involved in asthma treatment. A panel of 17 Brazilian pulmonologists was invited to review recent evidence on the diagnosis and management of severe asthma, adapting it to the Brazilian reality. Each of the experts was responsible for reviewing a topic or question relevant to the topic. In a second phase, four experts discussed and structured the texts produced, and, in the last phase, all experts reviewed and approved the present manuscript and its recommendations.
Collapse
Affiliation(s)
- Regina Maria de Carvalho-Pinto
- . Divisão de Pneumologia, Instituto do Coração − InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | | | - Jussara Fiterman
- . Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS − Porto Alegre (RS) Brasil
| | - Adalberto Sperb Rubin
- . Universidade Federal de Ciências da Saúde de Porto Alegre − UFCSPA − Porto Alegre (RS) Brasil
- . Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (RS) Brasil
| | - Alcindo Cerci
- . Universidade Estadual de Londrina − UEL − Londrina (PR) Brasil
- . Pontifícia Universidade Católica do Paraná − PUCPR − Londrina (PR) Brasil
| | - Álvaro Augusto Cruz
- . Universidade Federal da Bahia − UFBA − Salvador (BA) Brasil
- . Fundação ProAR, Salvador (BA) Brasil
| | | | - Ana Maria Silva Araujo
- . Instituto de Doenças do Tórax, Universidade Federal do Rio de Janeiro − IDT/UFRJ − Rio de Janeiro (RJ) Brasil
| | - Daniela Cavalet Blanco
- . Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS − Porto Alegre (RS), Brasil
| | - Gediel Cordeiro
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
- . Hospital Madre Teresa, Belo Horizonte (MG) Brasil
| | | | - Marcelo Fouad Rabahi
- . Faculdade de Medicina, Universidade Federal de Goiás − UFG − Goiânia (GO) Brasil
| | - Marcelo Bezerra de Menezes
- . Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | | | | | | |
Collapse
|
27
|
Clinical Experience with Anti-IgE Monoclonal Antibody (Omalizumab) in Pediatric Severe Allergic Asthma-A Romanian Perspective. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121141. [PMID: 34943337 PMCID: PMC8700741 DOI: 10.3390/children8121141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/01/2021] [Accepted: 12/01/2021] [Indexed: 11/21/2022]
Abstract
Background: Asthma is the most common chronic disease affecting children, with a negative impact on their quality of life. Asthma is often associated with comorbid allergic diseases, and its severity may be modulated by immunoglobulin E (IgE)-mediated allergen sensitization. Omalizumab is a humanized monoclonal anti-IgE antibody, the first biological therapy approved to treat patients aged ≥6 years with severe allergic asthma. The primary objective of our study was to investigate the efficacy and safety of Omalizumab in Romanian children with severe allergic asthma. Methods: In this observational real-life study, 12 children and adolescents aged 6 to 18 years (mean 12.4 years) with severe allergic asthma received Omalizumab as an add-on treatment. Asthma control, exacerbations, lung function, and adverse events were evaluated at baseline and after the first year of treatment. Results: We observed general improvement in total asthma symptom scores and reduction in the rate of exacerbation of severe asthma. Omalizumab treatment was associated with improvement in the measures of lung function, and no serious adverse reactions were reported. FEV1 improved significantly after one year of treatment with Omalizumab [ΔFEV1 (% pred.) = 18.3], and [similarly, ΔMEF50 (%) = 25.8]. The mean severe exacerbation rate of asthma decreased from 4.1 ± 2.8 to 1.15 ± 0.78 (p < 0.0001) during the year of treatment with Omalizumab. Conclusions: This study showed that Omalizumab can be an effective and safe therapeutic option for Romanian children and adolescents with severe allergic asthma, providing clinically relevant information on asthma control and exacerbation rate in children and adolescents. The results demonstrated the positive effect of Omalizumab in young patients with asthma, starting from the first year of treatment.
Collapse
|
28
|
Menzella F, Ghidoni G, Fontana M, Capobelli S, Livrieri F, Castagnetti C, Facciolongo N. The role of systemic corticosteroids in severe asthma and new evidence in their management and tapering. Expert Rev Clin Immunol 2021; 17:1283-1299. [PMID: 34761712 DOI: 10.1080/1744666x.2021.2004123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Based on the latest literature evidence, between 30% and 60% of adults with severe refractory asthma (SRA) are systemic corticosteroid (SCS) dependent. There are numerous therapeutic options in asthma, which are often not effective in severe forms. In these cases, SCS should be considered, but it is increasingly recognized that their regular use is often associated with significant and potentially serious adverse events. AREAS COVERED The aim of this article is to provide an update about the recent and significant literature on SCS and to establish their role in the management of SRA. We summarized the most important and recent evidence and we provided useful indications for clinicians. EXPERT OPINION There is now strong evidence supporting the increased risk of comorbidities and complications with long-term SCS therapies, regardless of the dose. New evidence on SCS tapering and withdrawal will allow to define protocols to address SCS management with greater safety and effectiveness, after starting efficient steroid-sparing strategies. In the next 5years, it will be necessary to implement corrective actions to address these unmet needs, to reduce the inappropriate use of SCS by maximizing the application of more innovative and effective therapies.
Collapse
Affiliation(s)
- Francesco Menzella
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Giulia Ghidoni
- University Hospital of Modena, 208968,Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Matteo Fontana
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Silvia Capobelli
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Francesco Livrieri
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Claudia Castagnetti
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Nicola Facciolongo
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| |
Collapse
|
29
|
Blakey J, Chung LP, McDonald VM, Ruane L, Gornall J, Barton C, Bosnic-Anticevich S, Harrington J, Hew M, Holland AE, Hopkins T, Jayaram L, Reddel H, Upham JW, Gibson PG, Bardin P. Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand. Respirology 2021; 26:1112-1130. [PMID: 34587348 PMCID: PMC9291960 DOI: 10.1111/resp.14147] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 08/04/2021] [Accepted: 08/31/2021] [Indexed: 12/13/2022]
Abstract
Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over-reliance on OCS for asthma and that doses >1000 mg prednisolone-equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS-related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add-on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk-benefits of OCS medications, side effects, effective add-on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.
Collapse
Affiliation(s)
- John Blakey
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Medical School, Curtin University, Perth, Western Australia, Australia
| | - Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Laurence Ruane
- Monash Lung and Sleep, Monash University and Medical Centre, Melbourne, Victoria, Australia
| | - John Gornall
- Centre of Excellence in Severe Asthma, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Chris Barton
- Department of General Practice, Monash University, Melbourne, Victoria, Australia
| | - Sinthia Bosnic-Anticevich
- Sydney Pharmacy School, The University of Sydney AND Quality Use of Respiratory Medicines Group, The Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - John Harrington
- John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia
| | - Anne E Holland
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Trudy Hopkins
- South Eastern Sydney Health Department, Sydney, New South Wales, Australia
| | - Lata Jayaram
- Department of Respiratory Medicine, Western Health and University of Melbourne, Melbourne, Victoria, Australia
| | - Helen Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, New South Wales, Australia
| | - John W Upham
- The University of Queensland, Diamantina Institute AND Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia.,John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Philip Bardin
- Monash Lung Sleep Allergy & Immunology, Monash University and Medical Centre, Melbourne, Victoria, Australia
| |
Collapse
|
30
|
Maltby S, McDonald VM, Upham JW, Bowler SD, Chung LP, Denton EJ, Fingleton J, Garrett J, Grainge CL, Hew M, James AL, Jenkins C, Katsoulotos G, King GG, Langton D, Marks GB, Menzies-Gow A, Niven RM, Peters M, Reddel HK, Thien F, Thomas PS, Wark PAB, Yap E, Gibson PG. Severe asthma assessment, management and the organisation of care in Australia and New Zealand: expert forum roundtable meetings. Intern Med J 2021; 51:169-180. [PMID: 32104958 DOI: 10.1111/imj.14806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
Severe asthma imposes a significant burden on individuals, families and the healthcare system. Treatment is complex, due to disease heterogeneity, comorbidities and complexity in care pathways. New approaches and treatments improve health outcomes for people with severe asthma. However, emerging multidimensional and targeted treatment strategies require a reorganisation of asthma care. Consensus is required on how reorganisation should occur and what areas require further research. The Centre of Excellence in Severe Asthma convened three forums between 2015 and 2018, hosting experts from Australia, New Zealand and the UK. The forums were complemented by a survey of clinicians involved in the management of people with severe asthma. We sought to: (i) identify areas of consensus among experts; (ii) define activities and resources required for the implementation of findings into practice; and (iii) identify specific priority areas for future research. Discussions identified areas of unmet need including assessment and diagnosis of severe asthma, models of care and treatment pathways, add-on treatment approaches and patient perspectives. We recommend development of education and training activities, clinical resources and standards of care documents, increased stakeholder engagement and public awareness campaigns and improved access to infrastructure and funding. Further, we propose specific future research to inform clinical decision-making and develop novel therapies. A concerted effort is required from all stakeholders (including patients, healthcare professionals and organisations and government) to integrate new evidence-based practices into clinical care and to advance research to resolve questions relevant to improving outcomes for people with severe asthma.
Collapse
Affiliation(s)
- Steven Maltby
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - Vanessa M McDonald
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - John W Upham
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Department of Respiratory Medicine, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Simon D Bowler
- Immunity, Infection, and Inflammation Program, Mater Medical Research Institute, South Brisbane, Queensland, Australia
| | - Li P Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Eve J Denton
- Department of Respiratory Medicine, The Alfred Hospital and Austin Health, Melbourne, Victoria, Australia
| | - James Fingleton
- Capital and Coast District Health Board and Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Christopher L Grainge
- Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Mark Hew
- Department of Respiratory Medicine, The Alfred Hospital and Austin Health, Melbourne, Victoria, Australia
| | - Alan L James
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Australia and School of Medicine and Pharmacology, University of Western Australia, Western Australia, Australia
| | - Christine Jenkins
- Department of Thoracic Medicine, Concord Hospital, Concord Clinical School and Respiratory Discipline, University of Sydney, Concord, New South Wales, Australia.,The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, Liverpool, New South Wales, Australia
| | | | - Gregory G King
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - David Langton
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Thoracic Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Guy B Marks
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, UNSW, Australia
| | | | - Robert M Niven
- Division of Infection, Immunity & Respiratory Medicine, Manchester Academic Health Science Centre and North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Matthew Peters
- Department of Thoracic Medicine, Concord Hospital, Concord, New South Wales, Australia
| | - Helen K Reddel
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Francis Thien
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Department of Respiratory Medicine, Eastern Health and Monash University, Box Hill, Victoria, Australia
| | - Paul S Thomas
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Peter A B Wark
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Elaine Yap
- Middlemore Hospital, Auckland, New Zealand
| | - Peter G Gibson
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | | |
Collapse
|
31
|
Sood V, Rogers L, Khurana S. How I Do It: Managing Corticosteroid-Related Comorbidities in Severe Asthma. Chest 2021; 160:1614-1623. [PMID: 34019864 DOI: 10.1016/j.chest.2021.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/05/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022] Open
Abstract
Oral corticosteroid (OCS) use in severe asthma remains all too common despite advances in asthma treatment. Use of OCS is associated with significant toxicity that can have a lasting adverse impact on a patient's overall health. Monoclonal antibodies have been developed that reduce both the rate of occurrence of OCS-treated exacerbations and the OCS requirements in patients with oral corticosteroid-dependent asthma. This article describes strategies to prevent and best manage endocrine complications associated with OCS use and provides guidance on OCS dose management after the introduction of steroid-sparing therapies. (1) We identify OCS-dependent patients and assess for comorbidities including bone health, glycemic control, and adrenal function; (2) we begin attempts at OCS dose optimization before or soon after introducing a steroid-sparing biologic therapy; (3) we taper OCS, using explicit criteria for asthma control; (4) we assess hypothalamic-pituitary-adrenal axis integrity once a physiologic dose of OCS is achieved to guide further the rate of OCS taper; and (5) we manage corticosteroid-related comorbidities as detailed in this article.
Collapse
Affiliation(s)
- Vidushi Sood
- Division of Endocrinology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Linda Rogers
- Division of Pulmonary, Critical Care and Sleep, Mount Sinai-National Jewish Respiratory Institute and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sandhya Khurana
- Division of Pulmonary and Critical Care Medicine, Mary Parkes Center for Asthma, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| |
Collapse
|
32
|
Vlastos I, Mullol J, Hox V, Doulaptsi M, Seys S, Hellings P, Prokopakis E. Multidisciplinary Care for Severe or Uncontrolled Chronic Upper Airway Diseases. Curr Allergy Asthma Rep 2021; 21:27. [PMID: 33791881 DOI: 10.1007/s11882-021-01004-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW A multidisciplinary approach is regarded as the best practice for many chronic diseases, such as cancer and asthma, with well-documented value. There is also evidence that it may be beneficial to patients with chronic rhinosinusitis (CRS) and/or allergic airway disease presenting to tertiary referral centres. We discuss here whether and how organizing this kind of healthcare transition into a more integrated care pathway would benefit severe chronic upper airways disease (SCUAD) management. RECENT FINDINGS Based on a recent related EUFOREA panel discussion, literature search, and review of the best overseas practices, an appropriate implementation strategy of multidisciplinary care and its potential results are presented. Organizational principles, hurdles, and challenges of the process, as well as envisaged solutions and results, are being reported. The efficiency of care and the quality control assessment are concepts that are currently gaining importance. At the same time, novel treatment options based on molecular and precision medicine advancements, such as biologics, are being increasingly prescribed. Appropriately organized multidisciplinary care teams can adapt to new demands, data, and discoveries to assure maximum benefit for both patients and healthcare professionals.
Collapse
Affiliation(s)
- Ioannis Vlastos
- Department of Otorhinolaryngology, University of Crete School of Medicine, Crete, Greece
- Department of Otorhinolaryngology, Aghia Sophia Children's Hospital, Athens, Greece
| | - Joaquim Mullol
- Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic, Universitat de Barcelona; Clinical and Experimental Respiratory Immunoallergy, IDIBAPS; and CIBERES, Barcelona, Catalonia, Spain
| | - Valerie Hox
- Department of Otorhinolaryngology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Maria Doulaptsi
- Department of Otorhinolaryngology, University of Crete School of Medicine, Crete, Greece
| | - Sven Seys
- Allergy & Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
| | - Peter Hellings
- Allergy & Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
- Clinical Division of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Emmanuel Prokopakis
- Department of Otorhinolaryngology, University of Crete School of Medicine, Crete, Greece.
| |
Collapse
|
33
|
Clark VL, Gibson PG, McDonald VM. What matters to people with severe asthma? Exploring add-on asthma medication and outcomes of importance. ERJ Open Res 2021; 7:00497-2020. [PMID: 33816596 PMCID: PMC8005593 DOI: 10.1183/23120541.00497-2020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/08/2020] [Indexed: 12/19/2022] Open
Abstract
There is an increasing number of new therapies for severe asthma; however, what outcomes people with severe asthma would like improved and what aspects they prioritise in new medications remain unknown. This study aimed to understand what outcomes are important to patients when prescribed new treatments and to determine the characteristics of importance to patients in their choice of asthma treatments. Participants with severe asthma (n=50) completed a cross-sectional survey that ranked 17 potential hypothetical outcomes of treatment using a seven-point Likert scale, as well as selecting their top five overall outcomes. Participants also completed hypothetical scenarios trading off medication characteristics for four hypothetical add-on asthma treatments. Participants (58% male), had a mean±sd age of 62.2±13.5 years. Their top three prioritised outcomes were: to improve overall quality of life (selected by 83% of people), reduce number and severity of asthma attacks (72.3%), and being able to participate in physical activity (59.6%) When trading off medication characteristics, the majority of patients with severe asthma chose the hypothetical medication with the best treatment efficacy (68%). However, a subgroup of patients prioritised the medication's side-effect profile and mode of delivery to select their preferred medication. People with severe asthma value improved quality of life as an important outcome of treatment. Shared decision-making discussions between clinicians and patients that centre around medication efficacy and side-effect profile can incorporate patient preferences for add-on therapy in severe asthma. Improving quality of life is an important treatment outcome. Shared decision-making discussions between clinicians and patients that centre around efficacy and side-effect profile incorporate patient preferences for add-on therapy in severe asthma.https://bit.ly/2GY1Sc4
Collapse
Affiliation(s)
- Vanessa L Clark
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Callaghan, NSW, Australia.,School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW, Australia
| | - Peter G Gibson
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Callaghan, NSW, Australia.,Dept of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Vanessa M McDonald
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Callaghan, NSW, Australia.,School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW, Australia.,Dept of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| |
Collapse
|
34
|
Cazzola M, Ora J, Cavalli F, Rogliani P, Matera MG. Treatable Mechanisms in Asthma. Mol Diagn Ther 2021; 25:111-121. [PMID: 33570719 PMCID: PMC7956930 DOI: 10.1007/s40291-021-00514-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 02/06/2023]
Abstract
Asthma is a heterogeneous condition, but firm identification of heterogeneity-focused treatments is still lacking. Dividing patients into subgroups of asthma pheno-/endotypes based on combined clinical and cellular biological characteristics and linking them to targeted treatments could be a potentially useful approach to personalize therapy for better outcomes. Nonetheless, there are still many problems related to the identification and validation of asthma phenotypes and endotypes. Alternatively, a precision-medicine strategy for the management of patients with airways disease that is free from the traditional diagnostic labels and based on identifying "treatable traits" in each patient might be preferable. However, it would represent a quite unsophisticated approach because the definition of a treatable trait is too imprecise. In fact, there is still no understanding of the mechanisms underlying treatable traits that allow directing any targeted therapies against any particular treatable trait. Fortunately, in-depth identification of underlying molecular pathways to guide targeted treatment in individual patients is in progress thanks to the improvement in big data management obtained from '-omic' sciences that is greatly increasing knowledge concerning asthma.
Collapse
Affiliation(s)
- Mario Cazzola
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.
| | - Josuel Ora
- Respiratory Diseases Unit, "Tor Vergata" University Hospital, Rome, Italy
| | - Francesco Cavalli
- Respiratory Diseases Unit, "Tor Vergata" University Hospital, Rome, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
- Respiratory Diseases Unit, "Tor Vergata" University Hospital, Rome, Italy
| | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| |
Collapse
|
35
|
Abstract
PURPOSE OF REVIEW Severe asthma is often associated with numerous comorbidities that complicate disease management and affect patient's outcomes. They contribute to poor disease control and mimic asthma symptoms. Although some comorbidities such as obstructive sleep apnea, bronchiectasis, and chronic obstructive pulmonary disease are generally well recognized, many other may remain undiagnosed but may be detected in an expert specialist setting. The management of comorbidities seems to improve asthma outcomes, and optimizes therapy by avoiding overtreatment. The present review provides recent knowledge regarding the most common comorbidities which are associated with severe asthma. RECENT FINDINGS Comorbidities are more prevalent in severe asthma than in mild-to-moderate disease or in the general population. They can be grouped into two large domains: the pulmonary domain and the extrapulmonary domain. Pulmonary comorbidities include upper respiratory tract disorders (obstructive sleep apnea, allergic and nonallergic rhinitis, chronic rhinosinusitis, nasal polyposis) and middle/lower respiratory tract disorders (chronic obstructive pulmonary disease, allergic bronchopulmonary aspergillosis and fungal sensitization, bronchiectasis, dysfunctional breathing). Extrapulmonary comorbidities include anxiety, depression, gastro-esophageal reflux disease, obesity, cardiovascular, and metabolic diseases. SUMMARY The identification of comorbidities via multidimensional approach is needed to initiate appropriate multidisciplinary management of patients with severe asthma.
Collapse
|
36
|
Singer A, Ali FR, Quantrill S, North N, Stevens M, Lambourne J, Grigoriadou S, Pfeffer PE. Utility of immunology, microbiology, and helminth investigations in clinical assessment of severe asthma. J Asthma 2021; 59:541-551. [PMID: 33356678 DOI: 10.1080/02770903.2020.1868496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Systematic assessment of patients with potential severe asthma is key to identification of treatable traits and optimal management. Assessment of antimicrobial immune function is part of that assessment at many centers although there is little evidence-base on its added value in clinical assessment of this patient group. As part of reviewing our local pathway, we have retrospectively reviewed these tests in 327 consecutive referrals to our severe asthma service, in an evaluation to describe the utility of these tests and allow refinement of the local guideline for patient assessment. METHODS AND RESULTS Serum immunoglobulin concentrations were in the normal range in most patients though 12 patients had serum IgG < 5.5 g/L and many had suboptimal anti-Haemophilus (127 of 249 patients tested) and anti-Pneumococcal (111 of 239) immune responses. As expected many patients had evidence of sensitization to Aspergillus although specific IgG was not confined to those with evidence of allergic sensitization/allergic bronchopulmonary aspergillosis (ABPA). Eighteen of 277 patients tested had serological evidence of Strongyloides infection. Bacteria and/or yeast were cultured from the sputum in 76 out of 110 patients productive of sputum, and the most common microbes cultured were Candida sp. (44 patients), Staphylococcus aureus (21 patients), Haemophilus influenzae (18 patients). CONCLUSIONS Many patients had evidence of infection, colonization, or sensitization to potential pathogens relevant to asthma. Strongyloides infection was evident in several patients, which may be a major issue when considering the risk of hyper-infection following immunosuppression and supports our local screening strategy.
Collapse
Affiliation(s)
| | - F Runa Ali
- Barts Health NHS Trust, London, United Kingdom
| | | | | | | | | | | | - Paul E Pfeffer
- Barts Health NHS Trust, London, United Kingdom.,Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| |
Collapse
|
37
|
Feng M, Zhang X, Wu WW, Chen ZH, Oliver BG, McDonald VM, Zhang HP, Xie M, Qin L, Zhang J, Wang L, Li WM, Wang G, Gibson PG. Clinical and Inflammatory Features of Exacerbation-Prone Asthma: A Cross-Sectional Study Using Multidimensional Assessment. Respiration 2020; 99:1109-1121. [PMID: 33271561 DOI: 10.1159/000510793] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 08/06/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Reducing asthma exacerbations is a major target of current clinical guidelines, but identifying features of exacerbation-prone asthma (EPA) using multidimensional assessment (MDA) is lacking. OBJECTIVE To systemically explore the clinical and inflammatory features of adults with EPA in a Chinese population. METHODS We designed a cross-sectional study using the Severe Asthma Web-based Database from the Australasian Severe Asthma Network (ASAN). Eligible Chinese adults with asthma (n = 546) were assessed using MDA. We stratified patients based on exacerbation frequency: none, few (1 or 2), and exacerbation prone (≥3). Univariate and multivariable negative binomial regression analyses were performed to investigate features associated with the frequency of exacerbations. RESULTS Of 546 participants, 61.9% had no exacerbations (n = 338), 29.6% had few exacerbations (n = 162), and 8.4% were exacerbation prone (n = 46) within the preceding year. EPA patients were characterized by elevated blood and sputum eosinophils but less atopy, with more controller therapies but worse asthma control and quality of life (all p < 0.05). In multivariable models, blood and sputum eosinophils (adjusted rate ratio = 2.23, 95% confidence interval = [1.26, 3.84] and 1.67 [1.27, 2.21], respectively), FEV1 (0.90 [0.84, 0.96]), bronchodilator responsiveness (1.16 [1.05, 1.27]), COPD (2.22 [1.41, 3.51]), bronchiectasis (2.87 [1.69, 4.89]), anxiety (2.56 [1.10, 5.95]), and depression (1.94 [1.20, 3.13]) were found. Further, upper respiratory tract infection (1.83 [1.32, 2.54]) and food allergy (1.67 [1.23, 2.25]) were at high risk of asthma symptom triggers. CONCLUSION EPA is a clinically recognizable phenotype associated with several recognizable traits that could be addressed by targeted treatment.
Collapse
Affiliation(s)
- Min Feng
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Xin Zhang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Wen Wen Wu
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Zhi Hong Chen
- Shanghai Institute of Respiratory Disease, Respiratory Division of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Brian G Oliver
- School of Life Sciences, University of Technology Sydney, Ultimo, New South Wales, Australia.,Respiratory Cellular and Molecule Biology, Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Hong Ping Zhang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Min Xie
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Huazhong University of Science & Technology, Wuhan, China
| | - Ling Qin
- Department of Respiratory and Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Jie Zhang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Jilin University, Changchun, China
| | - Lei Wang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Wei Min Li
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Gang Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China, .,Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China,
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
| |
Collapse
|
38
|
Vertigan AE, Kapela SL, Gibson PG. Laryngeal Dysfunction in Severe Asthma: A Cross-Sectional Observational Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:897-905. [PMID: 33011304 DOI: 10.1016/j.jaip.2020.09.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/20/2020] [Accepted: 09/21/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laryngeal disorders can contribute to disease burden in severe asthma yet the nature of laryngeal disorders in severe asthma is poorly understood. OBJECTIVE The aim of this study was to examine laryngeal function in patients with severe asthma. METHOD A cross-sectional observational study involving 97 participants compared laryngeal function in patients with severe asthma (n = 53) with patients with laryngeal disorders of vocal cord dysfunction/inducible laryngeal obstruction (n = 16) and muscle tension dysphonia (n = 14), and with healthy controls (n = 13). A pre-post pilot study of speech pathology intervention for laryngeal symptoms was then provided to 11 participants with severe asthma and laryngeal dysfunction. RESULTS Laryngeal dysfunction was common in severe asthma. The majority of participants with severe asthma (87%) had laryngeal dysfunction, which affected respiration, phonation, or both. Three distinct patterns of laryngeal dysfunction in severe asthma were identified: (1) phonatory laryngeal dysfunction, (2) respiratory laryngeal dysfunction, and (3) combined laryngeal dysfunction. Laryngeal hypersensitivity and impaired voice measures were common in severe asthma. Patient-reported outcome measures improved after therapy, and laryngeal dysfunction improved in 7 (64%) participants. CONCLUSION Laryngeal dysfunction affects respiration and phonation in severe asthma. It requires identification and treatment to minimize its impact on asthma symptoms.
Collapse
Affiliation(s)
- Anne E Vertigan
- Speech Pathology Department, John Hunter Hospital, Newcastle, NSW, Australia; Hunter Medical Research Institute, Newcastle, NSW, Australia; University of Newcastle, Newcastle, NSW, Australia.
| | - Sarah L Kapela
- Speech Pathology Department, John Hunter Hospital, Newcastle, NSW, Australia
| | - Peter G Gibson
- Hunter Medical Research Institute, Newcastle, NSW, Australia; University of Newcastle, Newcastle, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| |
Collapse
|
39
|
Scichilone N, Barnes PJ, Battaglia S, Benfante A, Brown R, Canonica GW, Caramori G, Cazzola M, Centanni S, Cianferoni A, Corsico A, De Carlo G, Di Marco F, Gaga M, Hawrylowicz C, Heffler E, Matera MG, Matucci A, Paggiaro P, Papi A, Popov T, Rogliani P, Santus P, Solidoro P, Togias A, Boulet LP. The Hidden Burden of Severe Asthma: From Patient Perspective to New Opportunities for Clinicians. J Clin Med 2020; 9:jcm9082397. [PMID: 32727032 PMCID: PMC7463666 DOI: 10.3390/jcm9082397] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022] Open
Abstract
Severe asthma is an important topic in respiratory diseases, due to its high impact on morbidity and mortality as well as on health-care resources. The many challenges that still exist in the management of the most difficult-to-treat forms of the disease, and the acknowledgement of the existence of unexplored areas in the pathophysiological mechanisms and the therapeutic targets represent an opportunity to gather experts in the field with the immediate goals to summarize current understanding about the natural history of severe asthma and to identify gaps in knowledge and research opportunities, with the aim to contribute to improved medical care and health outcomes. This article is a consensus document from the “International Course on Severe Asthma” that took place in Palermo, Italy, on May 10–11, 2019. Emerging topics in severe asthma were addressed and discussed among experts, with special focus on patient’s needs and research opportunities, with the aim to highlight the unanswered questions in the diagnostic process and therapeutic approach.
Collapse
Affiliation(s)
- Nicola Scichilone
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
- Correspondence: ; Tel.: +39-091-655-2146
| | - Peter John Barnes
- Airway Disease Section, National Heart & Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LY, UK;
| | - Salvatore Battaglia
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
| | - Alida Benfante
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
| | - Robert Brown
- Department of Anesthesiology and Critical Care Medicine, Medicine, Department of Medicine, Division of Pulmonary Medicine, Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, MD 21287, USA;
| | - Giorgio Walter Canonica
- Personalised Medicine Clinic Asthma & Allergy, Humanitas University, Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (G.W.C.); (E.H.)
| | - Gaetano Caramori
- Respiratory Medicine Unit, Department of Biomedical Sciences, Dentistry and Morphological and Functional Imaging (BIOMORF), University of Messina, 98122 Messina, Italy;
| | - Mario Cazzola
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (M.C.); (P.R.)
| | - Stefano Centanni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, 20142 Milan, Italy;
| | - Antonella Cianferoni
- Pediatrics Department, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Angelo Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics – University of Pavia, 27100 Pavia, Italy;
| | - Giuseppe De Carlo
- The European Federation of Allergy and Airways Diseases Patients Associations (EFA), 1000 Brussels, Belgium;
| | - Fabiano Di Marco
- Respiratory Unit, ASST - Papa Giovanni XXIII Hospital, Bergamo, University of Milan, 24127 Milan, Italy;
| | - Mina Gaga
- 7th Respiratory Medicine Dept, Asthma Cen, Athens Chest Hospital, 11527 Athens, Greece;
| | - Catherine Hawrylowicz
- Division of Asthma, Allergy and Lung Biology, King’s College London, Guy’s Hospital, London SE1 9RT, UK;
| | - Enrico Heffler
- Personalised Medicine Clinic Asthma & Allergy, Humanitas University, Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (G.W.C.); (E.H.)
| | - Maria Gabriella Matera
- Unit of Pharmacology, Dept. Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Andrea Matucci
- Immunoallergology Unit, Careggi University Hospital, 50139 Florence, Italy;
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, 56126 Pisa, Italy;
| | - Alberto Papi
- Research Center on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Todor Popov
- Clinic of Occupational Diseases, University Hospital Sv. Ivan Rilski, 1431 Sofia, Bulgaria;
| | - Paola Rogliani
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (M.C.); (P.R.)
| | - Pierachille Santus
- Division of Respiratory Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy;
| | - Paolo Solidoro
- Pneumology Unit U, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, University of Turin, 10126 Turin, Italy;
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Bethesda, MD 20814, USA;
| | | |
Collapse
|
40
|
Papadopoulos NG, Barnes P, Canonica GW, Gaga M, Heaney L, Menzies-Gow A, Kritikos V, Fitzgerald M. The evolving algorithm of biological selection in severe asthma. Allergy 2020; 75:1555-1563. [PMID: 32124991 DOI: 10.1111/all.14256] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/08/2020] [Accepted: 02/26/2020] [Indexed: 12/15/2022]
Abstract
New therapeutic options for severe asthma have recently emerged, mostly in the form of monoclonal antibodies ("biologicals") targeting relevant inflammatory pathways. Currently available agents target different aspects of "Type 2" immunity, and their indications often include overlapping patient groups. We present a round-table discussion that took place during the Annual Meeting of the Respiratory Effectiveness Group (REG), on the reasoning behind the use of different add-on medications for severe asthma, and crucially, on selection strategies. The proposed rational is based on current evidence, including real-life studies, as well as on the appreciation of the relevant complexities. Direct head-to-head comparisons of biologicals are lacking; therefore, algorithms for initial choice and potential switch between agents should be based on understanding the key characteristics of different options and the development of a clear plan with predefined targets and shared decision-making, in a structured way.
Collapse
Affiliation(s)
- Nikolaos G Papadopoulos
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, UK
- Allergy Department, 2nd Pediatric Clinic, National Kapodistrian University of Athens, Athens, Greece
| | - Peter Barnes
- National Heart and Lung Institute, Imperial College, London, UK
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy - Humanitas Clinical and Research Center IRCCS, Rozzano, MI, Italy
| | - Mina Gaga
- 7th Respiratory Medicine Department and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Liam Heaney
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Belfast, UK
| | | | - Vicky Kritikos
- Quality Use of Respiratory Medicines Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Mark Fitzgerald
- Centre for Heart and Lung Health, The Lung Centre Vancouver General Hospital, UBC Institute for Heart and Lung Health, Vancouver, BC, Canada
| |
Collapse
|
41
|
Côté A, Godbout K, Boulet LP. The management of severe asthma in 2020. Biochem Pharmacol 2020; 179:114112. [PMID: 32598948 DOI: 10.1016/j.bcp.2020.114112] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 12/19/2022]
Abstract
Asthma is a chronic inflammatory disease of the airways affecting more than 300 million patients worldwide. The disease can be of various severity ranging from very mild to severe. The severe form of the disease only affects about 5% of patients but is responsible for a large component of the overall disease burden and results in about half of direct asthma-related costs. This led to important investments in research, which allowed better understanding of its pathophysiology and the development of new therapeutic strategies. Despite those breakthroughs, recent guidelines still emphasize the need to distinguish uncontrolled or difficult-to-control asthma from severe asthma. Indeed, a significant number of patients referred to severe asthma clinics are non-severe uncontrolled patients. However, the basics of asthma management such as ensuring that the patient has the right diagnosis, recognition of contributing comorbidities, avoidance of exposure to sensitizing agents in allergic individuals, regular assessment of control, and patient education should not be forgotten. The major improvements in pathophysiology arose from the evidences that asthma is of heterogeneous nature. Such heterogeneity has been particularly studied in severe asthma, leading to the recognition of more homogeneous groups referred to as phenotypes. Appropriate phenotyping of individual patients allows enforcing more specific treatment plans for patients, which is a step toward precision medicine. The high morbidity and socioeconomic burden of severe asthma has led to the development of optimized therapeutic strategies in addition to the commercialization of new drugs. Many of these have targeted the eosinophilic component of inflammatory asthma phenotypes while there is still a need to develop new therapies for non-eosinophilic asthma. When asthma is not controlled by optimal therapy, including a high-dose of inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA), a long acting anticholinergic agent can be added and if insufficient, a variety of biologic agents is now available in many countries. When biologics are not an option, thermoplasty and macrolides have also become available. Despite many recent breakthroughs in severe asthma, much research needs to be done. Improvement in availability of targeted asthma medications and asthma prevention should be top priorities.
Collapse
Affiliation(s)
- Andréanne Côté
- Quebec Heart and Lung Institute, Laval University, Canada
| | | | | |
Collapse
|
42
|
Henriksen DP, Bodtger U, Sidenius K, Maltbaek N, Pedersen L, Madsen H, Andersson EA, Norgaard O, Madsen LK, Chawes BL. Efficacy of omalizumab in children, adolescents, and adults with severe allergic asthma: a systematic review, meta-analysis, and call for new trials using current guidelines for assessment of severe asthma. Allergy Asthma Clin Immunol 2020; 16:49. [PMID: 32565844 PMCID: PMC7302157 DOI: 10.1186/s13223-020-00442-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 05/23/2020] [Indexed: 12/14/2022] Open
Abstract
Background Omalizumab is approved for treating severe allergic asthma from age 6, but the definition of severe asthma including a systematic assessment to rule out difficult-to-treat asthma has changed since the drug was approved in 2003. Methods We conducted a systematic review and meta-analysis of two critical (exacerbation rate, oral corticosteroid (OCS) treatment) and eight important clinical outcomes in children, adolescents and adults, and specifically searched papers for systematic assessment of severe asthma. Results Adults: seven studies (n = 2159) ascertaining exacerbation rate showing a 37% (95% CI 21–50) reduction in favor of omalizumab, larger than the pre-specified minimal clinically important difference (MCID) of 25%. Only one open-label study (n = 82) was identified assessing the percentage of patients experiencing reduction of OCS-maintenance treatment showing a significantly greater decrease in the omalizumab group (− 45% vs. + 18.3%, p = 0.002). Children and adolescents: four studies (n = 1551) reported data on exacerbations (no meta-analysis conducted), showed overall improvements in exacerbation rate and some passed MCID. No OCS studies were identified. No included studies provided systematic assessment of severe asthma according to current guidelines. Conclusions Omalizumab provides clinically relevant improvements in exacerbation rate among children, adolescents, and adults and in OCS-reduction among adults. New studies incorporating a guideline-approached definition of severe asthma are warranted.
Collapse
Affiliation(s)
- Daniel P Henriksen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Uffe Bodtger
- Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark.,Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | | | - Niels Maltbaek
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Lars Pedersen
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Hanne Madsen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Ehm A Andersson
- The Danish Medicines Council Secretariat, Copenhagen, Denmark
| | - Ole Norgaard
- The Danish Medicines Council Secretariat, Copenhagen, Denmark
| | - Louise K Madsen
- The Danish Medicines Council Secretariat, Copenhagen, Denmark
| | - Bo L Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte University Hospital, University of Copenhagen, Ledreborg Allé 34, Gentofte, 2820 Copenhagen, Denmark
| |
Collapse
|
43
|
Serino M, van Zeller M, Martins N, Drummond M. Severe asthma intervention in adult obese patients. Pulmonology 2020; 26:325-327. [PMID: 32553823 DOI: 10.1016/j.pulmoe.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- M Serino
- Pulmonology Department, Centro Hospitalar Universitário São João, Porto, Portugal.
| | - M van Zeller
- Pulmonology Department, Centro Hospitalar Universitário São João, Porto, Portugal; Faculty of Medicine, University of Porto, Portugal
| | - N Martins
- Pulmonology Department, Centro Hospitalar Universitário São João, Porto, Portugal; Faculty of Medicine, University of Porto, Portugal; Institute for Research and Innovation in Health, University of Porto, Portugal
| | - M Drummond
- Pulmonology Department, Centro Hospitalar Universitário São João, Porto, Portugal; Faculty of Medicine, University of Porto, Portugal
| |
Collapse
|
44
|
Perumal R, Leite M, van Zyl-Smit RN. The Relationship Between Clinical Trial Participation and Inhaler Technique Errors in Asthma and COPD Patients. Int J Chron Obstruct Pulmon Dis 2020; 15:1217-1224. [PMID: 32581528 PMCID: PMC7277230 DOI: 10.2147/copd.s249620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Incorrect inhaler use is associated with poorer health outcomes, reduced quality of life, and higher healthcare utilisation in patients with asthma and COPD. Methods We performed an observational study of pressurized metered-dose inhaler technique in patients with asthma or COPD. Patients were assessed using a six-point inhaler checklist to identify common critical inhaler technique errors. An inadequate inhaler technique was defined as the presence of one or more critical errors. A multivariate logistic regression model was used to determine the odds of an inadequate inhaler technique. Results During the 14-month study period, 357 patients were enrolled. At least one critical error was executed by 66.7% of participants, and 24.9% made four or more critical errors. The most common errors were failure to exhale completely prior to pMDI activation and inhalation (49.6%), failure to perform a slow, deep inhalation following device activation (48.7%), and failure to perform a breath-hold at the end of inspiration (47.3%). The risk of a critical error was higher in COPD patients (aOR 2.25, 95% CI 1.13-4.47). Prior training reduced error risk specifically when trained by a doctor (aOR 0.08, 95% CI 0.1-0.57) or a pharmacist (aOR 0.02, 95% CI 0.01-0.26) compared to those with no training. Previous clinical trial participation significantly reduced error risk and rate: <3 trials (aOR 0.35, 95% CI 0.19-0.66) and ≥3 trials (aOR 0.17, 95% CI 0.07-0.42). The rate of critical errors was not significantly associated with age, sex, or prior pMDI experience. Conclusion This study found a high rate of critical inhaler technique errors in a mixed population of asthma and COPD patients; however, prior training and, in particular, multiple previous clinical trial participation significantly reduced the risk of errors.
Collapse
Affiliation(s)
- Rubeshan Perumal
- Division of Pulmonology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Western Cape, South Africa
| | - Marcia Leite
- UCT Lung Institute, University of Cape Town, Western Cape, South Africa
| | - Richard Nellis van Zyl-Smit
- Division of Pulmonology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Western Cape, South Africa
- UCT Lung Institute, University of Cape Town, Western Cape, South Africa
| |
Collapse
|
45
|
Robinson R, Barber K, Jones G, Blakey J, Burhan H. Exploring the relationship between generalised anxiety/depression scales and asthma-specific quality of life/control questionnaires in a specialist asthma clinic. J Asthma 2020; 58:912-920. [PMID: 32186425 DOI: 10.1080/02770903.2020.1744640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Psychological issues are common in patients with chronic disabling diseases such as asthma. National guidance recommends that specialist asthma clinic attendees should complete questionnaires screening for psychological comorbidities. However, completing these in addition to asthma specific questionnaires can be burdensome. In order to investigate whether anxiety and depression questionnaires can be used in a targeted manner, this study investigates the correlation between the respective scores. We hypothesize that there is correlation between asthma-specific and anxiety/depression questionnaire scores. METHODS Three-hundred individuals with poorly controlled asthma attending a specialist clinic were asked to complete Asthma Control Questionnaire (ACQ), mini-Asthma Quality of Life Questionnaire (mini-AQLQ), Generalized Anxiety Disorder (GAD-7) and Patient Health Questionnaires (PHQ-9). A Pearson correlation coefficient was generated and area under ROC and confusion matrices were used to assess correlation. RESULTS 49% and 47% of patients completing the GAD-7 or PHQ-9 questionnaires, respectively had scores above the screening level for co-morbid anxiety and depression. Additional questionnaires were often incomplete (GAD-7 = 150 and PHQ-9 = 140). GAD-7 and PHQ-9 correlated with ACQ and mini-AQLQ (all p = <0.001, r values 0.53-0.65). Asthma-specific questionnaire scores were predictive of GAD-7 and PHQ-9 scores (AUCs of 0.78 to 0.84). 75% of patients with a mini-AQLQ score of <3 met the threshold GAD-7 and PHQ-9 score of 10. CONCLUSIONS ACQ and mini-AQLQ correlate with GAD-7 and PHQ-9 amongst specialist asthma clinic attendees. A mini-AQLQ >3 suggests patients are unlikely to have anxiety or depression. These findings could be used to identify patients requiring formal screening for psychological co-morbidity.
Collapse
Affiliation(s)
- R Robinson
- Respiratory Medicine, Royal Liverpool University Hospital, Liverpool, UK
| | - K Barber
- Respiratory Medicine, Countess of Chester Hospital, Chester, UK
| | - G Jones
- Respiratory Medicine, Royal Liverpool University Hospital, Liverpool, UK
| | - J Blakey
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia.,Curtin University Medical School, Perth, Australia
| | - H Burhan
- Respiratory Medicine, Royal Liverpool University Hospital, Liverpool, UK
| |
Collapse
|
46
|
Maltby S, Gibson PG, Reddel HK, Smith L, Wark PAB, King GG, Upham JW, Clark VL, Hew M, Owens L, Oo S, James AL, Thompson B, Marks GB, McDonald VM. Severe Asthma Toolkit: an online resource for multidisciplinary health professionals-needs assessment, development process and user analytics with survey feedback. BMJ Open 2020; 10:e032877. [PMID: 32209622 PMCID: PMC7202709 DOI: 10.1136/bmjopen-2019-032877] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Severe asthma imposes a significant burden on individuals, families and the healthcare system. New treatment and management approaches are emerging as effective options for severe asthma. Translating new knowledge to multidisciplinary healthcare professionals is a priority. We developed 'The Severe Asthma Toolkit' (https://toolkit.severeasthma.org.au) to increase awareness of severe asthma, provide evidence-based resources and support decisionmaking by healthcare providers. SETTING Roundtable discussions and a survey of Australians clinicians were conducted to determine clinician preferences, format and content for a severe asthma resource. PARTICIPANTS A reference group from stakeholder and consumer bodies and severe asthma experts provided advice and feedback. A multidisciplinary team of international experts was engaged to develop content. Written content was based on up-to-date literature. Peer and editorial review were performed to finalise content and inform web design. Website design focused on user experience, navigation, engagement, interactivity and tailoring of content for a clinical audience. RESULTS A web-based resource was developed. Roundtable discussions and a needs assessment survey identified the need for dedicated severe asthma management resources to support skills training. The end-product, which launched 26 March 2018, includes an overview of severe asthma, diagnosis and assessment, management, medications, comorbidities, living with severe asthma, establishing a clinic, paediatrics/adolescents and clinical resources. Analytics indicate access by users worldwide (32 169 users from 169 countries). User survey results (n=394) confirm access by the target audience (72% health professionals), who agreed the toolkit increased their knowledge (73%) and confidence in managing severe asthma (66%), and 75% are likely to use the resource in clinic. CONCLUSIONS The Severe Asthma Toolkit is a unique, evidence-based internet resource to support healthcare professionals providing optimal care for people with severe asthma. It is a comprehensive, accessible and independent resource developed by leading severe asthma experts to improve clinician knowledge and skills in severe asthma management.
Collapse
Affiliation(s)
- Steven Maltby
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Peter G Gibson
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Helen K Reddel
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Lorraine Smith
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- School of Pharmacy, University of Sydney Faculty of Pharmacy, Sydney, New South Wales, Australia
| | - Peter A B Wark
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Gregory G King
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - John W Upham
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Department of Respiratory Medicine, Princess Alexandra Hospital TRI, South Brisbane, Queensland, Australia
| | - Vanessa L Clark
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Mark Hew
- Department of Allergy, Immunology & Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Louisa Owens
- Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Stephen Oo
- Princess Margaret Hospital, Fiona Stanley Hospital and University of Western Australia, Perth, New South Wales, Australia
| | - Alan L James
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Bruce Thompson
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Guy B Marks
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
- South Western Sydney Clinical School UNSW, Sydney, New South Wales, Australia
| | - Vanessa M McDonald
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| |
Collapse
|
47
|
Hew M, Menzies-Gow A, Hull JH, Fleming L, Porsbjerg C, Brinke AT, Allen D, Gore R, Tay TR. Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2222-2233. [PMID: 32173508 DOI: 10.1016/j.jaip.2020.02.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.
Collapse
Affiliation(s)
- Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Andrew Menzies-Gow
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James H Hull
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Paediatric Difficult Asthma Service, Royal Brompton Hospital, London, United Kingdom
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anneke Ten Brinke
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - David Allen
- North West Lung Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Robin Gore
- Department of Respiratory Medicine, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| |
Collapse
|
48
|
McDonald VM, Clark VL, Cordova-Rivera L, Wark PAB, Baines KJ, Gibson PG. Targeting treatable traits in severe asthma: a randomised controlled trial. Eur Respir J 2020; 55:13993003.01509-2019. [PMID: 31806719 DOI: 10.1183/13993003.01509-2019] [Citation(s) in RCA: 118] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/23/2019] [Indexed: 01/15/2023]
Abstract
RATIONALE Treatable traits have been proposed as a new paradigm for airway disease management. OBJECTIVES To characterise treatable traits in a severe asthma population and to determine the efficacy of targeting treatments to these treatable traits in severe asthma. METHODS Participants (n=140) with severe asthma were recruited to a cross-sectional study and underwent a multidimensional assessment to characterise treatable traits. Eligible participants with severe asthma (n=55) participated in a 16-week parallel-group randomised controlled trial to determine the feasibility and efficacy of management targeted to predefined treatable traits, compared to usual care in a severe asthma clinic. The patient-reported outcome of health-related quality of life was the trial's primary end-point. MAIN RESULTS Participants with severe asthma had a mean±sd of 10.44±3.03 traits per person, comprising 3.01±1.54 pulmonary and 4.85±1.86 extrapulmonary traits and 2.58±1.31 behavioural/risk factors. Individualised treatment that targeted the traits was feasible and led to significantly improved health-related quality of life (0.86 units, p<0.001) and asthma control (0.73, p=0.01). CONCLUSIONS Multidimensional assessment enables detection of treatable traits and identifies a significant trait burden in severe asthma. Targeting these treatable traits using a personalised-medicine approach in severe asthma leads to improvements in health-related quality of life, asthma control and reduced primary care acute visits. Treatable traits may be an effective way to address the complexity of severe asthma.
Collapse
Affiliation(s)
- Vanessa M McDonald
- National Health and Medical Research Council, Centre of Excellence in Severe Asthma, Newcastle, Australia .,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Dept of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia.,School of Nursing and Midwifery, University of Newcastle, Newcastle, Australia
| | - Vanessa L Clark
- National Health and Medical Research Council, Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,School of Nursing and Midwifery, University of Newcastle, Newcastle, Australia
| | - Laura Cordova-Rivera
- National Health and Medical Research Council, Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - Peter A B Wark
- National Health and Medical Research Council, Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Dept of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Katherine J Baines
- National Health and Medical Research Council, Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - Peter G Gibson
- National Health and Medical Research Council, Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Dept of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| |
Collapse
|
49
|
Systematic Assessment for Difficult and Severe Asthma Improves Outcomes and Halves Oral Corticosteroid Burden Independent of Monoclonal Biologic Use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1616-1624. [PMID: 31954193 DOI: 10.1016/j.jaip.2019.12.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/22/2019] [Accepted: 12/28/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Guidelines endorse systematic assessment for severe asthma, with data indicating benefit across multiple outcome domains. OBJECTIVE We examined which patients respond to systematic assessment and whether oral corticosteroid burden can be decreased independent of monoclonal biologic use. METHODS Specialist-referred patients are assessed systematically for difficult asthma at our center. We undertook a responder analysis for improvements in the domains of symptom control, quality of life, exacerbations, and airflow obstruction, assessed 6 months after initial assessment. Multivariate analyses were performed for each domain to identify predictors of response. Changes in oral corticosteroid burden were also measured, stratified by monoclonal biologics commenced during assessment. RESULTS Among 161 patients assessed systematically, 64% had a reduction in exacerbations, 54% achieved minimum clinically important differences for both symptom control and quality of life, and 40% increased their forced expiratory volume in 1 second by ≥100 mL. Altogether, 87% of patients with asthma improved in at least 1 domain. The most consistent predictor of response across domains was poorer baseline asthma status. There was a substantial reduction in mean chronic oral corticosteroid dose (11-5 mg, n = 46, P < .001), even after excluding 7 patients commenced on monoclonal biologics (11-5.6 mg, n = 39, P < .001). CONCLUSIONS Almost 90% of patients undergoing systematic assessment for difficult asthma improve significantly in at least 1 key asthma outcome, with few reliable predictors of response. The halving of oral corticosteroid burden during systematic assessment is independent of, and comparable in magnitude with, that achieved by monoclonal biologics.
Collapse
|
50
|
Chung LP, Upham JW, Bardin PG, Hew M. Rational oral corticosteroid use in adult severe asthma: A narrative review. Respirology 2019; 25:161-172. [PMID: 31713955 PMCID: PMC7027745 DOI: 10.1111/resp.13730] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/05/2019] [Accepted: 10/22/2019] [Indexed: 12/17/2022]
Abstract
OCS play an important role in the management of asthma. However, steroid‐related AE are common and represent a leading cause of morbidity. Limited published studies suggest OCS usage varies across countries and recent registry data indicate that at least 25–60% of patients with severe asthma in developed countries may at some stage be prescribed OCS. Recent evidence indicate that many patients do not receive optimal therapy for asthma and are often prescribed maintenance OCS or repeated steroid bursts to treat exacerbations. Given the recent progress in adult severe asthma and new treatment options, judicious appraisal of steroid use is merited. A number of strategies and add‐on therapies are now available to treat severe asthma. These include increasing specialist referral for multidisciplinary assessments and implementing OCS‐sparing interventions, such as improving guideline adherence and add‐on tiotropium and macrolides. Biologics have recently become available for severe asthma; these agents reduce asthma exacerbations and lower OCS exposure. Further research, collaboration and consensus are necessary to develop a structured stewardship approach including realistic OCS‐weaning programmes for patients with severe asthma on regular OCS; education and public health campaigns to improve timely access to specialized severe asthma services for treatment optimization; and implementing targeted strategies to identify patients who warrant OCS use using objective biomarker‐based strategies.
Collapse
Affiliation(s)
- Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - John W Upham
- Department of Respiratory Medicine, Princess Alexandra Hospital and University of Queensland, Brisbane, QLD, Australia
| | - Philip G Bardin
- Department of Respiratory and Sleep Medicine, Monash Medical Centre, Monash University, Melbourne, VIC, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Hospital, Melbourne, VIC, Australia
| |
Collapse
|