Does gender affect asthma control in adult asthmatics?

Healthcare expenditure and its socio-demographic and clinical predictors in Australians with poorly controlled asthma

INTRODUCTION

Asthma has substantial and increasing health and economic burden worldwide. This study aimed to estimate healthcare expenditure and determine the factors that increase expenditure in Australians with poorly controlled asthma.

METHODS

Individuals ≥18 years of age with poorly controlled asthma, as determined by a score ≥1.5 on the Asthma Control Questionnaire, were included in the study. Healthcare utilization costs from medical services and medications were estimated over an average follow-up of 12 months from administratively linked data: the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme. A generalized linear model with gamma distribution and log link was used to predict participants' key baseline characteristics associated with variations in healthcare costs.

RESULTS

A total of 341 participants recruited through community pharmacies were included. The mean (standard deviation, SD) age of participants was 56.6 (SD 17.6) years, and approximately 71% were females. The adjusted average monthly healthcare expenditure per participant was $AU386 (95% CI: 336, 436). On top of the average monthly costs, an incremental expenditure was found for each year increase in age ($AU4; 95% CI: 0.78, 7), being unemployed ($AU201; 95% CI: 91, 311), one unit change in worsening quality of life ($AU35; 95% CI: 9, 61) and being diagnosed with depression and anxiety ($AU171; 95% CI: 36, 306).

CONCLUSIONS

In a cohort of Australian patients, characterized by poor asthma control and co-morbidities individuals impose substantial economic burden in terms of Medicare funded medical services and medications. Programs addressing strategies to improve the quality of life and manage co-morbid anxiety and depression and encourage asthma patients' engagement in clinically tolerable jobs, may result in significant cost savings to the health system.

What Is the Role of Sex-Related Differences in the Effectiveness and Safety of Biological Drugs Used in Patients With Severe Asthma?

Biological drugs are used to treat severe asthma with an improvement of clinical symptoms. Data on sex difference of these drugs in patients with severe asthma are sparse. This study aimed to assess the effects of sex-related differences on biological drugs in patients with severe asthma. In this observational, open-label, prospective, noncontrolled, single-center cohort pilot study, we enrolled adult patients aged >18 years diagnosed with severe asthma and not previously treated with biological drugs. The first clinical end point was the statistical difference (P < .05) in the efficacy of biological drugs evaluated using the asthma control test and spirometry between sexes. The first safety end point was the statistical difference (P < .05) in developing adverse drug reactions between sexes. We enrolled 74 patients with severe asthma (48 women and 26 men) with a mean age of 59.4 (standard deviation, 11.8) years. The mean forced expiratory volume in 1 second was 6.9 (standard deviation, 13.9) for women and 9.4 (standard deviation, 10.7) for men and improved significantly after the treatment (P < .01), with no significant differences in sex (P = .8). Similarly, the asthma control test improved 12 months after the beginning of the treatment without significant differences between men and women (P = .5). The most common drug used was omalizumab (45.9% of the patients; P < .01) without significant differences between sex (P > .05). We did not observe the development of adverse drug reactions during the study. In conclusion, in asthmatic patients, sex does not have a role in either the effectiveness or safety of biological drugs.

A Smartphone App to Support Adherence to Inhaled Corticosteroids in Young Adults With Asthma: Multi-Methods Feasibility Study

Background

Young adults with asthma often report low adherence to inhaled corticosteroids (ICS), leading to uncontrolled symptoms and poor disease outcomes. Technology-enabled digital supports such as mobile health (mHealth) asthma smartphone apps have the potential to support adherence to ICS and asthma self-management. There is a need for feasibility studies to determine the usability, acceptability, and feasibility of these interventions. In addition, it is essential to determine the feasibility of recruiting and retaining young adults to plan future efficacy and effectiveness trials and therefore, establish evidence-based asthma apps.

Objective

This study aimed to determine (1) the feasibility of recruiting and retaining young adults to a trial and (2) the usability, acceptability, and feasibility of using the AsthmaMD app to support adherence to ICS in a population of young adults living with asthma.

Methods

A multi-methods feasibility study was conducted. Young adults aged 18-30 years with asthma and current prescription for ICS were eligible and invited to take part through a university circular email, social media, and general practice sites. Participation involved completing a baseline self-report questionnaire, downloading and using the AsthmaMD app for 2 weeks, and completing the follow-up assessment, including self-report and open-ended questions about participants’ experience of using the app. Primary outcomes included participant recruitment and retention and the usability, acceptability, and feasibility of using AsthmaMD. Quantitative self-report data were analyzed using descriptive statistics, and qualitative open-ended data were analyzed using inductive reflexive thematic analysis.

Results

A total of 122 young adults (females, n=101, 82.8%) with a mean age of 24.4 (SD 3.8) years were recruited and they completed baseline measures. Of the 122 young adults, 59 (48.4%) completed the study. The AsthmaMD app received a mean score of 63.1/100 (SD 20.1) on the System Usability Scale (ie, a standardized measure of usability for technology-based apps), and an overall user satisfaction score of 5.8/10 (SD 2.2). Of the 59 participants who completed the study, 49 (83%) participants used the app ≥1 day per week. Two main themes were identified in the qualitative analysis of user experiences: (1) learning how to use the app to suit the individual and (2) benefits and relevance of using the app.

Conclusions

The findings from this study indicate that it is feasible to recruit and retain young adults to examine efficacy and effectiveness in a future trial and that young adults living with asthma may find AsthmaMD to be usable, acceptable, and feasible to support adherence to ICS. Our findings also identified opportunities to further optimize the usability of AsthmaMD and similar apps. Based on our findings, we recommend providing more accessible information on how to use the app and replacing medical terminology with simplified language within the app to improve usability.

Trial Registration

ISRCTN Registry ISRCTN11295269; https://www.isrctn.com/ISRCTN11295269

Demographic and clinical patterns of severe asthma in the Middle East

BACKGROUND:

Severe asthma is a major burden on health-economic resources; hence, knowing the epidemiology of these patients is important in planning and provision of asthma care. In addition, identifying and managing the comorbidities helps improve symptoms and reduce associated morbidity and mortality.

OBJECTIVES:

Epidemiology of difficult asthma has not been well studied in the Middle East, so in this study, we present the demographic and clinical characteristics of severe asthma in the United Arab Emirates (UAE).

METHODS:

We retrospectively reviewed the notes of severe asthma patients attending three tertiary care hospitals between May 2015 and December 2019. Data on baseline demographics, asthma characteristics, treatment, and comorbidities were collected.

RESULTS:

We reviewed the notes of 458 patients (271 females and 187 males) that fulfilled the 2019 Global Initiative for Asthma guidelines for the diagnosis of severe asthma. The mean age was 47.7 (standard deviation 17.2) years. Males had significantly higher asthma control test scores (17.9 vs. 16, P = 0.01) and mean blood eosinophils (0.401 vs. 0.294, P <0.01) than females. The most common comorbidity observed was allergic rhinitis (52.2%) followed by gastroesophageal reflux disease (27.1%). In total, 109 (23.8%) patients were on biological therapies with most patients being on omalizumab and dupilumab (29 and 18 patients, respectively). Most patients were nonsmokers (97.2%), and majority were of TH2-high phenotype (75.7%).

CONCLUSIONS:

In this first report of severe asthma characteristics in the UAE, we found a pattern of female preponderance and most patients having a Th2-high phenotype. The findings are likely to help optimize asthma care in the region in the era of biologic therapies.

Role of Differential Estrogen Receptor Activation in Airway Hyperreactivity and Remodeling in a Murine Model of Asthma

Evidence suggests that airway hyperresponsiveness (AHR) is a characteristic feature of asthma. Epidemiological studies have confirmed that the severity of asthma is greater in women, suggesting a critical role of female sex steroid hormones (especially estrogen). Very few in vivo studies have examined the role of sex steroid hormones in asthma, and the sequence of events that occur through differential activation of estrogen receptors (ERs) remains to be determined in asthmatic airways. Our recent in vitro findings indicated that ERβ had increased expression in asthmatic airway smooth muscle (ASM), and that its activation by an ERβ-specific agonist downregulated airway remodeling. In this study, we translated the in vitro findings to a murine asthma model and examined the differential role of ER activation in modulating lung mechanics. C57BL/6J male, female, and ovariectomized mice were exposed to mixed allergen (MA) and subcutaneously implanted with sustained-release pellets of placebo, an ERα agonist (4,4',4″-(4-propyl-[1H]-pyrazole-1,3,5-triyl)trisphenol [PPT]), and/or an ERβ agonist (WAY-200070). We then evaluated the effects of these treatments on airway mechanics, biochemical, molecular, and histological parameters. Mice exposed to MA showed a significant increase in airway resistance, elastance, and tissue damping, and a decrease in compliance; pronounced effects were observed in females. Compared with PPT, WAY treatment significantly reversed the MA-induced changes. The increased mRNA/protein expression of ERα, ERβ, and remodeling genes observed in MA-treated mice was significantly reversed in WAY-treated mice. This novel study indicates that activation of ERβ signaling downregulates AHR and airway remodeling, and is a promising target in the development of treatments for asthma.

Role of Estrogen Receptors α and β in a Murine Model of Asthma: Exacerbated Airway Hyperresponsiveness and Remodeling in ERβ Knockout Mice

Epidemiological data suggests increased prevalence of asthma in females than males, suggesting a plausible role for sex-steroids, especially estrogen in the lungs. Estrogen primarily acts through estrogen-receptors (ERα and ERβ), which play a differential role in asthma. Our previous studies demonstrated increased expression of ERβ in asthmatic human airway smooth muscle (ASM) cells and its activation diminished ASM proliferation in vitro and airway hyperresponsiveness (AHR) in vivo in a mouse (wild-type, WT) model of asthma. In this study, we evaluated the receptor specific effect of circulating endogenous estrogen in regulating AHR and remodeling using ERα and ERβ knockout (KO) mice. C57BL/6J WT, ERα KO, and ERβ KO mice were challenged intranasally with a mixed-allergen (MA) or PBS. Lung function was measured using flexiVent followed by collection of broncho-alveolar lavage fluid for differential leukocyte count (DLC), histology using hematoxylin and eosin (H&E) and Sirius red-fast green (SRFG) and detecting αsmooth muscle actin (α-SMA), fibronectin and vimentin expression using immunofluorescence (IF). Resistance (Rrs), elastance (Ers), tissue-damping (G) and tissue-elasticity (H) were significantly increased, whereas compliance (Crs) was significantly decreased in WT, ERα KO, and ERβ KO mice (males and females) challenged with MA compared to PBS. Interestingly, ERβ KO mice showed declined lung function compared to ERα KO and WT mice at baseline. MA induced AHR, remodeling and immune-cell infiltration was more prominent in females compared to males across all populations, while ERβ KO females showed maximum AHR and DLC, except for neutrophil count. Histology using H&E suggests increased smooth muscle mass in airways with recruitment of inflammatory cells, while SRFG staining showed increased collagen deposition in MA challenged ERβ KO mice compared to ERα KO and WT mice (males and females), with pronounced effects in ERβ KO females. Furthermore, IF studies showed increased expression of α-SMA, fibronectin and vimentin in MA challenged populations compared to PBS, with prominent changes in ERβ KO females. This novel study indicates ERβ plays a pivotal role in airway remodeling and AHR and understanding the mechanisms involved might help to surface it out as a potential target to treat asthma.

Lung Sound Analysis Provides A Useful Index For Both Airway Narrowing And Airway Inflammation In Patients With Bronchial Asthma

Background

The expiration-to-inspiration sound power ratio in a midfrequency range (E/I MF), a parameter of lung sound analysis (LSA), has been reported to be useful as an index of airway inflammation in patients with bronchial asthma. However, the E/I MF reflects airway narrowing caused by airway inflammation, and there is thus concern that it may not be an index of airway eosinophilic inflammation itself.

Methods

A total of 131 patients with bronchial asthma were classified into four groups according to the presence or absence of airway narrowing and airway inflammation to examine whether the E/I MF could serve as an index of airway inflammation.

Results

The E/I MF was significantly higher in patients with a normal forced expiratory volume in one second (FEV₁) and high fractional exhaled nitric oxide (FeNO), those with a low FEV₁ and normal FeNO, and those with a low FEV₁ and high FeNO than in those with a normal FEV₁ and normal FeNO (p < 0.05–0.01). In particular, the E/I MF was high even in the patients who had no airway narrowing but had airway inflammation (p < 0.01). The results of multivariate analysis of factors involved in FeNO in patients with a normal FEV₁ revealed that the E/I MF was an independent factor (p = 0.0281).

Conclusion

The E/I MF is a useful index of airway inflammation in the treatment of asthma, regardless of the presence or absence of airway narrowing.

Factors associated with uncontrolled asthma in adult asthmatics in Kinshasa, Democratic Republic of Congo

Background

The ultimate goal of asthma treatment is long-term control. Uncontrolled asthma is a major public health problem worldwide, but there is a lack of data on asthma control and its causes in the Democratic Republic of Congo (DRC).

Objective

To determine the socio-demographic, environmental, clinical, and biological factors and comorbidities associated with uncontrolled adult asthma in Kinshasa, DRC.

Methods

We performed a cross-sectional study of 216 male and female asthmatics aged 18 and over consecutively recruited from tertiary clinics and the community in Kinshasa between June 2017 and February 2018. For each subject, socio-demographic, clinical, para clinical and environmental data were recorded. Forced Expiratory Volume in one second (FEV₁) values were obtained by Spirometry, allergen testing performed using the skin prick test, serum vitamin D levels measured by radioimmunoassay, and asthma control assessed using the asthma control test (ACT) score. Multiple logistic regression identified factors associated with uncontrolled asthma.

Results

The average age of participants was 45.2 (SD 17.6) years, 74% were female, and 42% had a low educational level. Among all asthmatics, the prevalence of uncontrolled asthma was 56%, abnormal serum vitamin D level 95%, abnormal FEV₁ 65%, sensitization to two allergens (cat dander and dust mites) 18%, sleep disorders 37%, and heartburn 60%. Male (aOR 2.24; 95% CIs 1.04–4.79), low educational level (aOR 3.26; 95% CIs 1.54–6.67), sensitization to both cat dander and dust mites (aOR 2.67; 95% CIs 1.16–6.14), FEV₁ ≤80% (aOR 2.07; 95% CIs 1.08–3.96), abnormal serum vitamin D level (aOR 5.11; 95% CIs 1.17–22.33), sleep disorders (aOR 1.96; 95% CIs 1.04–3.71), and heartburn (aOR 2.02; 95% CIs 1.04–3.92) were significantly associated with uncontrolled asthma.

Conclusion

Uncontrolled asthma is common in Kinshasa, and these factors associated with uncontrolled asthma may be considered as targets for future intervention strategies.

Asthma control and predictive factors among adults in Saudi Arabia: Results from the Epidemiological Study on the Management of Asthma in Asthmatic Middle East Adult Population study

CONTEXT:

Asthma control is suboptimal in the Middle East and North Africa (MENA).

AIMS:

The aim of this study is to assess the level of asthma control in Saudi patients as per the Global Initiative for Asthma 2012 classification and explore its potential predictive factors.

SETTINGS AND DESIGN:

Epidemiological Study on the Management of Asthma in Asthmatic Middle East Adult Population (ESMAA) is a multicentric, descriptive, epidemiological study assessing asthma management in the MENA region. In this article, we report the results of patients from Saudi Arabia included in the ESMAA study.

METHODS:

Adult patients diagnosed with asthma at least 1 year before study entry were considered for inclusion. Asthma control level and its predictive factors were explored. Treatment adherence and quality of life (QoL) were assessed by MMAS-4^© and Short Form 8 Health Survey QoL questionnaires, respectively.

STATISTICAL ANALYSIS USED:

Descriptive statistics were done considering two-sided 95% confidence intervals. Logistic regression was used to explore the potential predictive factors of asthma control. All statistical tests were two-sided, and P < 0.05 was considered statistically significant.

RESULTS:

Data of 1009 patients from Saudi Arabia were analyzed. Less than one-third of patients (30.1%) were found to have controlled asthma with significantly higher QoL. High level of asthma control was reported among male patients and those with high educational level, while age, body mass index, and adherence to treatment were found to have no effect on asthma control.

CONCLUSIONS:

Asthma control remains suboptimal among Saudi population. This needs huge efforts to achieve acceptable levels of control and better QoL for asthma patients. Further studies are still needed in Saudi Arabia and the Middle East region.

Asthma control, lung function, nutritional status, and health-related quality of life: differences between adult males and females with asthma

OBJECTIVE

To evaluate health-related quality of life in asthma patients treated at a referral center in southern Brazil, identifying differences between male and female patients, as well as to evaluate differences between the males and females in terms of asthma control, lung function, and nutritional status.

METHODS

This was a cross-sectional study involving patients ≥ 18 years of age treated at an asthma outpatient clinic. We evaluated clinical parameters, lung function, nutritional status, and quality of life.

RESULTS

A total of 198 patients completed the study. The mean age was 56.2 ± 14.8 years, and 81.8% were female. The proportion of patients with uncontrolled asthma was higher among females than among males (63.0% vs. 44.4%; p = 0.041). The body mass index (BMI) and percentage of body fat were higher in females than in males (30.2 ± 5.8 kg/m2 vs. 26.9 ± 4.5 kg/m2 and 37.4 ± 6.4% vs. 26.5 ± 7.4%; p = 0.002 and p < 0.001, respectively). Quality of life was lower in females than in males in the following domains: symptoms (3.8 ± 1.5 vs. 4.6 ± 1.7; p = 0.006); activity limitation (3.6 ± 1.3 vs. 4.4 ± 1.5; p = 0.001); emotional function (3.6 ± 1.9 vs. 4.5 ± 1.7; p = 0.014); and environmental stimuli (3.2 ± 1.6 vs. 4.3 ± 1.9; p = 0.001).

CONCLUSIONS

Male asthma patients appear to fare better than do female asthma patients in terms of health-related quality of life, asthma control, BMI, percentage of body fat, and comorbidities.

Demographic and medical factors affecting short-term changes in subjective evaluation of asthma control in adolescents

INTRODUCTION

Asthma control is an important measure of disease stabilization, which is linked to the treatment and lifestyle recommendations.

AIM

To assess the impact of selected factors on asthma control in adolescents, as assessed using the Asthma Control Test (ACT™).

MATERIAL AND METHODS

The prospective study included 100 asthma patients aged between 12 and 19. Asthma was assessed in three consecutive follow-up visits spaced 3 months apart, using the standardized ACT™ questionnaire.

RESULTS

Asthma was fully controlled (ACT score = 25 points) in more than half of the patients in all follow-up visits (53.0%, 54.0%, and 56.0%, respectively). More than one third of the participants scored between 20 and 24 points (37.0% vs. 39.0% vs. 40.0%). A minority of patients had uncontrolled asthma (scores below 20), and the group consistently diminished in subsequent visits (10% vs. 7% vs. 4%). Uncontrolled asthma was found significantly more often in female patients (33.33%; p < 0.001) and those living in rural areas (20.59%; p < 0.01). Treatment with a combination of inhaled corticosteroids (ICS) and LABAs was associated with worse asthma control (14.81%; p < 0.05). Better asthma control was found in patients with a family history of allergies (73.85% vs. 75.38% vs. 78.46%; p < 0.001) and in those with concurrent allergies (66.67% vs. 68.00% vs. 70.67%; p < 0.001).

CONCLUSIONS

Asthma control in adolescents differs by sex and residence. Concurrent allergies and family history of allergies improve asthma self-control in adolescents.

Asthma insights from Jordan: cross-sectional observational study

OBJECTIVE

The burden of uncontrolled asthma on patients in Jordan is largely unknown. This study assessed different aspects of asthma clinical features: the level of asthma control, its correlation with quality of life, and possible predictors of asthma control.

METHODS

Face-to-face interviews with asthmatic patients (≥16 years old) in north Jordan from 2013 to 2014 were conducted. Outcomes measures were assessed using the asthma control test (ACT), the mini asthma quality of life questionnaire (mini-AQLQ), and the Generic health-related quality of life (EQ-5D). The relationship between asthma control and quality of life was examined using Spearman's correlation coefficient. Predictors of asthma control were determined using multivariable logistic regression adjusted for confounders.

RESULTS

A total of 255 patients were recruited (mean age 45.16 years, 74.5% female). Approximately one-third of subjects (30.6%; n = 78) had controlled asthma (ACT ≥ 20). A strong correlation between asthma control and both mini-AQLQ and EQ-5D scores was identified (p < 0.001). Subjects who required to step-up treatment (OR = 0.12, 95% CI: 0.02-0.63, p = 0.01) and with acute asthma exacerbation (OR = 0.32, 95% CI: 0.18-0.58, p < 0.001) were independently associated with poor asthma control.

CONCLUSIONS

Most of the recruited patients have not achieved optimal asthma control and was associated with low quality of life. The study highlights that even in low-income countries, a simple assessment tool such as the ACT can be utilized to screen and categorize asthma control. This approach would facilitate a better treatment plan and eventually improve asthma control and quality of life in asthma patients.

The burden of adult asthma in a high GDP per capita country: the QASMA study

BACKGROUND

Asthma is a major health problem worldwide. Suboptimal asthma care and poor asthma control are common even in developed countries. Qatar has the highest gross domestic product per capita in the world and high per capita health expenditure. No prior study has assessed the burden of adult asthma in this country.

OBJECTIVES

To assess asthma control, patients' level of education about asthma, and level of asthma care in a country with the highest gross domestic product per capita in the world.

METHODS

A face-to-face, cross-sectional study of 520 adults with physician-diagnosed asthma conducted in various health care facilities in Qatar.

RESULTS

Thirty-three percent, 41%, and 26% of patients had uncontrolled, controlled, and partly controlled asthma, respectively. Only 4.9% of patients had previously received a written asthma management plan, 3.5% had a flow meter at home, and 37.2% had a spirometry performed in the previous 5 years. In addition, 42.9% misunderstood the role of reliever and controller medications. Inhaler technique was incorrect in 47% of these patients. There was a significant association between the type of physician practice and level of asthma control, with worst control being at the general practice level. Moreover, 57.3% of patients had at least 1 asthma-related visit to the emergency department in 1 year and 18.7% had more than 3 visits.

CONCLUSION

The very high gross domestic product per capita in Qatar and the high health expenditure per capita do not seem to have led to better asthma care and control. A comprehensive national asthma service improvement program is much needed.