Un-diagnosing persistent adult asthma

On the Ethics of Withholding and Withdrawing Unwarranted Diagnoses

The number of diagnoses and the number of persons having diagnoses have increased substantially, and studies indicate that diagnoses are given or upheld even if they are unwarranted, that is, that they do not satisfy professionally accepted diagnostic criteria. In this article, the authors investigate the ethics of withholding and withdrawing unwarranted diagnoses. First, they investigate ethical aspects that make it difficult to withhold and to withdraw such diagnoses. Second, they scrutinize whether there are psychological factors, both in persons/patients and healthcare professionals, making it difficult to withdraw and withhold unwarranted diagnoses. Lastly, they use recent elements of the withholding-versus-withdrawing treatment debate in medical ethics to investigate whether there are any differences between withholding and withdrawing treatment and withdrawing and withholding unwarranted diagnoses. The authors conclude that it is crucial to acknowledge and address all these issues to reduce and avoid unwarranted diagnoses.

The Clinical Course of Asthma After Withdrawal of Inhaled Corticosteroids

BACKGROUND

Maintenance of inhaled corticosteroids (ICSs) is recommended in adults with asthma. However, adherence rates in patients with mild asthma and side effects of long-term ICS use can lead to withdrawal.

OBJECTIVE

To analyze the real-world outcomes of ICS withdrawal by analyzing data from the Korean National Health Insurance database.

METHODS

Based on claims data from the National Health Insurance of Korea between 2011 and 2014, we identified patients diagnosed with asthma without chronic obstructive pulmonary disease or long-term systemic steroid use who had an ICS medication possession rate of more than 50% in a year. We compared patients who received ICS consistently (maintenance group) with patients who had no ICS prescription for more than 6 months (withdrawal group). We evaluated exacerbation leading to prescription of systemic steroid and emergency department visit or hospitalization.

RESULTS

Excluding patients with chronic obstructive pulmonary disease and long-term systemic steroid users, we identified 145,511 patients for the asthma cohort (mean age, 60.0 years; ever-smoker, 63.5%): 132,175 maintained ICS and 13,336 withdrew ICS for more than 6 months. Only 71 patients (0.5%) experienced exacerbation leading to an emergency department visit or hospitalization in the withdrawal group. ICS was restarted within 1 year for 33.6% of the withdrawal group, and 90% of these patients restarted ICS within 158 days.

CONCLUSIONS

This nationwide study of patients with asthma, characterized by a high proportion of elderly and smokers, showed that ICS withdrawal in about 10% of patients appeared to confer relatively minimal harm and exacerbation leading to hospitalization was not common. Further prospective studies are warranted to carefully explore the safety of ICS withdrawal in younger, nonsmoking, and well-controlled patients with asthma.

Pragmatic Clinical Perspective on Biologics for Severe Refractory Type 2 Asthma

Patients with severe refractory asthma present a challenging clinical conundrum for practicing clinicians. Biologics that target key mediators in the type 2 inflammation cascade, including IL-4, IL-5, IL-13, and IgE, can be effective strategies for these patients. However, with various biologics available, choosing the optimal one for a particular patient becomes a nuanced decision. We propose a pragmatic algorithm that identifies the optimal biologic class for patients who have specific type 2 disease endotypes. Patients with eosinophilic endotypes fare well with anti-IL-5(rα) medications, comprising mepolizumab, benralizumab, and reslizumab because they have been shown to reduce exacerbations in severe eosinophilic asthma by approximately 50%. In patients with fractional exhaled nitric oxide-high endotypes, anti-IL-4rα such as dupilumab is deemed to be most effective and has demonstrated a 47% reduction in asthma exacerbations. For patients with severe uncontrolled allergic asthma, anti-IgE (omalizumab) is effective and has been shown to confer a 25% reduction in asthma exacerbations. Type 2 comorbidities including chronic rhinosinusitis with nasal polyps, atopic dermatitis, chronic idiopathic urticaria, and eosinophilic esophagitis are important to bear in mind before the prescription of biologics. Further head-to-head studies are indicated to compare biologics in patients with mixed endotypes according to peripheral blood eosinophils, fractional exhaled nitric oxide, and allergic status. The evidence strongly supports endotype-driven prescribing of biologics to achieve clinically relevant outcomes in severe refractory asthma and related comorbidities.

Scottish consensus statement on the role of FeNO in adult asthma

Fractional exhaled nitric oxide (FeNO) is the only available point of care test to assess type-2 inflammation in asthma. In making a diagnosis of asthma, FeNO should be used together with blood eosinophils and spirometry, alongside a history. Raised FeNO in conjunction with blood eosinophilia are treatable traits of type 2 inflammation in asthma, which in turn may guide personalised management. A FeNO suppression test can be used to assess adherence and device use with ICS therapy. Furthermore FeNO may be used to provide feedback to patients in response to ICS, especially when spirometry is normal. FeNO may facilitate appropriate referral to secondary care for more definitive specialist investigations. In summary, FeNO is cost effective in the diagnosis and management of asthma and should be incorporated into primary and secondary care as part of routine clinical practice.

Undiagnosing to prevent overprescribing

Health care focuses on controlling symptoms and managing risk factors to improve survival by avoiding future complications. Diagnoses describe a group of signs and symptoms, often implying specific aetiologies and underlying pathophysiological disease processes. The diagnosis provides a tool for the health professional to conceptualise and classify a presentation, and thus manage the condition, and can provide the patient with an explanation or validation of their experience. Not every diagnosis holds significant clinical implications. There are diagnosed conditions that do not require treatment and, moreover, where treatment has the potential for harm without the potential for benefit. Promoting investigations and diagnoses can lead to overdiagnosis related to vested interests in increased services, use of devices or therapeutics. Multiple factors drive this issue, including broadening disease definitions and cultural factors that encourage tests and treatments, as well as medicolegal factors. While the traditional medicine review process typically involved cross-referencing medicines used with current diagnoses, a more sophisticated version of this process critically reviews the medicines and associated diagnosis, giving less emphasis to diagnoses that are no longer relevant. Known as undiagnosis, this process facilitates the withdrawal of corresponding medicines used to manage those conditions. Systematically reviewing diagnoses regularly and the associated medicine management strategies could reduce prescribing. The novel ERASE process can help clinicians Evaluate diagnoses to consider Resolved conditions, Ageing normally and Selecting appropriate targets to Eliminate unnecessary diagnoses and their corresponding medicines.