The use of the Asthma Control Test in general practice and its correlation with asthma control according to the GINA guidelines

Characteristics of Severe Asthma Patients and Predictors of Asthma Control in the Swiss Severe Asthma Registry

BACKGROUND

Asthma is a chronic airway disease, affecting over 300 million people worldwide. 5-10% of patients suffer from severe asthma and account for 50% of asthma-related financial burden. Availability of real-life data about the clinical course of severe asthma is insufficient.

OBJECTIVES

The aims of this study were to characterize patients with severe asthma in Switzerland, enrolled in the Swiss Severe Asthma Registry (SSAR), and evaluate predictors for asthma control.

METHOD

A descriptive characterisation of 278 patients was performed, who were prospectively enrolled in the registry until January 2022. Socio-demographic variables, comorbidities, diagnostic values, asthma treatment, and healthcare utilisation were evaluated. Groups of controlled and uncontrolled asthma according to the asthma control test were compared.

RESULTS

Forty-eight percent of patients were female and the mean age was 55.8 years (range 13-87). The mean body mass index (BMI) was 27.4 kg/m2 (±6). 10.8% of patients were current smokers. Allergic comorbidities occurred in 54.3% of patients, followed by chronic rhinosinusitis (46.4%) and nasal polyps (34.1%). According to the ACT score, 54.7% had well controlled, 16.2% partly controlled and 25.9% uncontrolled asthma. The most common inhalation therapy was combined inhaled corticosteroids/long-acting β2-agonists (78.8%). Biologics were administered to 81.7% of patients and 19.1% received oral steroids. The multivariable analysis indicated that treatment with biologics was positively associated with asthma control whereas higher BMI, oral steroids, exacerbations, and COPD were negative predictors for asthma control.

CONCLUSION

Biologics are associated with improved control in severe asthma. Further studies are required to complete the picture of severe asthma in order to provide improved care for those patients.

Characteristics of Asthma Exacerbations in Emergency Care in Switzerland-Demographics, Treatment, and Burden of Disease in Patients with Asthma Exacerbations Presenting to an Emergency Department in Switzerland (CARE-S)

Emergency care for asthma is provided by general practitioners, pulmonologists, and emergency departments (EDs). Although it is known that patients presenting to EDs with acute asthma exacerbations are a vulnerable population and that this mode of presentation is a risk marker for more severe complications, research on this population is scarce. We conducted a retrospective study on patients with asthma exacerbations who presented to the ED of the University Hospital Basel, Switzerland, during 2017-2020. Of the last 200 presentations, 100 were selected and analyzed to assess demographic information, the use of previous and ED-prescribed asthma medication, and clinical outcomes after a mean period of time of 18 months. Of these 100 asthma patients, 96 were self-presenters, and 43 had the second highest degree of acuity (emergency severity index 2). Global Initiative for Asthma (GINA) step 1 and step 3 were the most common among patients with known GINA levels, accounting for 22 and 18 patients, respectively. A total of 4 patients were undergoing treatment with oral corticosteroids at presentation, and 34 were at discharge. At presentation, 38 patients used the combination therapy of inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA), and 6 patients underwent ICS monotherapy. At discharge, 68 patients were prescribed with ICS/LABA. At entry to the ED, about one-third of patients did not use any asthma medication. In total, 10 patients were hospitalized. None of them needed invasive or non-invasive ventilation. A follow-up for the study was precluded by the majority of patients. This group of asthma patients seemed particularly vulnerable as their asthma medication at presentation was often not according to guidelines or even lacking, and almost all the patients had self-presented to the ED without any reference from a physician. The majority of patients did not give consent to the collection of any follow-up information. These medical shortcomings reflect an urgent medical need to improve care for patients at high risk of asthma exacerbations.

Development of a community pharmacy-based intervention for patients with uncontrolled asthma

Background

Objective

Methods

Results

Conclusions

Pragmatic Markers in the Management of Asthma: A Real-World-Based Approach

Bronchial hyperreactivity, reversible airflow limitation and chronic airway inflammation characterize asthma pathophysiology. Personalized medicine, i.e., a tailored management approach, is appropriate for asthma management and is based on the identification of peculiar phenotypes and endotypes. Biomarkers are necessary for defining phenotypes and endotypes. Several biomarkers have been described in asthma, but most of them are experimental and/or not commonly available. The current paper will, therefore, present pragmatic biomarkers useful for asthma management that are available in daily clinical practice. In this regard, eosinophil assessment and serum allergen-specific IgE assay are the most reliable biomarkers. Lung function, mainly concerning forced expiratory flow at 25-755 of vital capacity (FEF_25-75), and nasal cytology may be envisaged as ancillary biomarkers in asthma management. In conclusion, biomarkers have clinical relevance in asthma concerning both the endotype definition and the personalization of the therapy.

The Measurement of Asthma and Allergic Rhinitis Control in Children and Adolescents

Asthma and allergic rhinitis (AR) are frequently associated. The objective of the treatment of asthma and AR should be the control of symptoms and disease progression. Therefore, the combined measurement of disease control is desirable. In this regard, a questionnaire able to together assess asthma and AR control has been validated: the CARAT (Control of Allergic Rhinitis and Asthma Test). A further pediatric version (CARATkids) has been generated. The current real-world study used different disease control measures in children and adolescents with asthma and rhinitis. A total of 138 children and adolescents were recruited at three allergy centers. CARAT, CARATkids, ACT (Asthma Control Test), cACT (children ACT), GINA (Global Initiative for Asthma) disease control classification, VAS (Visual Analog Scale) for asthma and nasal symptoms, and lung function were used in all subjects. There was a predominance of males (67.4%) and asthma was well-controlled (according to GINA classification) in about half the subjects. In children, the median CARAT and cACT values were 5 and 22 respectively. In adolescents, the median CARAT and ACT values were 23 for both tests. There were significant differences between CARAT and ACT (p = 0.035) as well as between CARATkids and cACT (p = 0.0001). However, the tests’ outcomes were different as assessed in different domains. CARAT and CARATkids are disease-control measurements that give additional information to other tests, therefore, these different questionnaires to measure disease control complement each other.

Patient evaluations of asthma counselling quality in primary health care — a cross-sectional survey

Background

Healthcare staff have a key role in counselling patients. This study describes asthma patients’ evaluations of primary care counselling quality.

Methods

The research applied a cross-sectional study design, with data collected from adult asthma patients (n = 73). Data were analysed by descriptive statistics.

Results

Most of participating patients were women (73%) and over 60 years old (67%). The patients were generally satisfied with the counselling. Subjection to an asthma test (p = 0.009) and smoking (p = 0.019) were found to significantly positively affect patient perceptions of counselling quality. The patients also felt that support services should be covered more (74%). Patients with comprehensive education (p = 0.039) and smokers (p = 0.015) were more likely to be satisfied with the counselling than other patients. Counselling was client-oriented (53%) and most patients reported experiencing positive interactions (92%). Most patients agreed that counselling benefitted adherence to self-care (75%) and health promotion (67%). Moreover, almost all of the patients were satisfied with the staff members’ knowledge and skills (97%). Subjection to an asthma test (p = 0.043), age (p = 0.030), smoking (p = 0.014), and duration of illness (p = 0.002) influenced satisfaction with counselling resources.

Conclusion

The results indicate that counselling benefits asthma patients. Performing an asthma test, as well as considering smoking habits and educational level, can improve patient perceptions of counselling.

The first year of treatment predicts the prognosis of asthma over 25 y-A prospective study

BACKGROUND

An investigator-driven, real-life follow-up study of adult-onset steroid-naïve, newly diagnosed asthma (162 patients) to investigate the treatment results over the 25-year course of the disease and whether the first treatment year's forced expiratory volume in one second (FEV₁ ) predicts the long-term prognosis.

METHODS

Eighty-three per cent of the 133 living patients participated in the 25-year examinations. At this visit, basic asthma examinations including lung function, as well as questionnaires for health-related quality of life (HRQoL), GINA and the Asthma Control Test, were used for evaluation. The use of medication and remission was verified.

RESULTS

There was no statistically significant change in mean FEV₁ % predicted (FEV₁ %) from baseline to the 25-year control. The changes in FEV₁ % during the first year predicted the results at the end of follow-up. Normal FEV₁ % at the end of the first year predicted normal FEV₁ , and below-normal FEV₁ % at 1 year predicted below-normal FEV₁ % at 25 years. Twenty-nine patients (26.4%) had discontinued their medication, and six (5.5%) used ICS periodically. Clinical remission was reached by 16.4% of the patients, and 7.6% reached functional remission. The general HRQoL remained unchanged.

CONCLUSION

In adult-onset asthma, the level of FEV₁ reached during the first treatment year seems to predict the later lung function level. One quarter of the patients discontinued the asthma treatment, but their HRQoL was better than that of those continuing to use ICS. Clinical remission was reached by 16% of the patients, which is in concordance with other studies.

Impact of an Electronic Monitoring Intervention to Improve Adherence to Inhaled Medication in Patients with Asthma and Chronic Obstructive Pulmonary Disease: Study Protocol for a Randomized Controlled Trial

Background

Despite progress in pharmacological and non-pharmacological treatment in recent years, the burden of disease among patients with asthma and chronic obstructive pulmonary disease (COPD) is high and patients are frequently hospitalized due to exacerbations. Reasons for uncontrolled diseases are manifold, but are often associated with poor inhalation technique and non-adherence to the prescribed treatment plan. This causes substantial mortality, morbidity, and costs to the healthcare system. In this respect, the study of causes for non-adherence and the development of measures to increase and maintain treatment adherence in chronic diseases is of major clinical importance.

Objective

The primary objective of this study is to investigate the impact of using specific, validated electronic devices on adherence to inhaled medication in patients with chronic obstructive lung diseases such as asthma and COPD. Furthermore, it aims to assess the impact of a reminder and close supervision of the course of disease and quality of life.

Methods

In this ongoing prospective, single-blind, randomized controlled study, adherence to inhaled medication is analyzed over a 6-month period in at least 154 in- and outpatients with asthma or COPD who have experienced at least 1 exacerbation during the last year. Adherence is measured using electronic data capture devices, which save the date and time of each inhalative device actuation and transfer these data daily via a wireless connection to a Web-based database. Patients are randomly assigned to either the intervention or the control group. The clinical intervention consists of an automated and personal reminder. The intervention group receives an audio reminder and support calls in case medication has not been taken as prescribed or if rescue medication is used more frequently than pre-specified in the study protocol. During the study, participants are assessed every 2 months in the form of clinical visits.

Results

Recruitment started in January 2014. To date, a total of 169 patients have been recruited. Follow-up assessments are still ongoing. The study will be concluded in the first quarter of 2017. Data analysis will take place during 2017.

Conclusions

Few studies have investigated medication adherence in patients with chronic obstructive lung diseases. With this prospective study design and the use of state-of-the-art devices for measuring adherence, we expect scientifically relevant and clinically meaningful results that will have a substantial and positive impact on the provision of healthcare in chronically ill patients suffering from asthma or COPD.

Trial Registration

ClinicalTrials.gov: NCT02386722; https://clinicaltrials.gov/ct2/show/NCT02386722 (Archived by WebCite at http://www.webcitation.org/6oJq1fel0)

Introduction of a new paediatric asthma guideline: Effects on asthma control levels

BACKGROUND

In 2008, a new national paediatric asthma management guideline based on the international Global Initiative for Asthma (GINA) guideline was launched in the Netherlands. We studied whether asthma control and treatment regimens improved after introduction of the guideline by comparing survey data before and after the guideline introduction.

METHODS

Two comparable groups of children (6-16 years) with asthma were included before (2004) and after (2013) the introduction of the guideline. Children, parents and paediatricians completed questionnaires about asthma symptoms, medication and healthcare use. Spirometry was performed.

RESULTS

Data of 209 patients were analysed. Level of asthma control did not improve between 2004 and 2013 with a proportion of (partly) controlled asthmatics of 51% in 2004 and 59% in 2013 (p = 0.28). In 2013, paediatricians characterized 76% of children as (partly) controlled, while 59% of children was (partly) controlled according to GINA criteria (p < 0.05). Step-down treatment in controlled patients was more applied by paediatricians in 2013 compared to 2004 (from 8 to 40%, p < 0.05). Step-up treatment in uncontrolled patients did not improve.

CONCLUSIONS

Asthma control did not improve after the introduction of the new guideline. Compared to 2004, an improvement was observed in step-down treatment in patients with controlled disease.

The role of the pharmacy in the management of bronchial asthma: A literature-based evaluation

OBJECTIVE

Pharmacists play a relevant role in the real-life management of asthma because they are a first-line referral for patients. In fact, the role of pharmacies has been underlined and evidenced also in guidelines. Nonetheless, the true effect of pharmacy-based management of asthma has been assessed in only a few studies. We review the available literature on asthma management in a territorial pharmacy setting.

DATA SOURCES

The literature was searched for the keywords pharmacy, bronchial asthma, control, and management.

STUDY SELECTIONS

The available studies were subdivided into observational and interventional and described.

RESULTS

Seven observational studies and 14 interventional trials were found, involving approximately 20,000 individuals. Most of those studies were performed in Europe and Australia. A high proportion of patients had poorly controlled asthma in the observational studies. The active involvement of pharmacists, in the interventional trials, consistently led to an improvement of the quality of life, a better inhalation technique, and a reduction of exacerbations.

CONCLUSION

The literature analysis confirms the relevance of the role of pharmacists in the real-life management of bronchial asthma and underlines the need for a more specific training for those health care professionals.

Lipopolysaccharide-binding protein is efficient in biodosimetry during radiotherapy of lung cancer

The aim of the present study was to determine if the serum levels of early markers of inflammation, such as interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), C-reactive protein (CRP), and lipopolysaccharide-binding protein (LBP) were correlated with the radiation dose received by the pulmonary and mediastinal structures of patients with non-small cell lung cancer (NSCLC). This pilot study included 26 patients with NSCLC who received total radiation doses ranging from 54 to 74 Gy (2.0 Gy/fraction). Cytokines were measured at baseline by enzyme-linked immunosorbant assay, and following administration of total doses of 20 and 40 Gy. A control group of 26 participants was sampled for comparisons with patient baseline cytokine levels. Only data from the 40-Gy cytokine blood levels of patients with NSCLC were identified to be correlated with histograms of the parameters of each patient's radiotherapy protocol. The IL-6, TNF-α and CRP median baseline levels of the patients with NSCLC were significantly higher than those of the controls (all P≤0.01). No differences were observed between the LBP levels of the patients and controls [median, 36.34 (25-75%; 31.35-39.27) vs. 36.92 (30.20-44.05) µg/ml, respectively; P=0.42]. No significant differences in the levels of the four cytokines between baseline, and at 20 and 40 Gy were observed [IL-6 (P=0.19); TNF-α (P=0.68); CRP (P=0.44) and LBP (P=0.29)]. LBP was significantly and positively correlated with the mean radiation dose to the lung (r=0.409; P=0.038), and showed a positive correlation with the percentage of lung volume exposed to at least 20 Gy of the planned radiation dose (r=0.3536; P=0.0764). CRP levels were positively correlated with the mean radiation dose to the esophagus (r=0.404; P=0.041); however, IL-6, TNF-α and CRP were not significantly associated with other lung dosimetry parameters. Thus, LBP levels were correlated with radiation exposure of pulmonary tissues, and LBP may be a marker that warrants further investigation on radiotoxicity in NSCLC patients.

The integrated care of asthma in Switzerland (INCAS)-study: Patients' perspective of received asthma care and their interest in asthma education

OBJECTIVE

For successful long-term asthma care, self-management education is a cornerstone. Little is known about associations between patients' interest in education, asthma control and care delivery. We compared patients' characteristics, asthma control and patients' perspective about asthma care in subjects with and without interest in asthma education. Moreover, we assessed reasons, why patients denied participating in asthma education.

METHODS

Baseline data of 223 patients with asthma (age 43 ± 12 years, 38% male, 58% non-smokers, 13% current smokers), who participated in a multicentre longitudinal controlled study, are reported. At baseline, patients completed the Asthma Control Test (ACT), the Patient Assessment Chronic Illness Care questionnaire (PACIC 5A) and stated their interest in an asthma education programme.

RESULTS

Overall, 34% of all participants showed uncontrolled asthma. One hundred and twenty-five (56%) patients were interested in education. Compared to patients without interest, they were characterised by male gender (p = 0.013), worse asthma control (p < 0.001), and perception of lower quality of chronic asthma care delivery, in particular lower self-management support (p < 0.001). Main reasons for rejecting asthma education were having sufficient asthma knowledge, having only mild asthma, receiving adequate medical support and lack of time.

CONCLUSIONS

More than half of the patients were interested in asthma education. Interest was associated with worse asthma control and lower receipt of care according to the Chronic Care Model. Considering these aspects, this approach may help to improve care quality and allow targeting interventions to those patients who are interested in becoming active participants in their care and who might benefit most.

Antagonists of the TMEM16A calcium-activated chloride channel modulate airway smooth muscle tone and intracellular calcium

BACKGROUND

Perioperative bronchospasm refractory to β agonists continues to challenge anesthesiologists and intensivists. The TMEM16A calcium-activated chloride channel modulates airway smooth muscle (ASM) contraction. The authors hypothesized that TMEM16A antagonists would relax ASM contraction by modulating membrane potential and calcium flux.

METHODS

Human ASM, guinea pig tracheal rings, or mouse peripheral airways were contracted with acetylcholine or leukotriene D4 and then treated with the TMEM16A antagonists: benzbromarone, T16Ainh-A01, N-((4-methoxy)-2-naphthyl)-5-nitroanthranilic acid, or B25. In separate studies, guinea pig tracheal rings were contracted with acetylcholine and then exposed to increasing concentrations of isoproterenol (0.01 nM to 10 μM) ± benzbromarone. Plasma membrane potential and intracellular calcium concentrations were measured in human ASM cells.

RESULTS

Benzbromarone was the most potent TMEM16A antagonist tested for relaxing an acetylcholine -induced contraction in guinea pig tracheal rings (n = 6). Further studies were carried out to investigate the clinical utility of benzbromarone. In human ASM, benzbromarone relaxed either an acetylcholine- or a leukotriene D4-induced contraction (n = 8). Benzbromarone was also effective in relaxing peripheral airways (n = 9) and potentiating relaxation by β agonists (n = 5 to 10). In cellular mechanistic studies, benzbromarone hyperpolarized human ASM cells (n = 9 to 12) and attenuated intracellular calcium flux from both the plasma membrane and the sarcoplasmic reticulum (n = 6 to 12).

CONCLUSION

TMEM16A antagonists work synergistically with β agonists and through a novel pathway of interrupting ion flux at both the plasma membrane and sarcoplasmic reticulum to acutely relax human ASM.

Unfavorably Altered Fibrin Clot Properties in Patients with Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome): Association with Thrombin Generation and Eosinophilia

Objectives

Given reports on the increased prevalence of thromboembolic incidents in patients with eosinophilic granulomatosis with polyangiitis (EGPA; Churg-Strauss syndrome), we investigated whether fibrin clot properties are unfavorably altered in EGPA.

Methods

Ex vivo plasma fibrin clot characteristics, including clot permeability, turbidimetry and efficiency of fibrinolysis using two assays, were investigated in 34 consecutive patients with remission in EGPA according to the Birmingham Vasculitis Activity Score version 3 (23 female, 11 male), aged 48 (range, 21–80) years. The control group comprised 34 age- and sex- matched volunteers.

Results

Compared with controls, patients with EGPA were characterized by denser fiber clots (estimated pore size, K_s, 7.30±0.93 vs 10.14±1.07 10⁻⁹ cm²), faster fibrin polymerization (lag phase in a turbidimetric curve, 41.8±3.6 vs 47.4±2.9 s), thicker fibrin fibers (maximum absorbance, ΔAbs, 0.87±0.09 vs 0.72±0.07), higher maximum levels of D-dimer released from clots (DD_max 4.10±0.46 vs 3.54±0.35 mg/L), and prolonged clot lysis time (t_50%; 9.50±1.45 vs 7.56±0.87 min); all p<0.0001. Scanning electron microscopy images confirmed denser plasma fibrin networks composed of thinner fibers formed in EGPA. Antineutrophil cytoplasmic antibody status and C-reactive protein did not affect clot variables. Multivariate analysis adjusted for fibrinogen showed that K_s was predicted by eosinophil count, peak thrombin generation, factor VIII, and soluble CD40 ligand, whereas eosinophil count, peak thrombin generation and antiplasmin predicted t_50%.

Conclusion

This study is the first to show that EGPA is associated with prothrombotic plasma fibrin clot phenotype, which may contribute to thromboembolic manifestations reported in this disease.

The impact of anxiety and depression on outpatients with asthma

BACKGROUND

Anxiety and depression may frequently affect patients with asthma. However, the findings of several studies are partially conflicting and conducted in selected cohorts.

OBJECTIVE

To investigate the effect of anxiety and depression in a group of outpatients with asthma.

METHODS

This cross-sectional, real-life study included 263 patients (109 males; mean age, 39.2 years) with asthma. Clinical examination, lung function, fractional exhaled nitric oxide measurement, Asthma Control Test (ACT) score, asthma control grade, perception of symptoms by visual analog scale, and Hospital Anxiety and Depression Scale (HADS) questionnaires were evaluated.

RESULTS

Globally, 97 patients (36.9%) had anxiety, and 29 (11%) had depression. Of these patients, 71 had combined anxiety and depression. Anxiety and depression were associated with poor asthma control (P =.007 and .02, respectively). Patients with depression had higher body mass indexes (P =.002). Anxiety and depression were associated with lower ACT scores (P < .001 for both). The scores on the anxiety and depression subscales of HADS were moderately related (r = 0.57).

CONCLUSIONS

The present real-life study indicates that anxiety and depression are common and relevant comorbidities in asthmatic outpatients and are associated with uncontrolled asthma and lower ACT scores. Thus, assessment of comorbid mental disorders should be performed in common practice.

Symptom perception and asthma control

OBJECTIVES

Asthma control is the goal of asthma management. The perception of asthma symptoms represents a cornerstone aspect in this issue. The visual analogue scale (VAS) has been proposed as a useful tool for assessing respiratory symptoms perception. The present cross-sectional real-life study investigated whether VAS assessment of asthma symptoms perception could predict asthma control level.

METHODS

This cross-sectional study included a total of 370 (153 males, mean age 39.9 years) patients with asthma. Perception of asthma symptoms was assessed by VAS; clinical examination, lung function, fraction of exhaled nitric oxide (FeNO) measurement, Asthma Control Test (ACT) and Hospital Anxiety Depression Scale questionnaires were also evaluated.

RESULTS

Asthma was well controlled in 47% of patients. Considering most of the evaluated parameters, there were significant differences among patients with well-controlled, partly controlled and uncontrolled asthma. VAS values were significantly (p < 0.001) different considering the asthma control level. VAS score were significantly related with ACT scores (p < 0.001). A VAS <6 was able to reliably predict uncontrolled asthma (area under the curve: 0.74; odds ratio: 5.16).

CONCLUSION

The present real-life study demonstrates that asthma symptoms assessment by VAS might be useful for approximately predicting uncontrolled asthma in particular conditions, such as at home or at the general practitioner's office.

Chloride channel blockade relaxes airway smooth muscle and potentiates relaxation by β-agonists

Severe bronchospasm refractory to β-agonists continues to cause significant morbidity and mortality in asthmatic patients. We questioned whether chloride channels/transporters are novel targets for the relaxation of airway smooth muscle (ASM). We have screened a library of compounds, derivatives of anthranilic and indanyloxyacetic acid, that were originally developed to antagonize chloride channels in the kidney. We hypothesized that members of this library would be novel calcium-activated chloride channel blockers for the airway. The initial screen of this compound library identified 4 of 20 compounds that relaxed a tetraethylammonium chloride-induced contraction in guinea pig tracheal rings. The two most effective compounds, compounds 1 and 13, were further studied for their potential to either prevent the initiation of or relax the maintenance phase of an acetylcholine (ACh)-induced contraction or to potentiate β-agonist-mediated relaxation. Both relaxed an established ACh-induced contraction in human and guinea pig ex vivo ASM. In contrast, the prevention of an ACh-induced contraction required copretreatment with the sodium-potassium-chloride cotransporter blocker bumetanide. The combination of compound 13 and bumetanide also potentiated relaxation by the β-agonist isoproterenol in guinea pig tracheal rings. Compounds 1 and 13 hyperpolarized the plasma cell membrane of human ASM cells and blocked spontaneous transient inward currents, a measure of chloride currents in these cells. These functional and electrophysiological data suggest that modulating ASM chloride flux is a novel therapeutic target in asthma and other bronchoconstrictive diseases.

Clinical usefulness of a guideline-based screening tool for the diagnosis of allergic rhinitis in asthmatics: the Self Assessment of Allergic Rhinitis and Asthma questionnaire

BACKGROUND AND OBJECTIVE

Allergic rhinitis (AR) is common in asthmatic patients and may impair asthma control. However, this comorbidity is frequently missed. A simple test is needed to enable physicians to diagnose and evaluate the severity of both diseases. The Self Assessment of Allergic Rhinitis and Asthma (SACRA) questionnaire, which GINA and ARIA Japan committees developed in 2011, consist of questionnaires based on GINA and ARIA guidelines for the diagnosis and severity of AR and asthma, and a visual analogue scale (VAS) to evaluate the severity of both diseases. Our objective was to investigate the clinical usefulness of SACRA as a patient-based screening tool for identifying asthmatic patients with AR.

METHODS

SACRA, ACT (Asthma Control Test) and serum IgE RAST were performed in asthmatic patients. The correlation between SACRA and other parameters were analyzed.

RESULTS

Four hundred twenty asthmatic patients were enrolled. Among 168 subjects who self-reported no concomitant AR, 76 asthmatics scored one or more symptoms on SACRA. Eventually, 32 of these 76 subjects were diagnosed with AR by physicians based on laboratory data or physical examinations by ear, nose and throat specialists. The sensitivity and specificity of SACRA for the diagnosis of AR were 92% and 66%, respectively. The estimated prevalence of AR among asthmatics was 66%, almost identical to that of the previous nationwide study in Japan. The level of asthma control assessed by the VAS on SACRA and the ACT score showed a strong correlation (r = -0.700, P < 0.001).

CONCLUSIONS

SACRA may be a clinically useful tool for identifying bronchial asthma patients with AR.

Failure in asthma control: reasons and consequences

Clinical research showed that asthma control is an achievable target. However, real-life observations suggest that a significant proportion of patients suffer from symptoms and report lifestyle limitations with a considerable burden on patient's quality of life. The achievement of asthma control is the result of the interaction among different variables concerning the disease pattern and patients' and physicians' knowledge and behaviour. The failure in asthma control can be considered as the result of the complex interaction among different variables, such as the role of guidelines diffusion and implementation, some disease-related factors (i.e., the presence of common comorbidities in asthma such as gastroesophageal reflux disease (GERD), sleep disturbances and obstructive sleep apnea (OSA), and rhinitis) or patient-related factors (i.e., adherence to treatment, alexithymia, and coping strategies). Asthma control may be reached through a tailored treatment plan taking into account the complexity of factors that contribute to achieve and maintain this objective.

The role of community pharmacists in screening and subsequent management of chronic respiratory diseases: a systematic review

OBJECTIVE

The purpose of this review was to evaluate the role of community pharmacists in provision of screening with/without subsequent management of undiagnosed chronic obstructive pulmonary disease (COPD) and uncontrolled asthma.

METHODS

An extensive literature search using four databases (ie. Medline, PubMed, International Pharmaceutical Abstracts (IPA) and Scopus) with search terms pharmacy, screening, asthma or COPD was conducted. Searches were limited to the years 2003-2013, those in English and those reporting research with humans. Data retrieval, analysis and result presentation employed a scoping review method.

RESULTS

Seventeen articles met the inclusion/exclusion criteria, of which fifteen studies were based on people with asthma and two were based on people with COPD. Only seven asthma studies and one COPD study involved screening followed by subsequent management. More than half of the people screened were found to be poorly controlled and up to 62% of people were identified at high risk for COPD by community pharmacists. The studies varied in the method and type of asthma control assessment/screening, the type of intervention provided and the outcomes measured. The limitations of the reviewed studies included varying definitions of asthma control, different study methodologies, and the lack of long-term follow-up. While many different methods were used for risk assessment and management services by the pharmacists, all the studies demonstrated that community pharmacists were capable of identifying people with poorly controlled asthma and undiagnosed COPD and providing them with suitable interventions.

CONCLUSIONS

The literature review identified that community pharmacists can play an effective role in screening of people with poorly controlled asthma and undiagnosed COPD along with delivering management interventions. However, there is very little literature available on screening for these chronic respiratory conditions. Future research should focus on development of patient care delivery model incorporating a screening protocol followed by targeted management interventions delivered by the community pharmacist.

Factors influencing asthma control: results of a real-life prospective observational asthma inhaler treatment (ASIT) study

Background

Despite the availability of new pharmacological options and novel combinations of existing drug therapies, the rate of suboptimal asthma control is still high. Therefore, early identification of the clinical and behavioral factors responsible for poor asthma control, and interventions during routine outpatient visits to improve asthma trigger management, are strongly recommended. This study was designed to evaluate the profiles of asthmatic patients and their inhaler treatment devices in relation to asthma control in Turkey.

Methods

A total of 572 patients with persistent asthma (mean [standard deviation] age: 42.7 [12.1] years; 76% female) were included in this prospective observational study. A baseline visit (0 month, visit 1) and three follow-up visits (1, 3 and 6 months after enrolment) were conducted to collect data on demographics, past medical and asthma history, and inhaler device use.

Results

Asthma control was identified in 61.5% of patients at visit 1 and increased to 87.3% at visit 4 (P < 0.001), regardless of sociodemographics, asthma duration, body mass index or smoking status. The presence of asthma-related comorbidity had a significantly negative effect on asthma control (P = 0.004). A significant decrease was determined, in the rate of uncontrolled asthma, upon follow-up among patients who were using a variety of fixed dose combination inhalers (P < 0.001 for each). Logistic regression analysis was used to show that the presence of asthma-related comorbidity (odds ratio [OR], 0.602; 95% confidence interval [CI], 0.419; 0.863, P = 0.006) and active smoking (OR, 0.522; 95% CI, 0.330; 0.825, P = 0.005) were significant predictors of asthma control.

Conclusion

Our findings indicate that, despite ongoing treatment, asthma control rate was 61.5% at visit 1 in adult outpatients with persistent asthma. However, by the final follow-up 6 months later, this had increased to 87.3%, independent of sociodemographic and clinical characteristics. Poor asthma control was associated with asthma-related comorbid diseases, while the efficacy of fixed dose combinations was evident in the achievement of asthma control.

Visual analog scale as a predictor of GINA-defined asthma control. The SACRA study in Japan

OBJECTIVE

The assessment of asthma control is pivotal to treatment decisions. A questionnaire that assesses the Global Initiative for Asthma (GINA)-defined control requires four questions. A visual analog scale (VAS) to evaluate asthma control can be simply marked, but its correlation with GINA-defined control has been insufficiently evaluated. The purpose of this study is to evaluate whether VAS levels can predict GINA-defined asthma control with particular emphasis on the distinctions between "partly controlled" and "uncontrolled" and between "partly controlled" and "controlled" asthma,

METHODS

A cross-sectional multicenter study was carried out throughout Japan (SACRA) from March to August 2009 among patients with a diagnosis and treatment of asthma. Asthma control was studied using the GINA questionnaire and a VAS measurement of asthma severity. Pulmonary function testing was not carried out,

RESULTS

1910 physicians enrolled 29,518 patients with asthma. 15,051 (51.0%) questionnaires were administered by physicians; patients filled out 14,076 (47.7%) questionnaires themselves. 28,225 (95.6%) of the patients were evaluable. VAS measurement of asthma symptoms was useful in predicting levels of GINA-defined control categories (the area under the receiver operating characteristic curve ranging from 0.704 to 0.837). Patients with "controlled," "partly controlled," and "uncontrolled" asthma were discriminated by VAS levels (1.50, 4.79, and 7.19). Similar results have been obtained with self- and physician-administered questionnaires showing the validity of results.

CONCLUSION

Measurement of VAS levels is able to discriminate between patients with "controlled," "partly controlled," and "uncontrolled" asthma. The VAS score could be a simple guide in clinical situations requiring daily or regular evaluation of asthma control.

Utilization and responsiveness of the asthma control test (ACT) at the initiation of therapy for patients with asthma: a randomized controlled trial

Background

The aim of this study was to assess the responsiveness of the asthma control test (ACT) to detect changes at the initiation of therapy and its utilization in the initiation of asthma treatment.

Methods

This study was designed as a randomized clinical trial conducted in a primary care setting. The subjects were asthma patients who had not received controller therapy for at least two months. The patients were randomized into two groups: The Saudi Initiative for Asthma (SINA) group and the Global Initiative for Asthma (GINA) group. Treatment in the SINA group was initiated at step1 when the ACT scores ≥ 20, step 2 when the score between16-19, and step 3 when the score < 16 began at step 3. The GINA group patients were started on step 2 when they had persistent asthma symptoms or step 3 when they had severely uncontrolled disease.

Results

Forty-five patients were analyzed in each group. The improvement in ACT score after treatment initiation was significantly higher when the SINA approach was used (2.9 in the SINA group compared to 1.7 in the GINA group (p = 0.04)). The improvement in FEV₁ was 5.8% in the SINA group compared to 3.4% in the GINA group (p = 0.46). The number of patients who achieved asthma control at the follow-up visit and required no treatment adjustment was 33 (73.3%) in the SINA group and 27 (60%) in the GINA group (p = 0.0125).

Conclusion

The ACT was responsive to change at the initiation of asthma treatment and was useful for the initiation of asthma treatment.

Trial Registration number

ISRCTN31998214