Picturing asthma in Turkey: results from the Turkish adult asthma registry

INTRODUCTION

National data on asthma characteristics and the factors associated with uncontrolled asthma seem to be necessary for every country. For this purpose, we developed the Turkish Adult Asthma Registry for patients with asthma aiming to take a snapshot of our patients, thereby assigning the unmet needs and niche areas of intervention.

METHODS

Case entries were performed between March 2018 and March 2022. A web-based application was used to record data. Study outcomes were demographic features, disease characteristics, asthma control levels, and phenotypes.

RESULTS

The registry included 2053 patients from 36 study centers in Turkey. Female subjects dominated the group (n = 1535, 74.8%). The majority of the patients had allergic (n = 1158, 65.3%) and eosinophilic (n = 1174, 57.2%) asthma. Six hundred nineteen (32.2%) of the patients had obese asthma. Severe asthma existed in 670 (32.6%) patients. Majority of cases were on step 3-5 treatment (n: 1525; 88.1%). Uncontrolled asthma was associated with low educational level, severe asthma attacks in the last year, low FEV1, existence of chronic rhinosinusitis and living in particular regions.

CONCLUSION

The picture of this registry showed a dominancy of middle-aged obese women with moderate-to-severe asthma. We also determined particular strategic targets such as low educational level, severe asthma attacks, low FEV1, and chronic rhinosinusitis to decrease uncontrolled asthma in our country. Moreover, some regional strategies may also be needed as uncontrolled asthma is higher in certain regions. We believe that these data will guide authorities to reestablish national asthma programs to improve asthma service delivery.

Hypersensitivity reactions to nonsteroidal anti-inflammatory drugs in adults: Beyond current classification

BACKGROUND

Hypersensitivity reactions (HSRs) to nonsteroidal anti-inflammatory drugs (NSAIDs) are a significant clinical issue. Several classifications have been proposed to categorize these reactions, including the current European Academy of Allergy and Clinical Immunology/European Network for Drug Allergy (EAACI/ENDA) classification. This study aimed to evaluate the applicability of this classification in a real-world clinical setting.

METHODS

We conducted a national multicenter study involving patients from nine hospitals in four major urban centers in Turkey. All patients had a suggestive clinical history of hypersensitivity reactions to NSAIDs. Researchers collected data using a structured form and classified reactions based on the EAACI/ENDA classification. Oral provocation tests with several NSAIDs were performed using a single-blind challenge per EAACI/ENDA guidelines.

RESULTS

Our retrospective study included 966 adult patients with a history of hypersensitivity to NSAIDs. The most common triggers were Acetylsalicylic Acid (ASA), paracetamol, and metamizole. The most prevalent acute NSAID hypersensitivity group was NSAID-induced urticaria/angioedema (NIUA) (34.3%). However, 17.3% of patients did not fit neatly into the current EAACI/ENDA classification. Notably, patients with underlying asthma or allergic rhinoconjunctivitis exhibited unusual reactions, such as urticaria and/or angioedema induced by multiple chemical groups of NSAIDs, blended mixed reactions, and isolated periorbital angioedema in response to multiple chemical groups of NSAIDs.

CONCLUSIONS

While the EAACI/ENDA classification system stratifies NSAID-induced hypersensitivity reactions into five distinct endotypes or phenotypes, it may not fully capture the diversity of these reactions. Our findings suggest a need for further research to refine this classification system and better accommodate patients with atypical presentations.

Demographic, Clinical and Management Characteristics of Newly Diagnosed COPD Patients in Turkey: A Real-Life Study

Purpose

In order to determine the clinical and sociodemographic characteristics of newly diagnosed treatment-naïve asthma and COPD patients in Turkey, a multicenter study in 2012 was initiated . We aimed to investigate the characteristics and therapies of COPD patients in the original study in more detail.

Patients and Methods

This nation-wide, multicentric, non-interventional, prospective, real-life observational cohort study was conducted in 122 centers. The newly diagnosed patients were not receiving any treatment before the recruitment. Their general characteristics, the combined GOLD 2011 COPD categories and exacerbation histories were noted. The patients were followed up with 3 voluntary visits for 1 year. Their adherence to the inhaled treatment according to GOLD 2011 was evaluated during follow-up visits.

Results

The study included 776 COPD patients. Their mean age was 59.4±9.1 years, and 11.9% of the patients were female. 35.1% of the patients were in the GOLD 2011 C and D category. 12.6% are frequent exacerbators, and 52.8% had at least one comorbid condition. 71.8% overtreatment rate was detected. Their attendance rates for three follow-up visits became 55.9%, 32.9% and 18.7%, respectively. The adherence rate to the treatment was measured as 81.9%.

Conclusion

Although these patients were diagnosed for the first time, the GOLD C and D categories and frequent exacerbator phenotype were found at a high rate. They were usually prescribed an overtreatment regimen. We think that newly diagnosed COPD patients should be evaluated carefully, and best effort should be made to treat these patients in accordance with the recommendations of the major COPD guidelines.

Asthma control and adherence in newly diagnosed young and elderly adult patients with asthma in Turkey

OBJECTIVE

This study aimed to evaluate the factors that affect asthma control and adherence to treatment in newly diagnosed elderly asthmatics in Turkey compared with younger patients.

METHODS

This real-life prospective observational cohort study was conducted at 136 centers. A web-based questionnaire was administered to the patients who were followed up for 12 months.

RESULTS

Analysis included 1037 young adult asthma patients (age <65 years) and 79 elderly asthma patients (age ≥65 years). The percentage of patients with total control in the elderly and young groups were 33.9% and 37.1% at visit 1, 20.0% and 42.1% (p = 0.012) at visit 2, and 50.0% and 49.8% at visit 3, respectively. Adherence to treatment was similar for both groups. Visit compliance was better in the elderly group than in the young group at visit 1 (72.2% vs. 60.8%, p = 0.045), visit 2 (51.9% vs. 34.9%, p = 0.002), and visit 3 (32.9% vs. 19.4%, p = 0.004). Adherence to treatment increased with asthma control in both groups (both p < 0.001) but decreased with the presence of gastritis/ulcer, gastroesophageal reflux, and coronary artery disease in the elderly.

CONCLUSIONS

Asthma control and adherence to treatment were similar for the elderly and young asthma patients, though the follow-up rate was lower in young patients. The presence of gastritis/ulcer, gastroesophageal reflux and coronary artery disease had negative impacts on the adherence to treatment in elderly adult patients.

Tiotropium may improve asthma symptoms and lung function in asthmatic patients with irreversible airway obstruction: the real-life data

BACKGROUND AND AIMS

Some patients with asthma have poorly controlled disease despite the use of high-dose inhaled corticosteroids (ICS), long-acting β2 agonists (LABAs) and antileukotrienes. The aim of the study was to assess the effectiveness of tiotropium as an add-on therapy to the standard treatment with high-dose ICS/LABA on asthma control and lung function in patients with severe asthma.

METHODS

Of the 633 asthmatic patients, 64 (10.1%) patients with severe asthma who were add-on treated at least for 3 months were evaluated. Number of exacerbations, emergency department visits, hospitalizations and lung functions of patients belonging to 12 months before starting add-on treatment were compared with those of 12 months after starting add-on treatment.

RESULTS

The mean duration of add-on tiotropium treatment was 8.3 ± 0.5 months. For patients with severe asthma that was poorly controlled with standard combination therapy, tiotropium improved asthma control in 42.2%, decreased the number of emergency department visits in 46.9% and decreased the number of hospitalizations in 50.0% of them. The mean baseline forced expiratory volume in 1 s before add-on tiotropium was 57.5 ± 1.9% and forced vital capacity was 74.3 ± 15.6%. However, after 12 months of add-on tiotropium treatment, these rates became 65.5 ± 1.9% and 82.5 ± 15.1%, respectively. The addition of tiotropium significantly improved the percentages of the number of emergency department visits, the number of hospitalizations (P < 0.05).

CONCLUSION

Our study has suggested that, for patients with poorly controlled asthma despite of the use of ICS/LABA, the addition of tiotropium to standard care may be beneficial.

The frequency of chronic rhinosinusitis/nasal polyp in COPD and its effect on the severity of COPD

This study aimed to investigate the effect of chronic rhinosinusitis/nasal polyposis on the severity of COPD and to find out whether the 'united airway disease' hypothesis is valid for COPD. The study enrolled 90 patients diagnosed and staged according to criteria of an international guideline for diagnosis and management of COPD. The patients in stages I and II were classified as Group 1 and the patients in stages III and IV as Group 2. All the patients were questioned about the presence of major and minor criteria of sinusitis, underwent paranasal sinus computed tomography (PNS-CT) scans, and answered a questionnaire based on a quality of life test for sinusitis (SNOT-20). Sinusitis was present in 48 (53%) patients according to criteria of major and minor symptoms, and in 58 (64%) patients according to Lund-Mackay scoring system of PNS-CT. There was no significant difference in CT score between Group 1 and Group 2 (2.3 +/- 0.5 vs. 2.1 +/- 0.4, p > 0.05). However, the frequency of minor symptoms was greater in Group 2. SNOT-20 score was significantly higher in Group 2 than in Group 1 (28.7 +/- 1.7 and 22.2 +/- 1.9, respectively, p = 0.014). A significant correlation was determined between Lund-Mackay and SNOT-20 scores. The presence of CRS should be assessed in COPD patients, especially in those with severe disease. Further research is needed to disclose possible common immunopathological mechanisms in the pathogeneses of COPD and CRS.

The frequency of self-reported allergic diseases in patients with crimean-congo haemorrhagic fever

BACKGROUND

Crimean-Congo haemorrhagic fever (CCHF) is an acute, tick-borne viral disease. In temperate areas, CCHF cases occur between spring and early autumn when tick activity is high. This period is also the pollen season during which symptoms of allergic diseases are exacerbated. Viruses induce inflammatory and antiviral responses by binding to specific receptors on the surface of airway epithelial cells, resulting in activation of innate immune responses; release of mediators such as cytokines and chemokines; and recruitment of neutrophils and mononuclear cells to the area.

AIM

We aimed to evaluate the frequency of self-reported allergic diseases and the effect on CCHF severity.

METHOD

Between June and August 2008, a questionnaire was applied to 114 CCHF (+) patients and 122 healthy control subjects, 16 to 88 years old who attended the Infectious Diseases clinic and were hospitalised with CCHF suspected, by face to face interview including history of allergic rhinitis (AR), asthma symptoms and nonspecific bronchial reactivity, doctor diagnosed AR and/or asthma, and familial allergic diseases history.

RESULTS

According to PCR and/or enzyme-linked immunoassay (ELISA) results, 51.7% of patients (n=114) had CCHF. There was no significant relation between CCHF and history of AR, asthma symptoms and nonspecific bronchial reactivity, doctor diagnosed AR and/or asthma, and familial allergic diseases history. The severity of CCHF has not affected these parameters (p>.05). Of patients with positive CCHF test, 2.6% (n=3) and 3.5% (n=4) had doctor diagnosed AR and asthma, respectively.

CONCLUSION

Self-reported allergic diseases and CCHF are not related with each other.

Leukotriene receptor antagonists: a good choice in the treatment of premenstrual asthma?

The aim of this study was to investigate the effects of leukotriene receptor antagonists (LTRAs) on the premenstrual exacerbation of asthma (PMA). Twenty-four female patients with mild asthma were enrolled in the study. Patients were followed for three menstrual cycles and separated into two groups based on whether they exhibit premenstrual worsening of asthma symptoms (n = 11) or not (n = 13). During the first month all were treated with only inhaled steroids (IS) (run-in period); during the second month they received IS plus placebo; and during the third month they were given IS plus montelukast. Furthermore, they were advised to use beta(2)-agonists as needed. Peak expiratory flow rate (PEFR) and symptom scores were recorded during the 3 months. Pulmonary function tests (PFT) and the levels of oestrogen, progesterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were measured a week before the beginning of the menstrual period. At the end of the 3-month period, it was observed that following therapy with montelukast, the patients with PMA showed significant improvement in PEFR variability and symptom scores when compared with the placebo group. Baseline FSH levels were higher, but FSH and other hormone levels and PFTs did not change in these groups. However, in the group without PMA there was no difference between the montelukast or placebo groups in PEFR variability, symptom scores, PFTs, and hormone levels. Based on the data in hand, it could be stated that LTRAs have ensured the control of symptoms and improved PEFR variability in patients with PMA by suppressing inflammation. We are of the view that LTRAs would be a right choice in the treatment of patients with PMA.

The view of patients with asthma or chronic obstructive pulmonary disease (COPD) on complementary and alternative medicine

BACKGROUND

The popularity of complementary and alternative medicine (CAM), particularly for chronic diseases such as asthma, is growing rapidly, but little is known about the characteristics of CAM use by patients with asthma and chronic obstructive pulmonary diseases (COPD). The aim of the present study is to compare the knowledge and preferences of patients with asthma or COPD about CAM, to evaluate the extent, characteristics and possible predictors of CAM use.

METHODS

A face-to-face interview questionnaire was administered to the patients who attended the Allergic Diseases and Chest Diseases clinics between May 2005-January 2006, and 364 patients answered the questionnaire.

RESULTS

43.1 % (n = 90) of the 209 asthmatic patients, and 43.2 % (n = 67) of the 155 COPD patients had used some type of CAM previously. The asthmatic patients who have been admitted to the Emergency Room(ER) more frequently tend to use CAM methods (p = 0.03), whereas duration of doctor diagnosis, hospitalizations, admissions to ER and to be educated for diseases have a higher impact on CAM use in COPD patients (p = 0.00, p = 0.00, p = 0.00 and p = 0.04, respectively). The most commonly used forms of CAM were herbal medicines (57.8 % vs. 70.1 %) and quail egg (46.7 % vs. 37.3 %) in patients with asthma and COPD, respectively. The reported frequency of the subjective sense of improvement was higher in asthmatic patients than COPD patients but this difference was insignificant (50.0 % vs.39.4 %; p = 0.24).

CONCLUSION

Most of the patients with asthma or COPD prefer alternative medicine. CAM use by patients with COPD should be asked about by their doctors, strongly advised about continuing their medicines and about side effects of CAM.

Psychological status of patients with chronic urticaria

Although chronic urticaria is the most common cutaneous disorder seen in our outpatient allergy clinics, to our knowledge, no study of psychiatric morbidity in allergy departments has been carried out in our country. For the present study, we used the Minnesota Multiphasic Personality Inventory (MMPI) to evaluate the personality traits and psychological status of patients with chronic idiopathic urticaria (CIU). Fifty-nine outpatients with CIU and 59 healthy control subjects were enrolled in the study. Patients were included if no specific cause for their urticaria could be identified by detailed history and appropriate investigations. Psychiatric evaluation for all patients and controls was conducted at the Department of Psychiatry by using MMPI. Analysis of the MMPI profile showed that the scores for hypochondriasis, depression, hysteria, psychopathic deviance, paranoia, psychasthenia, schizophrenia, and social introversion were higher in patients with CIU compared to the control group (P < 0.05). The mean score of hysteria was significantly higher in women. There were no significant correlations between the scores of MMPI and duration of the disease. These data indicate that our patients with CIU seem to have more depressive, hysteric, touchy and suspicious personality traits with hypochondriac tendencies and in more conflict with their social environment. Attitudes such as perfectionism, need for approval, external control and need to be loved were also characteristics of the patient group. We believe that psychological status should be considered for effective management of patients with CIU.

Use of alternative medicines by allergic patients in Turkey

BACKGROUND

Although complementary and alternative medicines are frequently used in Turkey, no studies with large series have yet been published.

OBJECTIVE

Our aim was to determine the prevalences of the use of various types of complementary and alternative medicines in patients with asthma, seasonal allergic rhinitis (SAR) and chronic urticaria (CU) and the relationship between the use of these substances and patients' social, economic and demographic characteristics.

METHODS

All patients completed a questionnaire about the use of complementary and alternative medicines, including herbal products, animal products, acupuncture, yoga, massage therapies, Turkish-baths, speleotherapy, and psychoreligious methods for curing their diseases.

RESULTS

The overall use of complementary and alternative medicines was 38 %. The most common alternative therapy treatment was herbal therapy (30.5 %). The prevalence of the use of these therapies was higher in asthmatics than in patients with SAR and CU. In all patients, variables associated with the use of these therapies were older age and having asthma. Among asthmatics, the use of these therapies within the previous 12 months was higher in patients with hospitalization and acute attacks than in those without hospitalization or acute attacks. In this group important covariates in the use of complementary and alternative medicines were older age and severe disease. Approximately half of the patients and 41.2 % of asthmatics discontinued pharmacological therapy during alternative treatment or had not yet started it.

CONCLUSION

Because of the high prevalence of the use of complementary and alternative medicines and the tendency to discontinue drug therapy during these treatments, patients should be educated about the importance of pharmacological therapies.

The effect of montelukast on eosinophil apoptosis: induced sputum findings of patients with mild persistent asthma

BACKGROUND

Apoptosis may be important in limiting airway eosinophilia. Treatment with leukotriene antagonists decreases the number of eosinophils in both peripheral blood and sputum.

AIM

To assess the effect of montelukast on eosinophil apoptosis in a group of patients with mild persistent asthma (MPA) and to compare this effect with the apoptotic effect of fluticasone propionate (FP).

METHODS

Randomly selected patients with MPA (n = 22) who had not taken anti-inflammatory therapy within the preceding 12 months were included in the study. The sputum induction procedure was performed and the patients were divided into two groups: group 1 (n = 10) received FP 250 microg/day and group 2 (n = 22) received montelukast 10 mg/day orally for 4 weeks. Sputum induction was repeated after the treatment period. The resulting cytospin slides were stained by Wright's stain and morphologic changes in apoptotic eosinophils were assessed by the use of light microscopy by two blinded expert pathologists. Serum soluble Fas ligand (sFasL) concentrations were measured by an ELISA method at baseline and after treatment in both groups, as well as in a group of healthy subjects.

RESULTS

In within-group comparisons, the apoptotic ratio (AR) increased at the end of the study period in group 1 (p = 0.05). In the group treated with FP the ratio of sputum eosinophils significantly decreased (p = 0.02), and the AR significantly increased (p < 0.005). No differences were found in the two study groups in serum sFasL levels at the end of the treatment period compared with baseline values (p > 0.05).

CONCLUSION

Our findings demonstrate that 4 weeks' treatment with a CysLT receptor antagonist (montelukast) resulted in an increase in eosinophil apoptosis comparable to that produced by FP, suggesting that induction of apoptosis may be a potential mechanism for the mode of action of CysLT receptor antagonists in asthma.

Effects of haemodialysis on pulmonary clearance of Tc-99m diethylene triamine pentaacetate (DTPA)

OBJECTIVES

Hypoxaemia occurring during haemodialysis has long been known. Several mechanisms in the pathogenesis have been proposed. The present study was conducted to test whether changes in pulmonary alveolar permeability were among the operating mechanisms.

MATERIALS AND METHODS

Twenty haemodialysis patients (12 male, 8 female) were included in the study. The mean age was 49 years (age range: 18-85 years). Patients with known pulmonary disease, current smokers and those gaining more than 1 kg weight during the interdialytic period were excluded. Complete blood count, arterial blood gas analysis, pulmonary function tests and Tc-99m diethylene triamine pentaacetate (DTPA) inhalation scintiscan were carried out before and after haemodialysis. A bronchial provocation test was carried out after each session. A postero-anterior chest radiogram was taken for each patient.

RESULTS

When the results before and after haemodialysis were compared, it was observed that the pH and serum bicarbonate levels, haemoglobin and haematocrit values were significantly higher after haemodialysis. However, the platelet count was found to be decreased significantly. Bronchial hyperreactivity, tested by metacholine, Was positive in 5 of 19 patients (26%). No correlation between bronchial hyperreactivity and other factors could be identified. No significant difference was observed in pulmonary Tc-99m DTPA clearance after haemodialysis. All chest radiograms were interpreted to be within normal limits.

CONCLUSIONS

Since we observed no hypoxaemia following haemodialysis, we cannot comment as to whether the changes in pulmonary clearance play a role in the pathogenesis of haemodialysis-associated hypoxaemia. In order to reach reliable conclusions, additional studies are needed.