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Hudson-Colby JJ, Lewis A, Varkonyi-Sepp J, Ainsworth B, Freeman A, Day A, Djukanovic R, Wei L, Haitchi HM, Kurukulaaratchy RJ. Understanding the impact of breathing pattern disorders in difficult-to-treat asthma. Expert Rev Respir Med 2024:1-12. [PMID: 39268799 DOI: 10.1080/17476348.2024.2404673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 09/05/2024] [Accepted: 09/11/2024] [Indexed: 09/15/2024]
Abstract
INTRODUCTION Difficult-to-treat asthma is defined as asthma that is uncontrolled despite high-level treatment or requires such treatment to maintain good control and reduce exacerbations. Breathing pattern disorders (BPD) have been reported as a comorbidity in ~ 24-42% % of patients with difficult-to-treat asthma. This narrative review will assess the association, impact, and management of BPD in difficult-to-treat asthma. AREAS COVERED We outline current understandings of the nature of difficult-to-treat asthma and BPD. We then review the impact of BPD on difficult-to-treat asthma and Multidisciplinary Team (MDT) approaches to assessing and managing BPD in this patient group. A comprehensive literature search was performed by an asthma specialist MDT including physiotherapists, psychologists, and physicians to create a holistic perspective on this subject. EXPERT OPINION BPD exerts significant negative impacts across multiple domains in patients with difficult-to treat asthma. There is a need for further observational, interventional, qualitative and quantitative research to develop better diagnosis, treatment, and awareness of the impacts of BPD including health economic analysis. Studies should develop multimodal approaches that better treat both BPD and associated comorbidities within the multimorbidity framework of difficult-to-treat asthma. Recognizing and addressing BPD should be key elements in future difficult-to-treat asthma management guidelines and clinical practice.
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Affiliation(s)
- J J Hudson-Colby
- School of Health Sciences, University of Southampton, Southampton, UK
- Physiotherapy Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Adam Lewis
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Judit Varkonyi-Sepp
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Psychology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ben Ainsworth
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Psychology, University of Southampton, Southampton, UK
| | - Anna Freeman
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Anneliese Day
- Psychology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ratko Djukanovic
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Liuyu Wei
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Hans Michael Haitchi
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, UK
| | - Ramesh J Kurukulaaratchy
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Psychology, University of Southampton, Southampton, UK
- The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, UK
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Denton E, Hew M, Peters MJ, Upham JW, Bulathsinhala L, Tran TN, Martin N, Bergeron C, Al-Ahmad M, Altraja A, Larenas-Linnemann D, Murray R, Celis-Preciado CA, Al-Lehebi R, Belhassen M, Bhutani M, Bosnic-Anticevich SZ, Bourdin A, Brusselle GG, Busby J, Canonica GW, Heffler E, Chapman KR, Charriot J, Christoff GC, Chung LP, Cosio BG, Côté A, Costello RW, Cushen B, Fingleton J, Fonseca JA, Gibson PG, Heaney LG, Huang EWC, Iwanaga T, Jackson DJ, Koh MS, Lehtimäki L, Máspero J, Mahboub B, Menzies-Gow AN, Mitchell PD, Papadopoulos NG, Papaioannou AI, Perez-de-Llano L, Perng DW, Pfeffer PE, Popov TA, Porsbjerg CM, Rhee CK, Roche N, Sadatsafavi M, Salvi S, Schmid JM, Sheu CC, Sirena C, Torres-Duque CA, Salameh L, Patel PH, Ulrik CS, Wang E, Wechsler ME, Price DB. Real-world biologics response and super-response in the International Severe Asthma Registry cohort. Allergy 2024. [PMID: 38923444 DOI: 10.1111/all.16178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 05/08/2024] [Accepted: 05/12/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Biologic asthma therapies reduce exacerbations and long-term oral corticosteroids (LTOCS) use in randomized controlled trials (RCTs); however, there are limited data on outcomes among patients ineligible for RCTs. Hence, we investigated responsiveness to biologics in a real-world population of adults with severe asthma. METHODS Adults in the International Severe Asthma Registry (ISAR) with ≥24 weeks of follow-up were grouped into those who did, or did not, initiate biologics (anti-IgE, anti-IL5/IL5R, anti-IL4/13). Treatment responses were examined across four domains: forced expiratory volume in 1 second (FEV1) increase by ≥100 mL, improved asthma control, annualized exacerbation rate (AER) reduction ≥50%, and any LTOCS dose reduction. Super-response criteria were: FEV1 increase by ≥500 mL, new well-controlled asthma, no exacerbations, and LTOCS cessation or tapering to ≤5 mg/day. RESULTS 5.3% of ISAR patients met basic RCT inclusion criteria; 2116/8451 started biologics. Biologic initiators had worse baseline impairment than non-initiators, despite having similar biomarker levels. Half or more of initiators had treatment responses: 59% AER reduction, 54% FEV1 increase, 49% improved control, 49% reduced LTOCS, of which 32%, 19%, 30%, and 39%, respectively, were super-responses. Responses/super-responses were more frequent in biologic initiators than in non-initiators; nevertheless, ~40-50% of initiators did not meet response criteria. CONCLUSIONS Most patients with severe asthma are ineligible for RCTs of biologic therapies. Biologics are initiated in patients who have worse baseline impairments than non-initiators despite similar biomarker levels. Although biologic initiators exhibited clinical responses and super-responses in all outcome domains, 40-50% did not meet the response criteria.
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Affiliation(s)
- Eve Denton
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia
- Department of Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia
- Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Matthew J Peters
- Department of Thoracic Medicine, Concord Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - John W Upham
- Frazer Institute & PA-Southside Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia
| | - Lakmini Bulathsinhala
- Optimum Patient Care Global, Cambridge, UK
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Trung N Tran
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland, USA
| | - Neil Martin
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland, USA
- Department of Respiratory Medicine, University of Leicester, Leicester, UK
| | - Celine Bergeron
- Centre for Lung Health, Vancouver General Hospital, Vancouver, British Columbia, Canada
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Mona Al-Ahmad
- Microbiology Department, College of Medicine, Kuwait University, Kuwait City, Kuwait
- Al-Rashed Allergy Center, Ministry of Health, Kuwait City, Kuwait
| | - Alan Altraja
- Department of Pulmonology, University of Tartu and Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | | | | | - Carlos Andrés Celis-Preciado
- Pulmonary Unit, Hospital Universitario San Ignacio, Bogota, Colombia
- Faculty of Medicine, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Riyad Al-Lehebi
- Department of Pulmonology, King Fahad Medical City, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | | | - Mohit Bhutani
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Alberta, Canada
| | - Sinthia Z Bosnic-Anticevich
- Faculty of Medicine, Health and Human Sciences, Macquarie Medical School, Macquarie University, Sydney, New South Wales, Australia
- Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - Arnaud Bourdin
- PhyMedExp, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Guy G Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Epidemiology and Respiratory Medicine, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - John Busby
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | | | - Jérémy Charriot
- PhyMedExp, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | | | - Li Ping Chung
- Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Borja G Cosio
- Son Espases University Hospital-IdISBa-Ciberes, Mallorca, Spain
| | - Andréanne Côté
- Department of Medicine, Laval University, Quebec City, Quebec, Canada
| | - Richard W Costello
- Department of Respiratory Medicine, Clinical Research Centre, Smurfit Building Beaumont Hospital, RCSI, Dublin, Ireland
| | - Breda Cushen
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - James Fingleton
- Capital and Coast District Health Board, Wellington, New Zealand
| | - João A Fonseca
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Peter G Gibson
- Australian Severe Asthma Network, Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Hunter Medical Research Institute, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Liam G Heaney
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Erick Wan-Chun Huang
- Department of Internal Medicine, Division of Pulmonary Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | | | - David J Jackson
- Guy's Severe Asthma Centre, Guy's Hospital, King's College London, London, UK
| | - Mariko Siyue Koh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jorge Máspero
- Clinical Research for Allergy and Respiratory Medicine, CIDEA Foundation, Buenos Aires, Argentina
- University Career of Specialists in Allergy and Clinical Immunology at the Buenos Aires University School of Medicine, Buenos Aires, Argentina
| | - Bassam Mahboub
- Rashid hospital, Dubai Health Authority (DHA), Dubai, United Arab Emirates
| | - Andrew N Menzies-Gow
- AstraZeneca, Cambridge, UK
- Lung Division, Royal Brompton & Harefield Hospital, London, UK
| | | | - Nikolaos G Papadopoulos
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, UK
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
| | - Andriana I Papaioannou
- 2nd Respiratory Medicine Department, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Luis Perez-de-Llano
- Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo, Spain
| | - Diahn-Warng Perng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Paul E Pfeffer
- Department of Respiratory Medicine, Barts Health NHS Trust, London, UK
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Todor A Popov
- University Hospital St. Ivan Rilski, Sofia, Bulgaria
| | - Celeste M Porsbjerg
- Department of Respiratory Medicine and Infectious Diseases, Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Chin Kook Rhee
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Nicolas Roche
- Department of Respiratory Medicine, APHP-Centre University Paris Cité, Cochin Hospital and Institute (UMR1016), Paris, France
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sundeep Salvi
- Pulmocare Research and Education Foundation, Pune, India
| | | | - Chau-Chyun Sheu
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | - Carlos A Torres-Duque
- CINEUMO, Respiratory Research Center, Fundación Neumológica Colombiana, Bogotá, Colombia
- Universidad de La Sabana, Chia, Colombia
| | - Laila Salameh
- Rashid hospital, Dubai Health Authority (DHA), Dubai, United Arab Emirates
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Pujan H Patel
- Respiratory Medicine, Royal Brompton Hospital, London, UK
| | | | - Eileen Wang
- Department of Medicine, Division of Allergy and Clinical Immunology, National Jewish Health and University of Colorado School of Medicine, Denver, Colorado, USA
| | - Michael E Wechsler
- Department of Medicine, NJH Cohen Family Asthma Institute, National Jewish Health, Denver, Colorado, USA
| | - David B Price
- Optimum Patient Care Global, Cambridge, UK
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
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Færk G, Ahlström MG, Lura VHE, Reventlow S, Johansen JD, Thyssen JP, Hansen KS, Skov L. Referral Pathways for Children with Atopic Diseases in Denmark. Acta Derm Venereol 2024; 104:adv34961. [PMID: 38828609 PMCID: PMC11161810 DOI: 10.2340/actadv.v104.34961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/18/2024] [Indexed: 06/05/2024] Open
Abstract
Atopic diseases such as atopic dermatitis, food allergy, allergic rhinoconjunctivitis, and/or asthma are common. In Denmark, however, there are multiple referral pathways for these diseases in the healthcare system and they are poorly understood. To describe how children with atopic diseases navigate their way through the Danish healthcare system, a questionnaire was distributed to children aged ≤ 17 years, who were being treated for atopic diseases between August 2020 and June 2021, either by a practising specialist or a hospital department, in the Capital Region of Denmark. A total of 279 children completed the questionnaire and most were referred to a specialist or to a hospital by their general practitioner. No "common track" to hospital existed for patients with ≥ 3 atopic diseases. These patients were more often referred to a hospital compared with children with 2 atopic diseases or fewer (odds ratio [OR] 3.79; 95% CI 2.07-7.24). The primary determinants for hospital treatment were food allergy (OR 4.69; 95% CI 2.07-10.61) and asthma (OR 2.58; 95% CI 1.18-5.63). In conclusion, children with multiple atopic diseases were more likely to be referred to hospital departments than to practising specialists, mainly due to food allergies.
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Affiliation(s)
- Gitte Færk
- Department of Dermatology and Allergy, Copenhagen University Hospital - Herlev and Gentofte, Denmark, The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark, and National Allergy Research Center, Copenhagen University Hospital - Herlev and Gentofte, Denmark.
| | - Malin Glindvad Ahlström
- National Allergy Research Center, Copenhagen University Hospital - Herlev and Gentofte, Denmark
| | - Viktoria Helt-Eggers Lura
- Department of Dermatology and Allergy, Copenhagen University Hospital - Herlev and Gentofte, Denmark
| | - Susanne Reventlow
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark
| | - Jeanne Duus Johansen
- National Allergy Research Center, Copenhagen University Hospital - Herlev and Gentofte, Denmark
| | - Jacob P Thyssen
- Department of Dermatology and Venereology, Copenhagen University Hospital - Bispebjerg, Denmark
| | - Kirsten Skamstrup Hansen
- Department of Dermatology and Allergy, Copenhagen University Hospital - Herlev and Gentofte, Denmark and Department of Pediatrics, Copenhagen University Hospital - Herlev and Gentofte, Denmark
| | - Lone Skov
- Department of Dermatology and Allergy, Copenhagen University Hospital - Herlev and Gentofte, Denmark and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Freeman A, Abraham S, Kadalayil L, Varkonyi-Sepp J, Ainsworth B, Hudson-Colby JJ, Barber C, Dennison P, Azim A, Mistry H, Howarth P, Djukanovic R, Zhang H, Arshad SH, Haitchi HM, Kurukulaaratchy RJ. Associations of Breathing Pattern Disorder and Nijmegen Score With Clinical Outcomes in Difficult-to-Treat Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:938-947.e6. [PMID: 38036249 DOI: 10.1016/j.jaip.2023.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Breathing pattern disorder (BPD) reflects altered biomechanical patterns of breathing that drive breathing difficulty and commonly accompanies difficult-to-treat asthma. Diagnosis of BPD has no gold standard, but Nijmegen Questionnaire (NQ) >23 is commonly used. OBJECTIVES We sought to advance clinical characterization of BPD and better understand the clinical utility of NQ in difficult asthma in patients from the Wessex AsThma CoHort of difficult asthma (WATCH) study. METHODS Associations between demographic and clinical factors in difficult asthma and BPD, ascertained by clinical diagnosis (yes/no, n = 476), by NQ scores (≤23: normal [no suggestion of BPD] and >23: abnormal [suggested BPD], n = 372), as well as the continuous raw NQ scores were assessed in univariate models to identify significant risk factors associated with the 3 BPD outcomes. For the clinician-diagnosed and NQ-based BPD, associations of continuous factors were assessed using the independent samples t test or the Mann-Whitney U test as appropriate for the data distribution or by the Spearman correlation test. Dichotomous associations were evaluated using χ2 tests. Multivariable logistic (dichotomous outcomes) and linear regression models (continuous outcomes) were developed to identify predictive factors associated with clinician-diagnosed and NQ-based BPD, dichotomous and continuous. Patients with data on NQ scores were grouped into NQ quartiles (low, moderate, high, and very high). The patterns of association of the quartiles with 4 health-related questionnaire outcomes were assessed using linear regression analyses. RESULTS Multivariable regression identified that clinically diagnosed BPD was associated with female sex (odds ratio [OR]: 1.85; 95% confidence interval [CI]: 1.07, 3.20), comorbidities (rhinitis [OR: 2.46; 95% CI: 1.45, 4.17], gastroesophageal reflux disease [GORD] [OR: 2.77; 95% CI: 1.58, 4.84], inducible laryngeal obstruction [OR: 4.37; 95% CI: 2.01, 9.50], and any psychological comorbidity [OR: 1.86; 95% CI: 1.13, 3.07]), and health care usage (exacerbations [OR: 1.07; 95% CI: 1.003, 1.14] and previous intensive care unit (ICU) admissions [OR: 2.03; 95% CI: 1.18, 3.47]). Abnormal NQ-based BPD diagnosis was associated with history of eczema (OR: 1.83; 95% CI: 1.07, 3.14), GORD (OR: 1.94; 95% CI: 1.15, 3.27), or any psychological comorbidity (OR: 4.29; 95% CI: 2.64, 6.95) at multivariable regression. Differences between clinical and NQ-based BPD traits were also found with 42% discordance in BPD state between these definitions. Multivariable linear regression analysis with NQ as a continuous outcome showed positive association with worse asthma outcomes (admission to ICU, P = .037), different phenotypic traits (female sex, P = .001; ever smoker, P = .025), and greater multimorbidity (GORD, P = .002; sleep apnea, P = .04; and any psychological comorbidity, P < .0001). CONCLUSION BPD is associated with worse health outcomes and negative health impacts in difficult asthma within a multimorbidity disease model. It therefore merits better recognition and prompt treatment. Clinical diagnosis and NQ offer different perspectives on BPD, so this goal may be best addressed by considering clinical features alongside the magnitude of NQ.
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Affiliation(s)
- Anna Freeman
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Steevo Abraham
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Latha Kadalayil
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Judit Varkonyi-Sepp
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Clinical Health Psychology Department, Southern Health NHS Foundation Trust/University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Ben Ainsworth
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Department of Psychology, University of Southampton, Southampton, United Kingdom
| | - J J Hudson-Colby
- Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Clair Barber
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Paddy Dennison
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Adnan Azim
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Heena Mistry
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Peter Howarth
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Ratko Djukanovic
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Hongmei Zhang
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tenn
| | - S Hasan Arshad
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, United Kingdom
| | - Hans Michael Haitchi
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Ramesh J Kurukulaaratchy
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, United Kingdom.
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Tiew PY, Tay TR, Chen W, Price DB, Ong KY, Chotirmall SH, Koh MS. Predictors of persistent poor control and validation of ASSESS score: Longitudinal 5-year follow-up of severe asthma cohort. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100188. [PMID: 38173699 PMCID: PMC10762473 DOI: 10.1016/j.jacig.2023.100188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 09/08/2023] [Accepted: 10/30/2023] [Indexed: 01/05/2024]
Abstract
Background Longitudinal predictors of persistent poor asthma control in severe asthma (SA) cohort remain scarce. The predictive value of the asthma severity scoring system (ASSESS) in the SA cohort outside the original study and in the Asian population is unknown. Objective We sought to determine the 5-year longitudinal outcome of patients with SA and validate the use of ASSESS score in predicting future outcomes in SA. Methods A prospective longitudinal observational study of patients with SA attending the multidisciplinary specialist SA clinic of the Singapore General Hospital from 2011 to 2021 was conducted. The number of exacerbations and asthma control test results were recorded yearly for 5 consecutive years. The ASSESS score was computed at baseline, and the area under the receiver-operating characteristic curve for predicting persistent poor asthma control was generated. Results Of the 489 patients recruited into the study, 306 patients with 5-year follow-up data were analyzed. Seventy-three percent had type 2 inflammation with increased overall exacerbations over 5 years (rate ratio, 2.55; 95% CI, 1.31-4.96; P = .006) relative to non-type 2 SA. In the multivariate model, bronchiectasis, gastroesophageal reflux disease, and an asthma control test score of less than 20 were significantly associated with persistent poor asthma control over 5 years. ASSESS scores were good at predicting persistent poor asthma control with an area under the receiver-operating characteristic curve of 0.71 (95% CI, 0.57-0.84). Conclusions Bronchiectasis and gastroesophageal reflux disease are predictors for persistent poor asthma control and targeted traits for precision medicine in SA. The ASSESS score has a good prediction for persistent poor asthma control over 5 years.
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Affiliation(s)
- Pei Yee Tiew
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Duke-NUS Medical School, Singapore
| | - Tunn Ren Tay
- Duke-NUS Medical School, Singapore
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Wenjia Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - David B. Price
- Observational and Pragmatic Research Institute, Singapore
- Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
| | - Kheng Yong Ong
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Sanjay H. Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Mariko Siyue Koh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
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6
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Thomas M, Beasley R. The treatable traits approach to adults with obstructive airways disease in primary and secondary care. Respirology 2023; 28:1101-1116. [PMID: 37877554 DOI: 10.1111/resp.14610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
The treatable traits approach is based on the recognition that the different clinical phenotypes of asthma and chronic obstructive airways disease (COPD) are a heterogeneous group of conditions with different underlying mechanisms and clinical manifestations, and that the identification and treatment of the specific clinical features or traits facilitates a personalised approach to management. Fundamentally, it recognises two important concepts. Firstly, that treatment for obstructive lung disease can achieve better outcomes if guided by specific clinical characteristics. Secondly, that in patients with a diagnosis of asthma, and/or COPD, poor respiratory health may also be due to numerous overlapping disorders that can present with symptoms that may be indistinguishable from asthma and/or COPD, comorbidities that might require treatment in their own right, and lifestyle or environmental factors that, if addressed, might lead to better control rather than simply increasing airways directed treatment. While these concepts are well accepted, how best to implement this personalised medicine approach in primary and secondary care within existing resource constraints remains uncertain. In this review, we consider the evidence base for this management approach and propose that the priority now is to assess different prototype templates for the identification and management of treatable traits in both asthma and COPD, in primary, secondary and tertiary care, to provide the evidence that will guide their use in clinical practice in different health care systems.
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Affiliation(s)
- Mike Thomas
- Primary Care Research, School of Primary Care, Population Sciences and Medical Education (PPM), Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Richard Beasley
- Medicine, Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University of Wellington, Wellington, New Zealand
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7
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Pfeffer PE, Rupani H, De Simoni A. Bringing the treatable traits approach to primary care asthma management. FRONTIERS IN ALLERGY 2023; 4:1240375. [PMID: 37799134 PMCID: PMC10548136 DOI: 10.3389/falgy.2023.1240375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023] Open
Abstract
Asthma continues to be a major cause of illness with a significant mortality, despite its increasing range of treatments. Adoption of a treatable traits approach in specialist centres has led to improvements in control of asthma and reduced exacerbations in patients with severe asthma. However, most patients with this illness, particularly those with mild-to-moderate asthma, are cared for in primary care according to guidelines that emphasise the use of pharmacotherapeutic ladders uniformly implemented across all patients. These pharmacotherapeutic ladders are more consistent with a "one-size-fits-all" approach than the treatable traits approach. This can be harmful, especially in patients whose symptoms and airway inflammation are discordant, and extra-pulmonary treatable traits are often overlooked. Primary care has extensive experience in patient-centred holistic care, and many aspects of the treatable traits approach could be rapidly implemented in primary care. Blood eosinophil counts, as a biomarker of the treatable trait of eosinophilia, are already included in routine haematology tests and could be used in primary care to guide titration of inhaled corticosteroids. Similarly, poor inhaler adherence could be further assessed and managed in primary care. However, further research is needed to guide how some treatable traits could feasibly be assessed and/or managed in primary care, for example, how to best manage patients in primary care, who are likely suffering from breathing pattern disorders and extra-pulmonary treatable traits, with frequent use of their reliever inhaler in the absence of raised T2 biomarkers. Implementation of the treatable traits approach across the disease severity spectrum will improve the quality of life of patients with asthma but will take time and research to embed across care settings.
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Affiliation(s)
- Paul E. Pfeffer
- Department of Respiratory Medicine, Barts Health NHS Trust, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Hitasha Rupani
- Department of Respiratory Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Anna De Simoni
- Wolfson Institute of Population Health and Asthma UK Centre for Applied Research, Queen Mary University of London, London, United Kingdom
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8
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Denton E, Hew M. Biologic Super-Response and Clinical Remission in Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2713-2714. [PMID: 37684073 DOI: 10.1016/j.jaip.2023.06.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Eve Denton
- Allergy, Asthma, and Clinical Immunology Department, Alfred Hospital, Melbourne, Victoria, Australia; Respiratory, Allergy, and Clinical Immunology Department, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma, and Clinical Immunology Department, Alfred Hospital, Melbourne, Victoria, Australia; Public Health and Preventive Medicine Department, Monash University, Melbourne, Victoria, Australia.
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9
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Lin T, Pham J, Denton E, Lee J, Hore-Lacy F, Sverrild A, Stojanovic S, Tay TR, Murthee KG, Radhakrishna N, Dols M, Bondarenko J, Mahoney J, O'Hehir RE, Dabscheck E, Hew M. Trait profiles in difficult-to-treat asthma: Clinical impact and response to systematic assessment. Allergy 2023; 78:2418-2427. [PMID: 36940306 DOI: 10.1111/all.15719] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/12/2023] [Accepted: 01/31/2023] [Indexed: 03/22/2023]
Abstract
BACKGROUND Multidisciplinary systematic assessment improves outcomes in difficult-to-treat asthma, but without clear response predictors. Using a treatable-traits framework, we stratified patients by trait profile, examining clinical impact and treatment responsiveness to systematic assessment. METHODS We performed latent class analysis using 12 traits on difficult-to-treat asthma patients undergoing systematic assessment at our institution. We examined Asthma Control Questionnaire (ACQ-6) and Asthma Quality of Life Questionnaire (AQLQ) scores, FEV1 , exacerbation frequency, and maintenance oral corticosteroid (mOCS) dose, at baseline and following systematic assessment. RESULTS Among 241 patients, two airway-centric profiles were characterized by early-onset with allergic rhinitis (n = 46) and adult onset with eosinophilia/chronic rhinosinusitis (n = 60), respectively, with minimal comorbid or psychosocial traits; three non-airway-centric profiles exhibited either comorbid (obesity, vocal cord dysfunction, dysfunctional breathing) dominance (n = 51), psychosocial (anxiety, depression, smoking, unemployment) dominance (n = 72), or multi-domain impairment (n = 12). Compared to airway-centric profiles, non-airway-centric profiles had worse baseline ACQ-6 (2.7 vs. 2.2, p < .001) and AQLQ (3.8 vs. 4.5, p < .001) scores. Following systematic assessment, the cohort showed overall improvements across all outcomes. However, airway-centric profiles had more FEV1 improvement (5.6% vs. 2.2% predicted, p < .05) while non-airway-centric profiles trended to greater exacerbation reduction (1.7 vs. 1.0, p = .07); mOCS dose reduction was similar (3.1 mg vs. 3.5 mg, p = .782). CONCLUSION Distinct trait profiles in difficult-to-treat asthma are associated with different clinical outcomes and treatment responsiveness to systematic assessment. These findings yield clinical and mechanistic insights into difficult-to-treat asthma, offer a conceptual framework to address disease heterogeneity, and highlight areas responsive to targeted intervention.
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Affiliation(s)
- Tiffany Lin
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Jonathan Pham
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Joy Lee
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Asger Sverrild
- Department of Respiratory Medicine, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Stephanie Stojanovic
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore City, Singapore
| | | | - Naghmeh Radhakrishna
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Monique Dols
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Janet Bondarenko
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Janine Mahoney
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Robyn E O'Hehir
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Eli Dabscheck
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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10
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Roberts E. Oral Corticosteroids for Patients with Eosinophilic Diseases: An Expert Panel View on Use, Overuse, and Strategies to Reduce Use. EUROPEAN MEDICAL JOURNAL 2023. [DOI: 10.33590/emj/10303904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Severe asthma (SA), chronic rhinosinusitis with nasal polyps (CRSwNP), and eosinophilic granulomatosis with polyangiitis (EGPA) are three conditions driven by IL-5 and eosinophilic inflammation. As these conditions have high use of healthcare services, as well as lifestyle and psychological burdens, safe treatment to achieve optimal control is key. In all three conditions, as for many other eosinophilic diseases (ED), oral corticosteroids (OCS) are often used for both acute and maintenance treatment where disease activity is high. While, in general, OCS are very effective, their use is limited by a well-recognised high potential for adverse effects (AE). Moreover, cumulative exposure to OCS may not be acknowledged in many patients, especially for those predominantly treated in primary care, exposing patients to potentially damaging long-term OCS-related AEs. To discuss the use of OCS for these eosinophilic diseases, as well as to provide guidance on how to help limit their use, a board of European experts within each field was gathered. The experts completed questionnaires regarding treatment and referral pathways for patients with SA, CRSwNP, or EGPA; then, in an online meeting, discussed a number of issues in regard to OCS use. Here, the authors present the key recommendations from the expert advisory panel alongside some background to these conditions regarding treatment with OCS.
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11
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Redmond C, Heaney LG, Chaudhuri R, Jackson DJ, Menzies-Gow A, Pfeffer P, Busby J. Benefits of specialist severe asthma management: demographic and geographic disparities. Eur Respir J 2022; 60:2200660. [PMID: 35777771 PMCID: PMC9753476 DOI: 10.1183/13993003.00660-2022] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/23/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The benefits of specialist assessment and management have yet to be evaluated within the biologic era of UK severe asthma treatment, and potential disparities have not been considered. METHODS In an uncontrolled before-and-after study, we compared asthma symptoms (Asthma Control Questionnaire-6 (ACQ-6)), exacerbations, unscheduled secondary care use, lung function (forced expiratory volume in 1 s (FEV1)) and oral corticosteroid (OCS) dose after 1 year. We compared outcomes by sex, age (18-34, 35-49, 50-64 and ≥65 years), ethnicity (Caucasian versus non-Caucasian) and hospital site after adjusting for demographics and variation in biologic therapy use. RESULTS 1140 patients were followed-up for 1370 person-years from 12 specialist centres. At annual review, ACQ-6 score was reduced by a median (interquartile range (IQR)) of 0.7 (0.0-1.5), exacerbations by 75% (33-100%) and unscheduled secondary care by 100% (67-100%). FEV1 increased by a median (IQR) of 20 (-200-340) mL, while OCS dose decreased for 67% of patients. Clinically meaningful improvements occurred across almost all patients, including those not receiving biologic therapy. There was little evidence of differences across demographic groups, although those aged ≥65 years demonstrated larger reductions in exacerbations (69% versus 52%; p<0.001) and unscheduled care use (77% versus 50%; p<0.001) compared with patients aged 18-34 years. There were >2-fold differences between the best and worst performing centres across all study outcomes. CONCLUSIONS Specialist assessment and management is associated with substantially improved patient outcomes, which are broadly consistent across demographic groups and are not restricted to those receiving biologic therapy. Significant variation exists between hospitals, which requires further investigation.
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Affiliation(s)
- Charlene Redmond
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Liam G Heaney
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
- Belfast Health and Social Care NHS Trust, Belfast, UK
| | | | - David J Jackson
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals, London, UK
- School of Immunology and Microbial Sciences, King's College London, London, UK
| | | | | | - John Busby
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
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12
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Varkonyi-Sepp J, Freeman A, Ainsworth B, Kadalayil LP, Haitchi HM, Kurukulaaratchy RJ. Multimorbidity in Difficult Asthma: The Need for Personalised and Non-Pharmacological Approaches to Address a Difficult Breathing Syndrome. J Pers Med 2022; 12:1435. [PMID: 36143220 PMCID: PMC9500722 DOI: 10.3390/jpm12091435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/21/2022] Open
Abstract
Three to ten percent of people living with asthma have difficult-to-treat asthma that remains poorly controlled despite maximum levels of guideline-based pharmacotherapy. This may result from a combination of multiple adverse health issues including aggravating comorbidities, inadequate treatment, suboptimal inhaler technique and/or poor adherence that may individually or collectively contribute to poor asthma control. Many of these are potentially "treatable traits" that can be pulmonary, extrapulmonary, behavioural or environmental factors. Whilst evidence-based guidelines lead clinicians in pharmacological treatment of pulmonary and many extrapulmonary traits, multiple comorbidities increase the burden of polypharmacy for the patient with asthma. Many of the treatable traits can be addressed with non-pharmacological approaches. In the current healthcare model, these are delivered by separate and often disjointed specialist services. This leaves the patients feeling lost in a fragmented healthcare system where clinical outcomes remain suboptimal even with the best current practice applied in each discipline. Our review aims to address this challenge calling for a paradigm change to conceptualise difficult-to-treat asthma as a multimorbid condition of a "Difficult Breathing Syndrome" that consequently needs a holistic personalised care attitude by combining pharmacotherapy with the non-pharmacological approaches. Therefore, we propose a roadmap for an evidence-based multi-disciplinary stepped care model to deliver this.
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Affiliation(s)
- Judit Varkonyi-Sepp
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical Health Psychology Department, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Anna Freeman
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Ben Ainsworth
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Department of Psychology, University of Bath, Bath BA2 7AY, UK
| | - Latha Perunthadambil Kadalayil
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Hans Michael Haitchi
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Institute for Life Sciences, University of Southampton, Southampton SO16 6YD, UK
| | - Ramesh J. Kurukulaaratchy
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- The David Hide Asthma & Allergy Research Centre, St Mary’s Hospital, Isle of Wight, Newport PO30 5TG, UK
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13
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Hogan MB, Zhao W. High SABA Using and Poor Asthma Control: Blaming Poor Adherence or Missing the Phenotype? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE 2022; 10:2084-2085. [PMID: 35961733 DOI: 10.1016/j.jaip.2022.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/27/2022]
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14
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McDonald VM, Gibson PG. Multidisciplinary care in chronic airway diseases: the Newcastle model. ERJ Open Res 2022; 8:00215-2022. [PMID: 35983538 PMCID: PMC9379354 DOI: 10.1183/23120541.00215-2022] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/10/2022] [Indexed: 11/05/2022] Open
Abstract
Chronic airway diseases including, asthma and chronic obstructive pulmonary disease (COPD) are prevalent and high burden conditions with the majority of patients successfully managed in the primary care setting. However, some patients with more complex disease such as difficult-to-treat or severe asthma, or complex COPD, tertiary care is required. This review provides an overview of the successful tertiary care multidisciplinary respiratory service that operates in Newcastle, New South Wales, Australia, which has been integrated into the tertiary care outpatient clinics for almost three decades. The service is multifaceted in terms of the clinical care it provides, and includes an “Inpatient service”, “Asthma Management Service”, “Difficult Airway Clinic”, “Drug Administration Clinic”, “Rapid Access Clinic”, “Pulmonary Rehabilitation” and has an integrated research programme. The core of the multidisciplinary approach to airway diseases is a person-centred model of care, the “Treatable Traits” approach. The staffing of this service comprises of consultant physicians, respiratory advanced trainees, respiratory scientists, physiotherapists, speech pathologists, nurse specialists and a nurse consultant. Patients that present to this service undergo an initial assessment and clinical review by team members, synthesis of relevant data, and development of a diagnosis and management plan. Based on this review specific interventions are determined according to the traits identified. Overtime the service has evolved to accommodate the increasing numbers of patients requiring access to the “Difficult Airways Clinic” assessment and therapies. This has been facilitated by partnered with the Centres of Excellence in Severe Asthma and Treatable Traits to develop educational and practice management tools.
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15
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Sarwar MR, McDonald VM, Abramson MJ, McLoughlin RF, Geethadevi GM, George J. Effectiveness of Interventions Targeting Treatable Traits for the Management of Obstructive Airway Diseases: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2333-2345.e21. [PMID: 35643276 DOI: 10.1016/j.jaip.2022.05.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 03/30/2022] [Accepted: 05/02/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND The management of obstructive airway diseases (OADs) is complex. The treatable traits (TTs) approach may be an effective strategy for managing OADs. OBJECTIVE To determine the effectiveness of interventions targeting TTs for managing OADs. METHODS Ovid Embase, Medline, CENTRAL, and CINAHL Plus were searched from inception to March 9, 2022. Studies of interventions targeting at least 1 TT from pulmonary, extrapulmonary, and behavioral/lifestyle domains were included. Two reviewers independently extracted relevant data and performed risk-of-bias assessments. Meta-analyses were performed using random-effects models. Subgroup and sensitivity analyses were carried out to explore heterogeneity and to determine the effects of outlying studies. RESULTS Eleven studies that used the TTs approach for OAD management were identified. Traits targeted within each study ranged from 13 to 36. Seven controlled trials were included in meta-analyses. TT interventions were effective at improving health-related quality of life (mean difference [MD] = -6.96, 95% CI: -9.92 to -4.01), hospitalizations (odds ratio [OR] = 0.52, 95% CI: 0.39 to 0.69), all-cause-1-year mortality (OR = 0.65, 95% CI: 0.45 to 0.95), dyspnea score (MD = -0.29, 95% CI: -0.46 to -0.12), anxiety (MD = -1.61, 95% CI: -2.92 to -0.30), and depression (MD = -2.00, 95% CI: -3.53 to -0.47). CONCLUSION Characterizing TTs and targeted interventions can improve outcomes in OADs, which offer a promising model of care for OADs.
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Affiliation(s)
- Muhammad Rehan Sarwar
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Vanessa Marie McDonald
- National Health and Medical Research Council, Centre for Research Excellence in Severe Asthma and Centre of Excellence in Treatable Traits, the University of Newcastle, Newcastle, Australia; The Priority Research Centre for Healthy Lungs, School of Nursing and Midwifery, Newcastle, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, Australia
| | - Michael John Abramson
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Rebecca Frances McLoughlin
- National Health and Medical Research Council, Centre for Research Excellence in Severe Asthma and Centre of Excellence in Treatable Traits, the University of Newcastle, Newcastle, Australia; The Priority Research Centre for Healthy Lungs, School of Nursing and Midwifery, Newcastle, Australia
| | | | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.
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16
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Busse WW, Kraft M. Current unmet needs and potential solutions to uncontrolled asthma. Eur Respir Rev 2022; 31:210176. [PMID: 35082128 PMCID: PMC9488919 DOI: 10.1183/16000617.0176-2021] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/28/2021] [Indexed: 12/16/2022] Open
Abstract
Despite the availability of effective inhaled therapies, many patients with asthma have poor asthma control. Uncontrolled asthma presents a significant burden on the patient and society, and, for many, remains largely preventable. There are numerous reasons why a patient may remain uncontrolled despite access to therapies, including incorrect inhaler technique, poor adherence to treatment, oversight of triggers and suboptimal medical care. Shared decision-making, good patient-clinician communication, supported self-management, multidisciplinary patient education, new technology and risk stratification may all provide solutions to this major unmet need in asthma. Novel treatments such as biologics could benefit patients' lives, while the investigations into biomarkers, non-Type 2 asthma, treatable traits and disease modification give an exciting glimpse into the future of asthma care.
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Affiliation(s)
- William W Busse
- Dept of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Monica Kraft
- University of Arizona College of Medicine, Tucson, AZ, USA
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17
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Denton E, Hew M, Gibson PG, Vertigan A. Lone Ranger or Handpicked Posse? How Multidisciplinary Assessment Helps Evaluate Suspected Laryngeal Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:609-611. [PMID: 35144775 DOI: 10.1016/j.jaip.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 12/27/2022]
Affiliation(s)
- Eve Denton
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter G Gibson
- National Health and Medical Research Council Centre of Excellence in Treatable Traits, the University of Newcastle, Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Anne Vertigan
- Speech Pathology, John Hunter Hospital, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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18
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van der Valk JPM, Kappen JH, van Campen JSJA, Epping G, Retera JMAM, de Bondt D, Suwandy F, Tolboom M, 't Veen JCCMI, Braunstahl GJ. Roadmap to improve regional care for patients with severe asthma. Clin Transl Allergy 2021; 11:e12080. [PMID: 34962718 PMCID: PMC8805686 DOI: 10.1002/clt2.12080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- J P M van der Valk
- Department of Pulmonary Medicine, STZ Center of Excellence for Asthma and COPD, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - J H Kappen
- Department of Pulmonary Medicine, STZ Center of Excellence for Asthma and COPD, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - J S J A van Campen
- Department of Pulmonary Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | - G Epping
- Department of Pulmonary Medicine, STZ Center of Excellence for Asthma and COPD, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - J M A M Retera
- Department of Pulmonary Medicine, Elizabeth Twee-Steden Hospital, Tilburg, The Netherlands
| | - D de Bondt
- AstraZeneca BV, The Hague, The Netherlands
| | - F Suwandy
- Vintura, Health Care, Baarn, The Netherlands
| | - M Tolboom
- Vintura, Health Care, Baarn, The Netherlands
| | - J C C M In 't Veen
- Department of Pulmonary Medicine, STZ Center of Excellence for Asthma and COPD, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.,Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - G J Braunstahl
- Department of Pulmonary Medicine, STZ Center of Excellence for Asthma and COPD, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.,Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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19
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Rupani H, Hew M. Super-Responders to Severe Asthma Treatments: Defining a New Paradigm. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4005-4006. [PMID: 34749947 DOI: 10.1016/j.jaip.2021.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 08/17/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Hitasha Rupani
- Department of Respiratory Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Mark Hew
- Allergy, Asthma, and Clinical Immunology, Alfred Health, Melbourne, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
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20
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Dynamics of inhaled corticosteroid use are associated with asthma attacks. Sci Rep 2021; 11:14715. [PMID: 34282212 PMCID: PMC8289909 DOI: 10.1038/s41598-021-94219-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 06/30/2021] [Indexed: 12/15/2022] Open
Abstract
Inhaled corticosteroids (ICS) suppress eosinophilic airway inflammation in asthma, but patients may not adhere to prescribed use. Mean adherence-averaging total doses taken over prescribed-fails to capture many aspects of adherence. Patients with difficult-to-treat asthma underwent electronic monitoring of ICS, with data collected over 50 days. These were used to calculate entropy (H) a measure of irregular inhaler use over this period, defined in terms of transitional probabilities between different levels of adherence, further partitioned into increasing (Hinc) or decreasing (Hdec) adherence. Mean adherence, time between actuations (Gapmax), and cumulative time- and dose-based variability (area-under-the-curve) were measured. Associations between adherence metrics and 6-month asthma status and attacks were assessed. Only H and Hdec were associated with poor baseline status and 6-month outcomes: H and Hdec correlated negatively with baseline quality of life (H:Spearman rS = - 0·330, p = 0·019, Hdec:rS = - 0·385, p = 0·006) and symptom control (H:rS = - 0·288, p = 0·041, Hdec: rS = - 0·351, p = 0·012). H was associated with subsequent asthma attacks requiring hospitalisation (Wilcoxon Z-statistic = - 2.34, p = 0·019), and Hdec with subsequent asthma attacks of other severities. Significant associations were maintained in multivariable analyses, except when adjusted for blood eosinophils. Entropy analysis may provide insight into adherence behavior, and guide assessment and improvement of adherence in uncontrolled asthma.
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21
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Hull JH, Jackson AR, Ranson C, Brown F, Wootten M, Loosemore M. The benefits of a systematic assessment of respiratory health in illness-susceptible athletes. Eur Respir J 2021; 57:13993003.03722-2020. [PMID: 33334943 DOI: 10.1183/13993003.03722-2020] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/26/2020] [Indexed: 12/15/2022]
Abstract
Respiratory tract illness is a leading cause of training and in-competition time loss in elite athletes. Asthma is known to be prevalent in athletes, but the coexistence of other respiratory problems in those deemed to be susceptible to respiratory tract illness is unknown. The aim of this study was to apply a comprehensive prospective approach to identify respiratory problems and explore relationships in athletes with heightened respiratory illness susceptibility.UK World Class Performance Programme athletes prospectively completed a systematic review of respiratory health with validated questionnaires and respiratory-focused investigations, including studies of nasal flow, exhaled nitric oxide, spirometry, bronchoprovocation testing and allergy testing.Systematic respiratory health assessment was completed by 122 athletes (55 females, mean±sd age 24±4 years). At least one respiratory health issue, requiring intervention, was identified in 97 (80%) athletes and at least two abnormalities were found in 73 (60%). Sinonasal problems were the most commonly identified problem (49%) and 22% of athletes had a positive indirect bronchoprovocation test. Analysis revealed two respiratory health clusters: 1) asthma, sinus problems and allergy; and 2) laryngeal and breathing pattern dysfunction. Respiratory illness susceptible athletes had 3.6±2.5 episodes in the year prior to assessment and were more likely to have allergy (OR 2.6, 95% CI 1.0-6.5), sinonasal problems (2.6, 1.1-6.0) and symptoms of laryngeal (5.4, 1.8-16.8) and breathing pattern dysfunction (3.9, 1.1-14.0) than nonsusceptible athletes (all p<0.05).A systematic approach to respiratory assessment identifies a high prevalence and coexistence of multiple respiratory problems in illness-susceptible athletes.
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Affiliation(s)
- James H Hull
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK .,National Heart and Lung Institute, Imperial College, London, UK.,The Institute of Sport, Exercise and Health, University College London, London, UK
| | - Anna R Jackson
- Athlete Health, English Institute of Sport, Manchester, UK
| | - Craig Ranson
- Athlete Health, English Institute of Sport, Manchester, UK
| | | | | | - Mike Loosemore
- The Institute of Sport, Exercise and Health, University College London, London, UK.,Athlete Health, English Institute of Sport, Manchester, UK
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22
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Wang G, McDonald VM. Contemporary Concise Review 2020: Asthma. Respirology 2021; 26:804-811. [PMID: 34164877 DOI: 10.1111/resp.14099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/19/2021] [Accepted: 05/25/2021] [Indexed: 02/05/2023]
Abstract
Bushfires and coronavirus 2019 (COVID-19) were dominate features of 2020. Patients with asthma were significantly affected by the 2019/2020 bushfire season with an increased burden compared to the general population. Patients with controlled asthma do not appear to be at higher risk of severe COVID-19 infection or death than the general population. Personalized medicine is proposed as the next era for asthma management, with treatable traits as a strategy to implement personalized medicine into practice. Patient engagement in personalized medicine strategies is important and needs to be further explored. Oral corticosteroid (OCS) use in asthma is common and contributes a major burden. OCS stewardship is recommended. Biologic therapies reduce exacerbations of severe asthma and biomarkers can be used to predict treatment responders. Epithelia at mucosal and cutaneous surfaces are components in asthma pathogenesis, through airway immunity and inflammation. Dysregulation of resident microbial communities in the lung, gut and skin microbiome is relevant to asthma pathogenesis, but there are still many unknowns in this field.
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Affiliation(s)
- Gang Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Centre for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Centre for Disease-Related Molecular Network, Sichuan University, Chengdu, China
| | - Vanessa M McDonald
- Priority Research Centre of Healthy Lungs, School of Nursing and Midwifery, The University of Newcastle, New Lambton Heights, New South Wales, Australia
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23
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Most JF, Ambrose CS, Chung Y, Kreindler JL, Near A, Brunton S, Cao Y, Huang H, Zhao X. Real-World Assessment of Asthma Specialist Visits Among U.S. Patients with Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3662-3671.e1. [PMID: 34148858 DOI: 10.1016/j.jaip.2021.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/23/2021] [Accepted: 05/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND U.S. guidelines recommend that patients with severe asthma be referred to specialists (allergists/immunologists or pulmonologists) for systematic assessment or comanagement; however, contemporary, real-world data on the frequency and impact of specialist care among U.S. severe asthma patients are lacking. OBJECTIVES To quantify the frequency of asthma specialist visits among U.S. patients with severe asthma, identify patient demographic and clinical characteristics associated with specialist visits and describe health outcomes following specialist care. METHODS Severe asthma patients aged 6 years or older were identified between January 1, 2015, and December 31, 2017, in the IQVIA PharMetrics® Plus database of commercially insured individuals, based on Healthcare Effectiveness Data and Information Set (HEDIS) criteria and Global Initiative for Asthma (GINA) step 4 or 5 treatment regimens. The frequency of asthma specialist (allergist/immunologist or pulmonologist) visits was described over 2 years. Patient characteristics associated with having 1 or more specialist visits were analyzed using multivariate regressions. Asthma exacerbations and health care resource utilization before and after specialist visit were compared. RESULTS Of 54,332 patients identified, 38.2% had 1 or more specialist visits over 2 years. Patient characteristics predictive of specialist visits were asthma exacerbation frequency, younger age, and allergy/respiratory comorbidity burden (all P < .001). Among patients with 1 or more specialist visits, a lower prevalence of asthma exacerbations and rescue inhaler use was observed following the first observed specialist visit. CONCLUSIONS Specialist care was observed in fewer than half of U.S. patients with severe asthma and was least frequent among older adult patients and those with more nonrespiratory comorbidities. Increased specialist involvement in managing severe asthma may help improve care and patient outcomes.
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Affiliation(s)
- Jessica F Most
- Jefferson Health/National Jewish Health, Philadelphia, Pa
| | - Christopher S Ambrose
- Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Wilmington, Del
| | - Yen Chung
- Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Md
| | - James L Kreindler
- Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Md
| | | | | | - Yao Cao
- Real-World Evidence, IQVIA, Durham, NC
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24
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Hew M, Denton E. Prioritizing Treatable Traits in Airways Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1265-1266. [PMID: 33685609 DOI: 10.1016/j.jaip.2020.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia.
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
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25
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Ryan D, Heatley H, Heaney LG, Jackson DJ, Pfeffer PE, Busby J, Menzies-Gow AN, Jones R, Tran TN, Al-Ahmad M, Backer V, Belhassen M, Bosnic-Anticevich S, Bourdin A, Bulathsinhala L, Carter V, Chaudhry I, Eleangovan N, FitzGerald JM, Gibson PG, Hosseini N, Kaplan A, Murray RB, Rhee CK, Van Ganse E, Price DB. Potential Severe Asthma Hidden in UK Primary Care. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1612-1623.e9. [PMID: 33309935 DOI: 10.1016/j.jaip.2020.11.053] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Severe asthma may be underrecognized in primary care. OBJECTIVE Identify and quantify patients with potential severe asthma (PSA) in UK primary care, the proportion not referred, and compare primary care patients with PSA with patients with confirmed severe asthma from UK tertiary care. METHODS This was a historical cohort study including patients from the Optimum Patient Care Research Database (aged ≥16 years, active asthma diagnosis pre-2014) and UK patients in the International Severe Asthma Registry (UK-ISAR aged ≥18 years, confirmed severe asthma in tertiary care). In the OPCRD, PSA was defined as Global INitiative for Asthma 2018 step 4 treatment and 2 or more exacerbations/y or at Global INitiative for Asthma step 5. The proportion of these patients and their referral status in the last year were quantified. Demographic and clinical characteristics of groups were compared. RESULTS Of 207,557 Optimum Patient Care Research Database patients with asthma, 16,409 (8%) had PSA. Of these, 72% had no referral/specialist review in the past year. Referred patients with PSA tended to have greater prevalence of inhaled corticosteroid/long-acting β2-agonist add-ons (54.1 vs 39.8%), and experienced significantly (P < .001) more exacerbations per year (median, 3 vs 2/y), worse asthma control, and worse lung function (% predicted postbronchodilator FEV1/forced vital capacity, 0.69 vs 0.72) versus nonreferred patients. Confirmed patients with severe asthma (ie, UK patients in the International Severe Asthma Registry) were younger (51 vs 65 years; P < .001), and significantly (P < .001) more likely to have uncontrolled asthma (91.4% vs 62.5%), a higher exacerbation rate (4/y [initial assessment] vs 3/y), use inhaled corticosteroid/long-acting β2-agonist add-ons (67.7% vs 54.1%), and have nasal polyposis (24.2% vs 6.8) than referred patients with PSA. CONCLUSIONS Large numbers of patients with PSA in the United Kingdom are underrecognized in primary care. These patients would benefit from a more systematic assessment in primary care and possible specialist referral.
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Affiliation(s)
- Dermot Ryan
- Usher Institute, University of Edinburgh, United Kingdom
| | - Heath Heatley
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Liam G Heaney
- UK Severe Asthma Network and National Registry, Queen's University Belfast, Belfast, Northern Ireland
| | - David J Jackson
- UK Severe Asthma Network and National Registry, Guy's and St Thomas' NHS Trust and Division of Asthma, Allergy & Lung Biology, King's College London, London, United Kingdom
| | - Paul E Pfeffer
- UK Severe Asthma Network, Barts Health NHS Trust and Queen Mary University of London, London, United Kingdom
| | - John Busby
- UK Severe Asthma Network and National Registry, Queen's University Belfast, Belfast, Northern Ireland
| | - Andrew N Menzies-Gow
- UK Severe Asthma Network and National Registry, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Rupert Jones
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | | | - Mona Al-Ahmad
- Al-Rashed Allergy Center, Ministry of Health, Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait
| | - Vibeke Backer
- Department of ENT & Centre for Physical Activity Research, Rigshospitalet and Copenhagen University, Copenhagen, Denmark
| | - Manon Belhassen
- PELyon, HESPER 7425, Claude Bernard University, Lyon, France
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney and Sydney Local Health District, Glebe, NSW, Australia
| | - Arnaud Bourdin
- Department of Respiratory Diseases, Montpellier University Hospitals, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Lakmini Bulathsinhala
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - Isha Chaudhry
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Neva Eleangovan
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | | | - Peter G Gibson
- Australian Severe Asthma Network, Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, NSW, Australia; Hunter Medical Research Institute, Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | | | - Alan Kaplan
- Family Physician Airways Group of Canada, Stouffville, ON, Canada; University of Toronto, Toronto, ON, Canada
| | | | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eric Van Ganse
- PELyon, HESPER 7425, Claude Bernard University, Lyon, France
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
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26
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Hew M, McDonald VM, Bardin PG, Chung LP, Farah CS, Barnard A, Cooper MS, Gibson PG, Upham JW. Cumulative dispensing of high oral corticosteroid doses for treating asthma in Australia. Med J Aust 2020; 213:316-320. [PMID: 32906192 PMCID: PMC7589219 DOI: 10.5694/mja2.50758] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/23/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To estimate the level of dispensing of oral corticosteroids (OCS) for managing asthma in Australia, with a particular focus on the cumulative dispensing of doses associated with long term toxicity (≥ 1000 mg prednisolone-equivalent). DESIGN Retrospective cohort study; analysis of 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data. PARTICIPANTS, SETTING People aged 12 years or more treated for asthma during 2014-2018, according to dispensing of controller inhaled corticosteroids (ICS). MAIN OUTCOME MEASURES Number of people dispensed OCS for managing asthma during 2014-2018; proportion who were cumulatively dispensed at least 1000 mg prednisolone-equivalent. The secondary outcome was the number of people dispensed at least 1000 mg prednisolone-equivalent during 2018, stratified by inhaler controller dose and use. RESULTS 124 011 people had been dispensed at least two prescriptions of ICS during 2014-2018 and met the study definition for asthma, of whom 64 112 (51.7%) had also been dispensed OCS, including 34 580 (27.9% of the asthma group) cumulatively dispensed 1000 mg prednisolone-equivalent or more. Of 138 073 people dispensed OCS at this level, 68 077 (49%) were patients with airway diseases. Dispensing of diabetes and osteoporosis medications was more common for people cumulatively dispensed 1000 mg prednisolone-equivalent or more. During 2018, 4633 people with asthma using high dose ICS controllers were dispensed 1000 mg prednisolone-equivalent or more, for 2316 of whom (50%) controller use was inadequate. CONCLUSIONS Cumulative exposure to OCS in Australia reaches levels associated with toxicity in one-quarter of patients with asthma using ICS. Cumulative dispensing of potentially toxic OCS amounts often accompanies inadequate inhaler controller dispensing. Better approaches are needed to improve adherence to controller therapy, improve outcomes for people with asthma, and to minimise the use and toxicity of OCS.
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Affiliation(s)
| | | | | | | | | | - Amanda Barnard
- Rural Clinical School, Australian National University, Canberra, ACT
| | | | - Peter G Gibson
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW
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27
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Hew M, Menzies-Gow A, Hull JH, Fleming L, Porsbjerg C, Brinke AT, Allen D, Gore R, Tay TR. Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2222-2233. [PMID: 32173508 DOI: 10.1016/j.jaip.2020.02.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.
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Affiliation(s)
- Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Andrew Menzies-Gow
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James H Hull
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Paediatric Difficult Asthma Service, Royal Brompton Hospital, London, United Kingdom
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anneke Ten Brinke
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - David Allen
- North West Lung Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Robin Gore
- Department of Respiratory Medicine, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
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