Many patients fail to achieve good asthma control despite stepped treatment optimization
medwireNews: Stepped increases to optimize treatment improve asthma control, but for many patients optimal control still remains elusive, suggest findings from the real-life COAS study.
The results show that, while 32.8% of 1299 patients with uncontrolled asthma according to the Global Initiative for Asthma (GINA) 2010 criteria at baseline achieved control 3 months after treatment optimization, asthma remained uncontrolled (partially and not controlled) in the remaining 67.2% of patients.
The participants, aged between 18 and 75 years, had a mean forced expiratory volume in 1 second of 76.4% predicted at baseline and the mean post-bronchodilator increase was 14.9%. They were being treated at specialized allergy and pulmonology centers, with most at step 3 and taking inhaled corticosteroids (ICS) either alone (30.6%) or with long-acting β2-agonists (LABA; 39.1%).
The researchers note that only 66.7% of the patients were using short-acting β2-agonists, despite having uncontrolled asthma.
The majority of patients, at 85.6%, needed to increase at least one treatment step over the following 3 months, with 6% increasing more than two steps, suggesting that “under-treatment is a major cause of uncontrolled disease in asthma patients,” say the researchers led by Rosa Munoz-Cano (Hospital Clinic Barcelona, Spain).
Stepped treatment mainly involved increased use of fixed combinations of ICS plus LABA, from an average 39.1% to 83.9%, while optimizing inhaler technique and treatment advice were sufficient for the 14.4% of patients whose treatment step was not changed.
Poor asthma control was significantly associated with older age, being overweight or obese, non-steroidal anti-inflammatory drug hypersensitivity, longer duration and worse severity of disease, poorer lung function, and greater bronchodilation.
It was not associated with poor adherence, however, which improved similarly in all groups. But the researchers say this result “should be evaluated with caution,” as the percentage of compliant patients was surprisingly high and may reflect the positive short-term effect of participating in the study.
Nevertheless, patients with poor adherence to inhaled treatment and a lack of knowledge of their treatment and how it works were more likely than others to present with worse asthma control after treatment optimization.
A possible solution for this, say the authors, is to develop “education plans with therapeutic guidelines negotiated with the patient.”
They also point out a lack of agreement between the GINA 2010 criteria and Asthma Control Test (ACT) results, with only 28.1% of patients classified as having well-controlled asthma by both after treatment optimization.
With 32.8% of patients having well-controlled asthma according to GINA 2010 criteria versus 57.2% according to ACT, the choice of instrument used could impact on the therapeutic strategy, says the team in the European Respiratory Journal.
In general, they found that patients and physicians overestimate asthma control compared with ACT findings, while ACT results overestimate control compared with GINA 2010 criteria.
By Lucy Piper
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