Structured management of overall health recommended for difficult-to-treat asthma
medwireNews: Researchers have found that a structured approach to managing specialist-referred patients with difficult-to-treat asthma, which includes assessing and treating associated comorbidities, improves symptom control and reduces exacerbation frequency.
Their approach focused on confirming diagnosis according to variable airflow obstruction, identifying associated comorbidities and contributory factors, establishing the severe asthma phenotype, and then optimizing treatment accordingly across three outpatient visits, 2 and then 3 months apart.
For the 65 specialist-referred patients managed using this structured approach, the average Asthma Control Test Score improved significantly from 14 to 16 (p<0.001) over a 6-month period. The average Asthma Quality of Life Questionnaire score also improved, from 4.29 to 4.65, albeit not significantly (p=0.073), and the frequency of exacerbations fell from a median of two at baseline to zero at the 6-month visit.
The team led by Tunn Ren Tay (The Alfred Hospital, Melbourne, Victoria, Australia) points out that there was no overall escalation of inhaled or oral corticosteroids as a result of the protocol, whereas multiple interventions for comorbidities were initiated.
A median of three comorbidities were identified in the patients from questionnaires administered at the first consultation and subjected to clinical assessment, with obesity, chronic rhinosinusitis, dysfunctional breathing, vocal cord dysfunction, allergic rhinitis, and probable sleep apnea each reported in at least 30% of patients.
Only those patients with clinical symptoms consistent with a particular comorbidity were considered for specific treatment or referral, providing a more bespoke strategy rather than a blanket approach, the team explains.
Pharmacological treatment for sinonasal disease and gastroesophageal reflux disease was initiated or escalated in 44.6% and 7.7% of patients, respectively. And a total of 94 referrals were made to other subspecialty and allied health professionals.
“We therefore postulate that control of key comorbidities may have had the greatest impact on asthma outcomes in our cohort,” say Tay and colleagues.
“This explanation may not hold true in other settings, especially those with higher rates of misdiagnosis or more rapid access to biological therapy,” they caution, observing that a correct nonasthma diagnosis for three patients in the cohort and provision of phenotype-specific biologics in a further two would have contributed to the patients’ improvements.
The team also notes the benefits of improved asthma education and monitoring of medication adherence in all patients at each visit.
“Therefore, we believe all aspects of our multidimensional assessment protocol to be necessary for optimal outcomes,” they comment in the Journal of Allergy and Clinical Immunology: In Practice.
The researchers conclude that their findings highlight “the central role of systematic evaluation in optimizing overall patient care, before treating severe asthma biology with the expensive targeted therapies now entering clinical practice.”
By Lucy Piper
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