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Defining Asthma control

For patients with uncontrolled persistent asthma, disease management focusing on exacerbation reduction may fail to address key limitations and concerns. In addition to higher exacerbation rates, impaired lung function, risk of long-term side effects from OCS and poor QoL are significant factors of disease burden and long-term health risks for these patients. Optimal asthma control should focus on comprehensive care, including improving lung function.

DIAGNOSIS

Asthma diagnosis is difficult; being a clinical syndrome there is no gold standard for diagnosis. Diagnosis should not be based solely on clinical characteristics but should incorporate a combination of clinical symptoms and the physiological manifestations including reversible airflow limitation and/or airway hyper-responsiveness.1

There is no single test that can be administered to definitively diagnose asthma, however a combination of methods are used to determine its likelihood in a patient. This includes measuring airflow obstruction (spirometry and peak flow); assessing reversibility with bronchodilators and testing for airway inflammation. Additional methods of testing include skin or blood prick tests determining allergic responses to the environment and measures of airway hyperactivity.1

The test (or combination of tests) that can most accurately diagnose asthma is still a topic of debate.1

ASTHMA CONTROL GOES BEYOND EXACERBATION REDUCTION

Patients with uncontrolled persistent asthma may experience high exacerbation rates, impaired lung function, risk of long-term OCS side effects, and poor QoL.2–6

HIGH
EXACERBATION
RATES

Exacerbations were 3 times more likely to occur in patients with uncontrolled asthma than in those with better asthma control2

 
IMPAIRED
LUNG
FUNCTION

Airway remodelling, often driven by persistent Type 2 inflammation, can lead to impaired lung function in both the large and small airways8–10

 
SIDE EFFECTS
WITH LONG‑TERM
OCS USE

Due to the potential for substantial side effects with OCS use, guidelines suggest not using OCS as maintenance therapy until all other pharmacologic options have been exhausted4,11,12

Long-term use of OCS has been associated with osteoporosis, arterial hypertension, diabetes and metabolic syndrome, dyslipidaemia, obesity, cataracts, glaucoma, gastrointestinal bleeds/ulcers, tuberculosis, depression, herpes, and sepsis6

 
POOR
QoL

Patients miss out on outdoor, physical, and other daily activities13

Anxiety and depression worsen symptoms and complicate disease management5

 
UNMET
NEED

There remains an unmet need to provide comprehensive care for patients with uncontrolled persistent asthma, including:2,4,12,14

  • Reducing exacerbations
  • Improving and preserving lung function
  • Reducing potential OCS side effects
  • Improving patient-reported outcomes
 
LUNG FUNCTION
ASSESSMENT

Lung function is critical to the assessment of future risk in patients with asthma12

  • Patients with frequent exacerbations and moderate-to-severe asthma experienced a significantly greater annual decline in FEV1 in a long-term study, compared with patients who had infrequent exacerbations15
  • Early and sustained improvement in lung function following therapy initiation reduced the rate and severity of future exacerbations3
45%of patients with asthma
were classified as having
uncontrolled disease7

NICE GUIDANCE DEVELOPED FOR DIAGNOSIS, MONITORING AND CHRONIC ASTHMA MANAGEMENT

In 2017, the National Institute of Health and Care Excellence developed guidance for the diagnosis, monitoring and management of chronic asthma. The guidance is projected to save approximately 12 million pounds per year across England in pre-implementation costs.1

Key topics covered include:1
  • Initial assessment (family history; employment history; triggers; wheeze, cough or breathlessness; physical examination)
  • Objective tests – used in combination with symptom check (diagnostic algorithms; fractional exhaled nitric oxide [FeNO]; lung function test: spirometry and peak flow variability)
  • Pharmacological treatment
  • Adherence and self-management
  • Asthma control monitoring
The NICE guidance summarises:
  • An algorithm for the initial clinical assessment of adults, young people and children with suspected asthma1
  • Thresholds for objective tests used for diagnosis1

PATHOPHYSIOLOGY OF TYPE 2 ASTHMA

Learn about the key drivers of
Type 2 inflammation.

Explore key drivers

BURDEN OF
ASTHMA

Learn about the prevalence and
healthcare burden of asthma.

Explore facts & figures

TYPE 2
COMORBIDITIES

Type 2 inflammation has been associated with several chronic conditions. Find out how they can present additional challenges.

Learn about comorbidities

BDR, bronchodilator reversibility; FeNO, fractional exhaled nitric oxide; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; IgE, immunoglobulin E; NICE, The National Institute of Health and care Excellence; OCS, oral corticosteroids; PC20, provocative concentration of methacholine causing a 20% fall in FEV1; ppb, parts per billion; QoL, quality of life.

References:
  1. © NICE [2017] Asthma: diagnosis, monitoring and chronic asthma management. Available from www.nice.org.uk/guidance/ng80. All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. Date accessed: October 2019.
  2. Haselkorn T, Fish J, Zeiger R, et al; TENOR Study Group. Consistently very poorly controlled asthma, as defined by the impairment domain of the Expert Panel Report 3 guidelines, increases risk for future severe asthma exacerbations in The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study. J Allergy Clin Immunol. 2009;124(5):895–902.
  3. O'Byrne P, Pedersen S, Lamm C, et al; START Investigators Group. Severe exacerbations and decline in lung function in asthma. Am J Respir Crit Care Med. 2009;179(1):19–24.
  4. Nguyen V and Ulrik C. Measures to reduce maintenance therapy with oral corticosteroid in adults with severe asthma. Allergy Asthma Proc. 2016;37(6):125–139.
  5. Di Marco F, et al. Close correlation between anxiety, depression, and asthma control. Respir Med. 2010;104(1):22–28.
  6. Sullivan P, et al. Oral corticosteroid exposure and adverse effects in asthmatic patients. J Allergy Clin Immunol. 2018;141(1):110–116.
  7. Price D, Fletcher M and Van der Molen T. Asthma control and management in 8,000 European patients: the REcognise Asthma and LInk to Symptoms and Experience (REALISE) survey. NPJ Prim Care Respir Med. 2014;24:1–10.
  8. Elliot J, Jones R, Abramson M, et al. Distribution of airway smooth muscle remodelling in asthma: relation to airway inflammation. Respirology. 2015;20(1):66–72.
  9. Mauad T, Bel E and Sterk P. Asthma therapy and airway remodelling. J Allergy Clin Immunol. 2007;120(5):997–1009.
  10. Holgate S. The airway epithelium is central to the pathogenesis of asthma. Allergol Int. 2008;57(1):1–10.
  11. NHLBI. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma—Full Report 2007. National Heart, Lung and Blood Institute publication 07-4051.
  12. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. GINA Report 2019. Available at: https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf/. Date accessed: October 2019.
  13. Haselkorn T, et al. Asthma control and activity limitations: insights from the Real-world Evaluation of Asthma Control and Treatment (REACT) Study. Ann Allergy Asthma Immunol. 2010;104(6):471–477.
  14. Bjermer L. Time for a paradigm shift in asthma treatment: from relieving bronchospasm to controlling systemic inflammation. J Allergy Clin lmmunol. 2007;120(6):1269–1275.
  15. Bai T, et al. Severe exacerbations predict excess lung function decline in asthma. Eur Respir J. 2007;30(3):452–456.