Workgroup releases consensus definition for clinical remission in asthma on treatment
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Key takeaways:
- There was no previous standard, accepted definition for remission in asthma.
- The panel unanimously supported three of its definition’s six criteria.
- The definition was drafted to support research.
A multi-organizational panel has developed a working definition for clinical remission in asthma, according to a paper published in Annals of Allergy, Asthma & Immunology.
This definition comprises three criteria that had unanimous consent from the panel and three that remain under consideration, John Oppenheimer, MD, FAAAAI, clinical professor of medicine at UMDNJ Rutgers, and colleagues wrote.
“Why are we even considering a definition of remission? Thankfully, with newer therapy available to treat asthma, we now have the ability to achieve greater control than ever in a subset of asthmatics,” Oppenheimer, who also is a Healio Allergy/Asthma Peer Perspective Board Member, told Healio.
“This was a multi-society panel that explored the literature, acknowledging that there were many issues still to be resolved in forming a definition,” Oppenheimer continued.
There is no current standard for defining asthma remission or clinical remission on treatment, the authors wrote, as guidelines emphasize disease control and recognize that asthma can wax and wane.
“We have had multiple definitions used for the description of asthma in remission on therapy,” Oppenheimer said.
Guidelines in proposed definitions have included 12 or more months without symptoms, optimization or stabilization of lung function, patient and provider agreement, an absence of systemic corticosteroid use, normalized spirometry, suppressed type 2 inflammation and comorbidity control.
Similarly, one proposed three-component definition includes an absence of exacerbations and oral corticosteroid use for 52 weeks along with an Asthma Control Test score of 20 or higher, with another definition adding a fourth component involving percent predicted post-bronchodilator FEV1 of 80% or higher.
“With that said, we were able to develop a consensus definition,” Oppenheimer said.
The consensus
Noting that the term “remission” historically has denoted total asthma control without any medication use, the authors said that there should be a high bar for achieving control. In their review, they propose six components for asthma clinical remission on treatment.
“We acknowledge that this is a very lofty goal and only a subgroup of asthmatic patients will be able to achieve this level of control,” Oppenheimer said.
First, the group unanimously said there should be no exacerbations that require a visit to a physician, emergency care, hospitalization, and/or systemic steroid use, and they called this a mandatory requirement for defining asthma clinical remission on treatment.
Next, they unanimously said there should be no missed work or school due to asthma-related symptoms over a 12-month period and called this a mandatory requirement for the definition as well.
Third, the group unanimously said that pulmonary function results should be stable and optimized on all occasions measured over 12 months, with a minimum of two measurements. However, the group said that they did not include any absolute numbers for this requirement because some patients with asthma may have baseline pulmonary function below what is accepted as normal because of previous remodeling.
Fourth, the definition allows for the continued use of a controller medication such as inhaled corticosteroids (ICS), an ICS/long-acting beta agonist (LABA) combination or a leukotriene receptor antagonist, but only at a low to medium dose as defined by the most recent Global Initiative for Asthma guidelines.
Remission should be more than good or great asthma control, the group said, with limited studies indicating tapering ICS use with monoclonal antibody therapy, so this component would be an aspiration for differentiating clinical remission from good control.
Fifth, most of the group supported asthma control scores including a score higher than 20 on the Asthma Control Test, a score less than 2 on the Baseline Asthma Impairment and Risk Questionnaire or a score of less than 0.75 on the Asthma Control Questionnaire on all occasions in the prior 12 months, with a minimum of two measurements.
Finally, the group included symptoms requiring one-time reliever therapy such as a short-acting beta agonist (SABA), ICS-SABA or ICS-LABA at a maximum of once a month, or no more than an average of two puffs per month. However, the group also said that more research is needed in this area.
Applications
These criteria are intended to be a template for further clinical research, the group said, adding that they expect the definition to evolve with time. This research may include health care utilization, quality of life, predictors for remission and how patients evaluate and prioritize these aspects of their disease.
“We note that it will likely undergo revision as further research using this definition emerges,” Oppenheimer said. “With that said, it represents a starting point.”
The 11 members of the panel included six allergists, three pulmonologists and two pediatricians representing the American College of Allergy, Asthma and Immunology; the American Thoracic Society (ATS); the American Academy of Allergy, Asthma and Immunology; and the European Forum for Research and Education in Allergy and Airway Diseases.
While all the groups endorsed the definition, the ATS clarified that its endorsement should not be interpreted as belief that it should be applied to clinical practice.
“As noted by the ATS, it is to be used for research purposes,” Oppenheimer said. “However, as time passes with further revision, it is hoped that this will be a definition used in the care of asthmatics.”
For more information:
John Oppenheimer, MD, FAAAAI, can be reached at nallopp22@gmail.com.
Perspective
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A definition of clinical remission would help health care providers identify which patients are lower risk for asthma exacerbations and identify those patients who would be ideal candidates for step-down therapy in medications when they have been under such good control.
This is a great starting point for creating a definition for clinical remission of asthma. It encompasses the big picture and, as research ensues, it will become more fine-tuned and detailed so that we can further identify traits in people that might make them less likely to be in clinical remission, such as ethnicity, sex, city vs. rural setting, age and type of asthma, such as eosinophilic vs. allergic vs. other.
Ongoing research into the definition of clinical asthma remission should involve age brackets (what age group is most likely to fit into clinical remission), sex (are males or females more likely to be in clinical remission), ethnicity (genetics and ethnicity can play a huge role in predicting who will be more likely to be in clinical remission) and living in a city vs. a rural area. Research also should investigate other triggers that might make it more difficult to be in clinical remission, such as pollution, rodents and other environmental factors, and identify comorbidities that might make it harder to achieve clinical remission.
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