Exacerbation frequency has greater impact on asthma burden than disease severity
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Key takeaways:
- 15.4% of the population had frequent exacerbations.
- Greater frequency was associated with higher corticosteroid doses.
- 50.1% of patients with frequent, severe exacerbations visited a pulmonologist.
Patients who have frequent asthma exacerbations are at greater risks for cumulative doses of corticosteroids, multiple comorbidities and mortality, according to a poster presented at the European Respiratory Society International Congress.
Also, the frequency of these exacerbations seems to have a larger impact on the burden of disease than asthma severity, Arja Viinanen, MD, PhD, division of medicine, department of pulmonary diseases, Turku University Hospital, and colleagues wrote.
“Asthma imposes a significant disease burden, which amplifies with severity and in the presence of comorbidities,” Viinanen told Healio.
Study design, results
The researchers evaluated comorbidities, health care resource use, sick leave, disability pensions and mortality in relation to both asthma severity and exacerbations, Viinanen said, noting that previous studies have not included these data.
The nationwide, registry-based study included adults with a reimbursement number for asthma who had purchased a drug for obstructive airways disease between January 2015 and December 2016. It did not include patients who were on biologic therapy or who had COPD.
The researchers defined severe asthma as high-intensity treatment during baseline, including 800 µg or more of fluticasone propionate each day and a second controller during four consecutive purchases.
They also defined frequent exacerbations as two ED visits or one hospitalization for asthma within the 2 years before the index or as an annual purchase of more than 600 mg of a prednisolone equivalent at baseline, which Viinanen said was enough to treat three or more exacerbations.
“Frequently exacerbating asthma patients were approximately 15% of the total adult asthma population,” Viinanen said.
The researchers assessed the comorbidities that these patients had from January 2012 and followed them through December 2020 and determined four cohorts based on the severity of their asthma and the frequency of their exacerbations:
- non-severe asthma with infrequent exacerbations: 77.1% (n = 111,006);
- non-severe asthma with frequent exacerbations: 11.5% (n = 16,532);
- severe asthma with infrequent exacerbations: 7.5% (n = 10,767); and
- severe asthma with frequent exacerbations: 4% (n = 5,708).
During their analysis, the researchers created groups of equal sizes by matching patients based on age, sex and hospital district. Each group comprised 5,525 patients (70% women) with a median age of 63 years.
The group with severe asthma and frequent exacerbations had the highest totals across all the categories assessed, followed by the group with non-severe, frequent exacerbations in nearly all the categories assessed.
“Frequent exacerbations, rather than the severity of asthma itself, appeared to be linked to an increased disease burden, although the burden was highest in severe asthma patients who had frequent exacerbations,” Viinanen said.
“Exacerbating patients also used high doses of [oral corticosteroids (OCS)], with cumulative exposure far exceeding that associated with adverse outcomes,” she continued.
Mean daily OCS doses of prednisolone equivalents included 0.82 mg for the non-severe, infrequent exacerbation group; 1.85 for the non-severe, frequent exacerbation group; 0.82 for the severe, infrequent exacerbation group; and 2.46 for the severe, frequent exacerbation group.
Cumulative follow-up OCS doses between 2017 and 2020 included 458 mg in the non-severe, infrequent exacerbation group; 2,384 mg in the non-severe, frequent exacerbation group; 814 mg in the severe, infrequent exacerbation group; and 3,028 in the severe, frequent exacerbation group.
Mortality rates per patient year during the follow-up included 0.016 for the non-severe, infrequent exacerbation group; 0.027 for the non-severe, frequent exacerbation group; 0.023 for the severe, infrequent exacerbation group; and 0.029 for the severe, frequent exacerbation group.
Mean cumulative numbers of disability pension days per patient year among patients aged younger than 65 years during follow-up included 35 for the non-severe, infrequent exacerbation group; 49 for the non-severe, frequent exacerbation group; 48 for the severe, infrequent exacerbation group; and 59 for the severe, frequent exacerbation group.
Similarly, mean cumulative numbers of sick leave days per patient year among patients aged younger than 65 years during follow-up included 16 for the non-severe, infrequent exacerbation group; 22 for the non-severe, frequent exacerbation group; 20 for the severe, infrequent exacerbation group; and 24 for the severe, frequent exacerbation group.
Mean numbers of asthma-related health care contacts per patient year during follow-up included eight for the non-severe, infrequent exacerbation group; 12 for the non-severe, frequent exacerbation group; 15 for the severe, infrequent exacerbation group; and 20 for the severe, frequent exacerbation group.
The mean number of ICD-10 codes indicating comorbidities per patient in the 5 years following the baseline included seven for the non-severe, infrequent exacerbation group 10 for the non-severe, frequent exacerbation group; eight for the severe, infrequent exacerbation group; and 11 for the severe, infrequent exacerbation group.
Specifically, 15.4% of the non-severe with infrequent exacerbation group, 29% of the non-severe with frequent exacerbation group, 27.9% of the severe with infrequent exacerbation group and 50.1% of the severe with frequent exacerbation group had a pulmonologist visit through the 4-year follow-up.
Conclusions, next steps
Based on these findings, the researchers concluded that patients with frequent asthma exacerbations are exposed to high cumulative OCS doses, have multiple morbidities and are at increased risk for mortality, impacting their disease burden.
Viinanen called the proportion of patients with frequent exacerbations higher than expected, noting that nearly three of four patients among them had non-severe asthma based on their daily medication usage.
“Exacerbation frequency rather than asthma severity per se appears to be associated with a larger comorbidity burden and an increased risk of mortality, which reinforces the need to focus on asthma management more holistically and improve patient pathways to reduce exacerbation risk,” Viinanen said.
Viinanen advised health care professionals to focus on improving asthma control and reducing the exacerbation risk to improve outcomes in these patients.
“Systematic evaluation of asthma, comorbidities, exposures and adherence to treatment is critical,” she said. “Optimized maintenance treatment and arrangement of regular check-ups in health care is important.”
Additionally, Viinanen said, the identification of patients who are multimorbid and at an increased risk for mortality emphasizes the need for a more comprehensive and tailored approach to the management of asthma and its comorbidities.
Viinanen and her colleagues plan on continuing their research as well.
“As a next step, we will further explore the costs of health care resource utilization associated with increased asthma severity and exacerbation frequency,” she said.
For more information:
Arja Viinanen, MD, PhD, can be reached at arja.viinanen@tyks.fi.
Perspective
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I am not surprised by the findings noted in the Finland study. In the United States, unfortunately, people die from asthma every day despite the many advancements in asthma treatment in recent years. We still see too many asthma attacks, especially associated with disparities and communities that are underserved.
Frequent asthma attacks often lead to increased OCS use. Overuse or over-reliance on OCS do have short-and long-term side effects. Some short-term side effects include insomnia, mood swings and hunger. Some long-term side effects include cataracts, adrenal insufficiency and cardiovascular impact. (Visit www.ocsoverexposed.com for more information.)
As noted in the study, comorbid conditions such as allergic rhinitis, sleep apnea and GERD can play a role in increased asthma attacks. Awareness of these conditions, how they affect asthma, and how to treat the comorbid condition is important for the patient and healthcare providers to improve asthma outcomes. For people with moderate to severe asthma and comorbid conditions, seeing an asthma specialist such as an allergist or pulmonologist is an important part of asthma management.
As a physician assistant and certified asthma educator working with allergists, and in my role with Allergy & Asthma Network, I have seen firsthand the effectiveness of asthma self-management education (ASME) and its impact on patients. For example, patients get a better understanding of their asthma, the treatments and correct medication use, asthma triggers and how to avoid them, and how to recognize asthma control. People with asthma who complete ASME feel empowered and have improved communication with their healthcare providers about their asthma.
Future asthma research focused on ASME, managing and treating comorbid conditions, providing access to specialty care, and affordability of medications and treatments will help asthma health outcomes.
For more information about free asthma ASME for adults with asthma, visit the Allergy & Asthma website.
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Viinanen A, et al. Poster 1767. Presented at: European Respiratory Society International Congress; Sept. 7-11, 2024; Vienna.
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