This article is more than 5 years old. Information may no longer be current.

Not all asthma diagnoses hold up over time

A third of all patients diagnosed with asthma showed no symptoms of the disease 5 years later, according to research published in JAMA,  suggesting clinicians should evaluate such patients on an ongoing basis.

“If a patient has asthma and is on medications and is no longer symptomatic, then the [doctor] and the patient might want to reassess the condition. Ideally the patient should have spirometry,” Shawn D. Aaron, MD, of the Ottawa Hospital Research Institute, Canada, told Healio Family Medicine. “If it is normal and the patient is asymptomatic, then the doctor should discuss gradual tapering of the asthma medications to see if the patient may not need them anymore. The doctor should follow the patient during this tapering off process.”

Aaron and colleagues conducted a prospective, multicenter cohort study among 701 adults recruited during a phone survey. These participants reported a history of physician-diagnosed asthma established within the past 5 years, were unable to be tested using spirometry and were not taking long-term oral steroids. Participants for whom a diagnosis of current asthma was ultimately ruled out were followed up clinically with repeated bronchial challenge tests over 1 year.

Researchers reported that in 33.1% of the participants, a current diagnosis of asthma could not be made. After an additional 12 months of follow-up, 29.5% still showed no clinical or laboratory evidence of asthma. Participants in whom current asthma was ruled out, compared with those in whom it was confirmed, were less likely to have undergone testing for airflow limitation in the community at the time of initial diagnosis (43.8% vs. 55.6%, 95% CI, 2.1-21.5).

In response to the findings, Aaron also provided doctors with suggestions for handling patients who present what he called new respiratory symptoms such as wheezing, coughing or shortness of breath.

“They need to have pre- and post-bronchodilator spirometry testing done, ideally prior to assigning a diagnosis and treatment,” he told Healio Family Medicine. “The doctor should explain this to the patient in terms they can understand, such as ‘You wouldn’t want me to diagnose diabetes without checking your blood sugar, I don’t want to diagnose asthma without checking your lung function’”.

In a related editorial, Helen M. Hollingsworth, MD, and George T. O’Connor, MD, MS, both of the Pulmonary Center at the Boston University School of Medicine, pointed to the limitations of Aaron and colleagues’ research.

“The study design may have left out a substantial number of individuals with moderate-to-severe asthma, making it difficult to estimate the rate of remission of adult-onset asthma across the full spectrum of asthma severity,” they wrote. “The finding that up to one-third of persons with a prior diagnosis of adult-onset asthma had resolution of symptoms and airway hyper-responsiveness is not consistent with the lower remission rates observed in the longitudinal cohort studies reviewed earlier.”

The study served to underscore the need for physiological testing as part of the assessment for asthma, Hollingsworth and O’Connor wrote.

“Physiological testing, such as spirometry before and after bronchodilator administration, is an essential component of the diagnosis of asthma to avoid unnecessary treatment or an incorrect diagnosis,” they said.

The fact that this testing was not available for a large number of participants, meant that it could not be determined whether patients were wrongly diagnosed, or if their asthma was in remission.

Hollingsworth and O’Connor also pointed out how critical it is to continue to confirm if an asthma diagnosis is warranted in the clinical care setting.

“The study by Aaron and colleagues is an important reminder that in addition to reviewing asthma symptoms and treatment, trying to understand if the diagnosis of asthma is still appropriate is an important part of clinical care,” they wrote.

Previously published research assessed the value of a primary care-based program to improve asthma detection. – by Janel Miller

Disclosure: Aaron and Hollingsworth report no relevant financial disclosures. O’Connor reports serving as a consultant for AstraZeneca and receiving grants from Janssen Pharmaceuticals and the NIH. Please see the study for a list of all other relevant financial disclosures.