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Patients with severe asthma have treatable traits
Treatable traits were more often found in patients with severe asthma than those with non-severe asthma, according to findings recently published in Respirology.
“While the method of assessing treatable traits has been described, the assessment of treatable traits in other clinically relevant settings is unknown,” Vanessa M. McDonald, PhD, of the Centre of Excellence in Severe Asthma in Australia and colleagues wrote.
“It is not known whether severe asthma registries can be used to identify treatable traits in severe asthma, nor whether these traits are able to predict future risk of asthma attacks,” they added.
Researchers enrolled 434 patients with severe asthma in The Australasian Severe Asthma Web-Based Database — a study across 26 sites in Australia, New Zealand and Singapore that consisted of a cross-sectional evaluation of patient characteristics and a 2-year prospective cohort study. The 434 patients’ traits were compared to 102 patients with non-severe asthma.
McDonald and colleagues found patients with severe asthma had more pulmonary and extrapulmonary treatable traits than patients with non-severe asthma. Eleven traits were more common in patients with severe asthma: neutrophilic inflammation, obesity, systemic inflammation, inhaler device polypharmacy, depression, GERD, Aspergillus sensitization, being prone to exacerbation, incompletely reversible airflow limitation, vocal cord dysfunction and obstructive sleep apnea.
Researchers also identified traits that predicted exacerbations, which included eosinophilic inflammation, being prone to exacerbations, upper airway disease, obstructive sleep apnea, depression, anxiety, systemic inflammation, inhaler device polypharmacy, being underweight and vocal cord dysfunction
“Most of these traits are supported by evidence-based treatment recommendations. For some traits, however, such as systematic inflammation and neutrophilic airway inflammation, the evidence to support current treatment strategies is less developed,” McDonald and colleagues wrote.
“Similarly, there is also some debate about what is and is not a treatable trait, for example: ‘Is [airflow limitation] in severe asthma treatable?’ We propose that further international consensus is required to determine the accepted treatable traits and their biomarkers.” – by Janel Miller
Disclosure: The authors report no relevant financial disclosures.
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This study — conducted by some of the most seasoned, prominent names in asthma research — was one of the first ever to put the symptoms of severe asthma into one place for the primary care physician. Perhaps the most interesting part of the study was that depression and anxiety can amplify a patient’s asthma symptoms and can increase the risk for exacerbations. PCPs should not be dismissive of patients who mention these symptoms as well as those patients who report frequently using a short-acting beta antagonist to control their asthma.
In general, most PCPs mistakenly view severe asthma as an episodic disease, rather than a chronic disease. With all the demands on a PCP’s time, I would encourage PCPs to refer their patients with the symptoms discussed by those in McDonald et al’s study, to an asthma professional or other lung specialist just as they would a patient with rheumatoid arthritis, hypertension, diabetes, or the myriad of chronic conditions and diseases that usually first present themselves in primary care.
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The treatment goal of asthma management is to minimize or eliminate symptoms and any impairment of daily activity in all facets of life (school, work, recreation). Advances in the diagnosis and treatment of asthma in the past 50 years have had a profound impact on our ability to achieve this goal. Newer treatments such as anti-IgE and anti-eosinophil biologics have allowed us to identify specific asthma phenotypes and provide even more effective targeted therapy for these patients.
Despite these advances, the number of asthmatics that continue to experience missed school/work days, frequent hospitalizations and even death due to asthma exacerbations remains unacceptably high. There is a strong body of evidence that asthma, especially severe asthma, is affected by both pulmonary and non-pulmonary factors. Identifying traits in high-risk patients and employing effective intervention in a timely manner remains an important step in overall prevention strategy.
In this study, McDonald et al, utilized an established asthma registry to compare severe asthmatics to well-controlled asthmatics to assess for differences in what have been termed “treatable traits.” That is, specific characteristics that are associated with asthma that can targeted for treatment. They also used the database to see if these traits could predict risk of exacerbation.
Importantly, these traits included non-pulmonary traits such as weight and anxiety in addition to traits specific to the lungs. They observed that many of these traits are found at similar rates in severe asthma and well controlled asthma patients but identified some traits that were present at higher rates in severe asthma. The strongest associations were seen in depression, sleep apnea, multiple inhaler prescriptions and vocal cord dysfunction.
Whereas mild to moderate asthma can often be relatively straightforward and responsive to established treatment protocols, severe asthma is a highly complex disease. Management requires appropriate diagnosis, identification-targeted medication management, close monitoring, and a systematic holistic approach to the patient. When asthma control is sub-optimal despite appropriate therapy, identifying and addressing additional factors, especially those not directly associated with asthma, may result in more effective control of exacerbations.
Routine use of an asthma registry is not practical at the clinical level for a number of reasons. Although additional research is required, in the future the data obtained from these patients may be useful in several ways. First, they can provide a continuous and cumulative body of data that could be used to predict what patients will be at higher risk for exacerbation based on the presence of specific risk factors. Second, they can be used to identify and refine additional risk factors and discern which risk factors can be modified to optimize outcomes. Finally, the early identification of the most relevant risk factors can be used to assist the clinician in developing a more comprehensive treatment plan to minimize or eliminate future exacerbations.