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Rachel Soon
Medical Writer
04 Aug 2017

Treatment of patients with difficult asthma would be improved by clinics using a protocolized approach to reduce erroneous diagnoses, unrecognized nonadherence, overlooked comorbidities and inappropriate treatment, says an expert.

“For many years, people have been calling for such an approach to these patients to make sure that we don’t make mistakes,” said Professor Dr. Martyn Partridge, professor of respiratory medicine at the National Heart and Lung Institute, Imperial College London.

Speaking at the Malaysian Thoracic Society (MTS) Annual Congress 2017, Partridge highlighted a recent Polish study which examined the long-term outcomes of patients with uncontrolled asthma who participated in a 1-day visit programme to a severe asthma centre—involving a multidisciplinary assessment by a specialized team, but with long-term supervision to be conducted by patient’s own pulmonologists. [Eur Respir J 2016;48:726–733]

Of the 40 patients who participated, 9% were found to not have asthma; 41% when objectively assessed were found to be nonadherent; 51% had severe asthma (just controlled or uncontrolled), while 40% had difficult to treat asthma; ie, they had significant comorbidities such as chronic rhinosinusitis; dysfunctional breathing; gastroesophageal reflux; obesity; obstructive sleep apneoa syndrome (OSAS); and psychological dysfunction.

“It was very small numbers, but what they showed was that there were improvements in asthma control on the ACQ (Asthma Control Questionnaire), quality of life as a result of this protocolized approach, and at 12 months a reduction in exacerbations in those patients,” said Partridge.

To illustrate issues with the lack of established protocols, Partridge recalled an earlier study which found widely varying responses in the methods used by 173 members of the British Thoracic Society to treat a hypothetical difficult asthma patient with the same case history.  [Eur Respir J 2006;28:968–973]

“Eight percent of them would always bronchoscope someone with that case, while 70% would always check Aspergillus fungus status, and psychiatric opinion was asked for by only 15%,” said Partridge, adding that when the doctors were divided into specialists and non-specialists, the former were more likely to have configured their clinics for easy access to other consultants inspeech therapy and psychiatry.

Essential steps in difficult asthma treatment

Partridge noted that in cases of apparently difficult of problematic asthma, treatment should not be escalated without first reassessing the initial diagnosis; second, assessing patient adherence to medication; and third, searching for and treating comorbidities.

Partridge highlighted a study of 182 patients in Northern Ireland difficult asthma specialist clinic in which it was found that 45% of patients prescribed oral steroids were nonadherent to their medication, while 88% of all patients admitted to poor adherence to inhaled therapy after initial denial. [Am J Respir Crit Care Med 2009; doi:10.1164/rccm.200902-0166OC]

“This is a sizable issue that we need to address in our clinical practice by sensitive questioning, and where possible by prednisolone assays; measurement of cortisol and/or FeNO; and increasingly by prescription monitoring and—in the future—the use of smart inhalers,” said Partridge. “[We must ask] about noncompliance in a way that acknowledges it is likely.”

Once noncompliance has been ruled out, potential comorbidities such as chronic obstructive pulmonary disease(COPD), hyperventilation with panic attacks, tracheal obstruction, dysfunctional breathing/vocal cord dysfunction, etc,must be ruled out to ensure the diagnosis can be adequately confirmed as asthma.

“Healthcare professionals should be aware that difficult asthma is commonly associated with coexistent psychological morbidity, with depression being particularly common,” said Partridge.

After a three-month followup, should the asthmatic symptoms still be uncontrolled, or ’just controlled‘—ie, needing maximal therapy such as high dose ICS, second controller and/or systemic steroids for control—then the case can be confirmed as severe asthma.

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