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      Current Control and Future Risk in Asthma Management

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          Abstract

          Despite international and national guidelines, poor asthma control remains an issue. Asthma exacerbations are costly to both the individual, and the healthcare provider. Improvements in our understanding of the therapeutic benefit of asthma therapies suggest that, in general, while long-acting bronchodilator therapy improves asthma symptoms, the anti-inflammatory activity of inhaled corticosteroids reduces acute asthma exacerbations. Studies have explored factors which could be predictive of exacerbations. A history of previous exacerbations, poor asthma control, poor inhaler technique, a history of lower respiratory tract infections, poor adherence to medication, the presence of allergic rhinitis, gastro-oesophageal reflux disease, psychological dysfunction, smoking and obesity have all been implicated as having a predictive role in the future risk of asthma exacerbation. Here we review the current literature and discuss this in the context of primary care management of asthma.

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          Measurement properties and interpretation of three shortened versions of the asthma control questionnaire.

          Elizabeth Juniper, Klas Svensson, Ann-Christin Mork … (2005)
          The Asthma Control Questionnaire (ACQ) measures the adequacy of asthma treatment as identified by international guidelines. It consists of seven items (5 x symptoms, rescue bronchodilator use and FEV1% of predicted normal). A validation study suggested that in clinical studies measurement of FEV1 and bronchodilator use may not be needed but this has never formally been tested in a clinical trial. The aims of this analysis were (1) to examine the measurement properties of three shortened versions of the ACQ (symptoms alone, symptoms plus FEV1 and symptoms plus short-acting beta2-agonist) and (2) to determine whether using the shortened versions would alter the results of a clinical trial. In the randomised trial, 552 adults completed the ACQ at baseline and after 13 and 26 weeks of treatment. The analysis showed that the measurement properties of all four versions of the ACQ are very similar. Agreement between the original ACQ and the reduced versions was high (intraclass correlation coefficients: 0.94-0.99). Mean differences between the ACQ and the shortened versions were less than 0.04 (on the 7-point scale). Clinical trial results using the four versions were almost identical with the mean treatment difference ranging from -0.09 (P=0.17), to -0.13 (P=0.07). For interpretability, the minimal important difference for all four versions was close to 0.5. In conclusion, these three shortened versions of the ACQ can be used in large clinical trials without loss of validity or change in interpretation.
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            Low-dose inhaled corticosteroids and the prevention of death from asthma.

            S Suissa, P. Ernst, S Benayoun … (2000)
            Although inhaled corticosteroids are effective for the treatment of asthma, it is uncertain whether their use can prevent death from asthma. We used the Saskatchewan Health data bases to form a population-based cohort of all subjects from 5 through 44 years of age who were using antiasthma drugs during the period from 1975 through 1991. We followed subjects until the end of 1997, their 55th birthday, death, emigration, or termination of health insurance coverage; whichever came first. We conducted a nested case-control study in which subjects who died of asthma were matched with controls within the cohort according to the length of follow-up at the time of death of the case patient (the index date), the date of study entry, and the severity of asthma. We calculated rate ratios after adjustment for the subject's age and sex; the number of prescriptions of theophylline, nebulized and oral beta-adrenergic agonists, and oral corticosteroids in the year before the index date; the number of canisters of inhaled beta-adrenergic agonists used in the year before the index date; and the number of hospitalizations for asthma in the two years before the index date. The cohort consisted of 30,569 subjects. Of the 562 deaths, 77 were classified as due to asthma. We matched the 66 subjects who died of asthma for whom there were complete data with 2681 controls. Fifty-three percent of the case patients and 46 percent of the control patients had used inhaled corticosteroids in the previous year, most commonly low-dose beclomethasone. The mean number of canisters was 1.18 for the patients who died and 1.57 for the controls. On the basis of a continuous dose-response analysis, we calculated that the rate of death from asthma decreased by 21 percent with each additional canister of inhaled corticosteroids used in the previous year (adjusted rate ratio, 0.79; 95 percent confidence interval, 0.65 to 0.97). The rate of death from asthma during the first three months after discontinuation of inhaled corticosteroids was higher than the rate among patients who continued to use the drugs. The regular use of low-dose inhaled corticosteroids is associated with a decreased risk of death from asthma.
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              A new perspective on concepts of asthma severity and control.

              P Chanez, Benjamin Partridge, Adam Gibson … (2008)
              Concepts of asthma severity and control are important in the evaluation of patients and their response to treatment but the terminology is not standardised and the terms are often used interchangeably. This review, arising from the work of an American Thoracic Society/European Respiratory Society Task Force, identifies the need for separate concepts of control and severity, describes their evolution in asthma guidelines and provides a framework for understanding the relationship between current concepts of asthma phenotype, severity and control. "Asthma control" refers to the extent to which the manifestations of asthma have been reduced or removed by treatment. Its assessment should incorporate the dual components of current clinical control (e.g. symptoms, reliever use and lung function) and future risk (e.g. exacerbations and lung function decline). The most clinically useful concept of asthma severity is based on the intensity of treatment required to achieve good asthma control, i.e. severity is assessed during treatment. Severe asthma is defined as the requirement for (not necessarily just prescription or use of) high-intensity treatment. Asthma severity may be influenced by the underlying disease activity and by the patient's phenotype, both of which may be further described using pathological and physiological markers. These markers can also act as surrogate measures for future risk.
              Article 0 comments Cited 101 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Allergy Asthma Immunol Res
                Journal ID (publisher-id): AAIR
                Title: Allergy, Asthma & Immunology Research
                Publisher: The Korean Academy of Asthma, Allergy and Clinical Immunology; The Korean Academy of Pediatric Allergy and Respiratory Disease
                ISSN (Print): 2092-7355
                ISSN (Electronic): 2092-7363
                Publication date (Print): October 2011
                Publication date (Electronic): 21 September 2011
                Volume: 3
                Issue: 4
                Pages: 217-225
                Affiliations
                [1 ]Research in Real Life Ltd., Warren House, Sankence, Aylsham, Norfolk, UK.
                [2 ]Norwich Medical School, University of East Anglia, Norwich, UK.
                [3 ]Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK.
                [4 ]The University of Edinburgh Medical School, Teviot Place, Edinburgh, UK.
                [5 ]Woodbrook Medical Centre, Loughborough, UK.
                Author notes
                Correspondence to: Prof. David Price, MD, PhD, Center for Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25, 2ZD, UK. Tel: +44-208-123-3923; Fax: +44-808-280-0792; david@ 123456rirl.org
                Article
                DOI: 10.4168/aair.2011.3.4.217
                PMC ID: 3178819
                PubMed ID: 21966601
                SO-VID: 1b46f58c-4a76-4816-9bb0-4bca463b4212
                Copyright © Copyright © 2011 The Korean Academy of Asthma, Allergy and Clinical Immunology • The Korean Academy of Pediatric Allergy and Respiratory Disease
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 07 July 2011
                Date accepted : 15 July 2011
                Categories
                Subject: Review

                ScienceOpen disciplines: Immunology
                Keywords: asthma,disease exacerbation,control,primary health care
                Data availability:
                ScienceOpen disciplines: Immunology
                Keywords: asthma, disease exacerbation, control, primary health care

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