Comorbid “treatable traits” in difficult asthma: Current evidence and clinical evaluation

Abstract

The care of patients with difficult-to-control asthma ("difficult asthma") is challenging and costly. Despite high-intensity asthma treatment, these patients experience poor asthma control and face the greatest risk of asthma morbidity and mortality.Poor asthma control is often driven by severe asthma biology, which has appropriately been the focus of intense research and phenotype-driven therapies. However, it is increasingly apparent that extra-pulmonary comorbidities also contribute substantially to poor asthma control and a heightened disease burden. These comorbidities have been proposed as "treatable traits" in chronic airways disease, adding impetus to their evaluation and management in difficult asthma. In this review, eight major asthma-related comorbidities are discussed: rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obstructive sleep apnoea, vocal cord dysfunction, obesity, dysfunctional breathing and anxiety/depression. We describe the prevalence, impact and treatment effects of these comorbidities in the difficult asthma population, emphasizing gaps in the current literature. We examine the associations between individual comorbidities and highlight the potential for comorbidity clusters to exert combined effects on asthma outcomes. We conclude by outlining a pragmatic clinical approach to assess comorbidities in difficult asthma.

EUFOREA consensus on biologics for CRSwNP with or without asthma

“…Treatable traits have been postulated as a management concept which complements the traditional diagnostic labels such as CRSwNP or CRSsNP, thereby focusing on therapy targeted to a patient's individual disease-associated characteristics. 28,29 Typical treatable traits in the upper airways can be smoking, allergy, occupation, and mucociliary clearance deficits. 30 Biological therapies have entered the market for patients with asthma almost 15 years ago with anti-IgE as first-line therapy for patients with severe allergic asthma 31 and urticaria.…”

Treatable traits in the European U‐BIOPRED adult asthma cohorts

“…Associations between traits were not explored here but have been discussed elsewhere. 8 In conclusion, the label-free, precision medicine approach provided by the treatable traits construct allowed for the identification of multiple treatment opportunities for patients with asthma, beyond the traditional stepwise approach. We eagerly await the results of prospective, longitudinal, clinical trials to determine whether this translates to improved clinical outcomes for individuals with respiratory disease.…”

Different endotypes and phenotypes drive the heterogeneity in severe asthma

“…19,20 These comorbidities appear to be very reproducibly represented in severe asthma cohorts and where possible should be considered potential targets for intervention or "treatable traits" in severe asthma. 21,22 As an exemplar of this complexity and how important it is to have a holistic approach to the assessment of poorly controlled severe asthma, Ten Brinke and colleagues examined risk factors for frequent exacerbations in difficult-to-treat asthma and demonstrated psychological dysfunction was the greatest driver of recurrent exacerbation in this population. 23 Thus, detailed systematic assessment, including a firm diagnosis of asthma and identification of all contributing factors and particularly traits which are potentially treatable, is an important part of clinical assessment in severe asthma rather than continually escalating treatment in response to persistent symptoms.…”