Confounders of severe asthma: diagnoses to consider when asthma symptoms persist despite optimal therapy

Gherasim, Alina; Dao, Ahn; Bernstein, Jonathan A.

doi:10.1186/s40413-018-0207-2

Cited by 28 publications

(20 citation statements)

References 93 publications

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“…The difficulty can start with the first step, which is proper confirmation of asthma diagnosis. Additionally, in many patients with difficult-to-control asthma, other factors may contribute to poor control, including GERD, vocal cord dysfunction, the use of beta-blockers or ACE-Is, anxiety, depression, obesity, or proper inhaler technique [ 3 , 31 , 32 ]. Before escalating therapy with the addition of biologics in patients whose disease is uncontrolled, current GINA 2020 guidelines recommend proper asthma diagnosis and thorough evaluation to exclude masquerading diseases and contributory factors.…”

Section: Discussionmentioning

confidence: 99%

How Frequently Is Asthma Objectively Demonstrated before Starting a Biologic? Quality Assessment of a Group Practice of Allergists and Immunologists

Dziewa

Craig

Al‐Shaikhly

2020

IJERPH

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Worldwide, asthma-related healthcare cost remains a major burden. Individuals with severe asthma account for 50% of that cost. Although they are expensive, biologics such as anti-IL5 and anti-IgE agents promise cost-effectiveness when judiciously used to decrease asthma-related hospitalization and the debilitating side effects of systemic corticosteroids. Before considering biologics to treat patients with asthma, current guidelines recommend confirmation of asthma and control of comorbid diseases. Diagnostic confirmation of asthma can be challenging among individuals with severe asthma. In this quality assessment study, we determined the frequency of objective asthma confirmation and addressing of comorbidities prior to starting biologics at a group practice of allergists and immunologists. We surveyed our specialty providers to understand habit(s) leading to the observed results. We identified 40 adult patients who started on biologic modifiers for asthma over the past 5 years. Only 58% of these patients had a proper diagnosis of asthma. Providers underutilized several diagnostic methods that may prove useful in confirming asthma diagnosis in this patient population. The factors contributing to poor asthma control were rarely addressed. A sense of urgency to initiate biologics was the primary reason for the observed results. Further interventions are needed to improve asthma diagnosis and management prior to the initiation of biologic therapeutics.

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Section: Discussionmentioning

confidence: 99%

How Frequently Is Asthma Objectively Demonstrated before Starting a Biologic? Quality Assessment of a Group Practice of Allergists and Immunologists

Dziewa

Craig

Al‐Shaikhly

2020

IJERPH

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“…According to pulmonologists' experiences, our results indicated that Croatian GPs rarely undertake diagnostic procedures to verify asthma quantitatively. In patients with SA, in addition to non-recognition of asthma mimickers, the main barrier to correct diagnosis is poor recognition and comprehension of the severity of the disorder [21,22]. This lack of appropriate testing and lack of recognition often result in delayed [21,23].…”

Section: Plos Onementioning

confidence: 99%

Attitudes of Croatian pulmonologists concerning obstacles to earlier, more appropriate use of biologics in severe asthma: Survey results

et al. 2021

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Aims Biologics have been proven efficacious for patients with severe asthma (SA). It is essential to diagnose such individuals correctly. This study was designed to survey pulmonologists to identify barriers to early diagnosis and subsequent appropriate use of biologics for SA in Croatia. Methods A pulmonologist group with expertise in SA developed the initial list of questions, with the final questionnaire created according to a 2-round Delphi method. The resulting survey consisted of 23 items consequently divided into 4 domains: 1) Pulmonologists’ demographics and professional experiences; 2) Concerns about asthma management; 3) Attitudes toward SA diagnosis; and 4) Beliefs and attitudes regarding the use of biologics in managing SA. The given answers represented the respondents’ estimates. Results Eighty-four surveys were analyzed, with pulmonologists observing that general practitioners often inaccurately diagnose asthma and treat acute exacerbations. Although specialist centers are capably and correctly equipped, the time to diagnose patients with SA is approximately 3.5 months, with initial use of biologics delayed an additional 2 months. The primary indications for prescribing biologics are conventional therapy with oral glucocorticoids (91.7%) and frequent acute exacerbations (82.1%). In addition to improper diagnosis (64.3%), many patients with SA do not receive the indicated biologics owing to strict administrative directives for reimbursement (70.2%) or limited hospital resources (57.1%). Limitations The limitations of this survey include the subjective nature of the collected data, the relatively small sample size, and the lack of the biologic efficacy evaluation. Conclusions Croatian pulmonologists observed that a significant number of patients with SA who are eligible for biologics are not prescribed them, largely because of an inaccurate and/or delayed diagnosis, a delayed referral to a specialist center, highly restrictive criteria for reimbursement, and/or institutional budgetary limitations.

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“…Treatable traits focusing on extrapulmonary and psychosocial aspects have to be checked and addressed at that stage (primary care). If asthma remains poorly controlled (difficult-to-treat asthma), asthma specialists will be involved to optimize inhaled treatment, reassess differential diagnosis and check and address more treatable traits, especially pulmonary traits (secondary care) (7). When these steps are achieved, if asthma is still uncontrolled, a biologic can be considered as an alternative or add on to a low dose of daily steroids.…”

Section: From Phenotypes To Targeted Therapies: Toward Deciphering Mumentioning

confidence: 99%

“…(iii) Do any asthma comorbidities remain uncontrolled? (7). Should a pharmacological treatment step-up strategy or a nonpharmacological approach (allergen or occupational avoidance, smoking cessation, anxiety-controlling strategies, respiratory rehabilitation) be considered?…”

Section: Introductionmentioning

confidence: 99%

Needs for Systems Approaches to Better Treat Individuals With Severe Asthma: Predicting Phenotypes and Responses to Treatments

2020

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Asthma is a frequent heterogeneous multifactorial chronic disease whose severe forms remain largely uncontrolled despite the availability of many drugs and educational therapy. Several phenotypes and endotypes of severe asthma have been described over the last two decades. Typical type-2-immunity-driven asthma remains the most frequent phenotype, and several targeted therapies have been developed and are now available. On the contrary, non-type-2 immunity-driven severe asthma is less understood and still requires efficient innovative therapies. A personalized approach would allow improving asthma control with the help of robust biomarkers able to predict phenotypes/endotypes, exacerbations, response to targeted treatments and, in the future, possible curative options. Some data from large multicenter cohorts have emerged in recent years, especially in transcriptomics. These data have to be integrated and reproduced longitudinally to provide a systems approach for asthma care. In this focused review, the needs for such an approach and the available data will be reviewed as well as the next steps for achieving personalized medicine in asthma.

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Confounders of severe asthma: diagnoses to consider when asthma symptoms persist despite optimal therapy

Cited by 28 publications

References 93 publications

How Frequently Is Asthma Objectively Demonstrated before Starting a Biologic? Quality Assessment of a Group Practice of Allergists and Immunologists

How Frequently Is Asthma Objectively Demonstrated before Starting a Biologic? Quality Assessment of a Group Practice of Allergists and Immunologists

Attitudes of Croatian pulmonologists concerning obstacles to earlier, more appropriate use of biologics in severe asthma: Survey results

Needs for Systems Approaches to Better Treat Individuals With Severe Asthma: Predicting Phenotypes and Responses to Treatments

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