Difficult asthma

Abstract

Asthma is usually easy to manage, but approximately 5% of patients are not controlled even on high doses of inhaled corticosteroids. It is important to assess these patients carefully in order to identify whether there are any correctable factors that may contribute to their poor control. It is critical to make a diagnosis of asthma and to exclude other airway diseases, particularly chronic obstructive pulmonary disease (COPD), and vocal cord dysfunction ("pseudo-asthma"). Poor adherence to therapy, particularly inhaled corticosteroids, is a common reason for a poor response. There may be unidentified exacerbating factors, including unrecognized allergens, occupational sensitizers, dietary additives, drugs, gastro-oesophageal reflux, upper airway disease, or other systemic diseases, that need to be identified and avoided or treated. Psychological factors may be important in some patients, but it is difficult to know whether these are causal or secondary to troublesome disease. Some patients have instability of their asthma, with resistant nocturnal asthma, premenstrual exacerbations or chaotic and unpredictable instability (brittle asthma). A few patients are completely resistant to corticosteroids, but more patients are relatively resistant and require relatively high doses of corticosteroids to control their symptoms (steroid-dependent). Some patients develop progressive loss of lung function, as in patients with COPD. Management of patients with difficult asthma should be supervised by a respiratory specialist and should involve careful assessment to confirm a diagnosis of asthma, identification and treatment of exacerbating factors, particularly allergens, and recording of peak expiratory flow patterns. A period of hospital admission may be the best way to assess and manage these patients. Treatment involves optimizing corticosteroids therapy, assessing additional controllers such as long-acting inhaled or subcutaneous beta2-agonists or subcutaneous, theophylline and antileukotrienes. In some patients, the use of immunosuppressive treatments may reduce steroid requirements, although these treatments are rarely effective and have side-effects. In the future, the nonsteroid anti-inflammatory treatments now in development may be useful in these patients.

A systematic review to examine the impact of psycho-educational interventions on health outcomes and costs in adults and children with difficult asthma

“…[25][26][27][28][29] Central to a definition of difficult asthma is, therefore, disease which remains poorly controlled despite medical treatment which would usually be effective. 26,30,31 A more detailed discussion of the concept of difficult asthma is provided in Chapter 2 and part of this review is concerned with further clarification of definitions and indicators for patients at risk from their asthma.…”

“…2, 26,31 Inevitably, it has profound effects on QoL for patients and prevention of emergency attendances, 32 hospitalisations, 24,33 ICU admissions 14 and deaths 22 associated with difficult asthma represents a challenge to clinicians. Again, although patients with difficult asthma make up a small proportion of the whole population with asthma, they account for a large and disproportionate share of mortality, morbidity and costs.…”

Asthma and Adherence to Inhaled Corticosteroids: Current Status and Future Perspectives

“…5 Multiple studies have shown ICS to improve symptoms and reduce asthma-related morbidity and mortality, [6][7][8] but despite this, a high number of patients being treated according to guidelines remain difficult to control with frequent exacerbations and persisting symptoms. 9 One of the plausible reasons for poorly controlled asthma may be that patients with asthma tend to exhibit poor adherence. 10 Poor adherence to controller medication may lead to a decline in lung function, 11 poor symptom control, 12 and increased risk of asthma-related hospitalizations.…”

“…2 The high percentage of patients not taking their ICS as prescribed also poses a challenge for health-care providers in identifying patients suffering from treatment-resistant or refractory asthma, which is generally defined as asthma not responding to high-dose therapy. 9 This could lead to non-adherent patients being prescribed newer and often more expensive medications, which are reserved for patients with moderate-to-severe asthma who are uncontrolled on high-dose ICS and long-acting ␤ 2 agonists, 14 even though it is likely that they would have achieved comparable asthma control with optimal adherence to ICS instead.…”

An exploratory, pragmatic, cluster randomised trial of practice nurse training in the use of asthma action plans

“…We audited practice records to identify patients with poor control, since poor control is associated with more frequent symptoms and bronchodilator use, and functional impairment, 24,25 as well as poor quality of life. 26 Thus, there is scope for improving asthma management in this group of patients.…”