Follow-up of patients with uncontrolled asthma: clinical features of asthma patients according to the level of control achieved (the COAS study)

Abstract

Our aim was to study the asthma control achieved in patients with uncontrolled asthma who had received appropriate treatment according to the Global Initiative for Asthma (GINA) 2010 (valid at the time the study was designed), and to analyse the factors associated with a lack of asthma control.This was a multicentre study in routine clinical practice performed in patients with uncontrolled asthma according to GINA 2010. At visit 1, we recorded demographics, asthma characteristics and spirometry. We assessed asthma control using GINA 2010 criteria and the Asthma Control Test (ACT). Treatment was optimised according to GINA 2010. At visit 2, 3 months later, we reassessed spirometry, asthma control and factors associated with failure to achieve control.We recruited 1299 patients with uncontrolled asthma (mean age 46.5±17.3 years, 60.7% women, 25.8% obese). The mean percentage of predicted forced expiratory volume in 1 s was 76.4±12.8% and the mean post-bronchodilator increase was 14.9±6.8%. We observed poor agreement between ACT and GINA 2010 when evaluating asthma control (kappa = -0.151). At visit 2, asthma in 71.2% of patients was still not fully controlled. Patients whose asthma remained uncontrolled were older, had a higher body mass index, greater disease severity, longer disease evolution and worse lung function.After treatment optimisation, most patients did not achieve optimal control according to GINA 2010. Risk factors for failure to achieve asthma control were time of disease evolution, severity, age, weight and lung function impairment (excluded in the GINA 2014).

Planned primary health care asthma contacts during 12-year follow-up after Finnish National Asthma Programme: focus on spirometry

“…Current GINA report recommends objective lung function measurements as necessary for initial diagnosis of asthma as well as long-term monitoring of asthma 1 . Previous studies have shown that reliance on patient-reported clinical symptoms [38][39][40][41] or ACT score can lead to overestimation of asthma control 41,42 . Inclusion of spirometry in the assessment guarantees more accurate monitoring of asthma control [38][39][40][41] without input from secondary care 43 .…”

Inhaled corticosteroids and asthma control in adult-onset asthma: 12-year follow-up study

“…The determinants which may contribute to inadequate asthma control include obesity, smoking and nonadherence to treatment [2,8,21]. Also incorrect use of inhaler devices and poor inhaling techniques are possible reasons leading to worsening of the asthma control [12]. It is commonly known that adherence to ICS treatment is unsatisfactory affecting management of asthma [11,28].…”

“…While assessing controller treatment and possible changes to ICS therapy the disease control, responsiveness to treatment and future risks must be taken into account for finding the appropriate step-up or step-down phases in treatment [2,15]. A previous study examined the effects of step-up treatment to uncontrolled adult asthma patients and showed that in spite of the optimization of the treatment most patients continued to show inadequately controlled asthma [12]. In our study patients with uncontrolled asthma had significantly more ICS dose changes and increases in ICS dose than patients with controlled asthma during 12-year follow-up period suggesting that physicians have tried to improve the management of asthma by changing the ICS dose of uncontrolled patients.…”

“…Before the era of different add-on therapies such as long-acting bronchodilators or leukotriene antagonists, an increase in the dose of ICS was the recommended step-up in the therapy and this option remains an effective second line option even in the current guidelines [2] and especially if exacerbations of asthma prevail [2,10]. Several factors such as correct use of inhalers and adherence to the treatment affect the outcome of the disease and have been described to be major barriers for successful treatment [11,12]. Another factor less studied is adherence to treatment guidelines, i.e.…”

“…In light of the fact that the achievement of good disease control is the target of asthma management, relatively little is known on the longterm variability in asthma control. Even though some interventional studies have shown that good asthma control can be achieved by stepping up treatment or by follow-up interventions [19,20], surprisingly large proportion of patients remain uncontrolled after stepping up the therapy [12]. Factors such as smoking and concurrent chronic obstructive disease, obesity, male sex and rhinitis have been reported to associate with an increased risk of uncontrolled asthma [8,21].…”