Multimorbidity in Difficult Asthma: The Need for Personalised and Non-Pharmacological Approaches to Address a Difficult Breathing Syndrome

Abstract

Three to ten percent of people living with asthma have difficult-to-treat asthma that remains poorly controlled despite maximum levels of guideline-based pharmacotherapy. This may result from a combination of multiple adverse health issues including aggravating comorbidities, inadequate treatment, suboptimal inhaler technique and/or poor adherence that may individually or collectively contribute to poor asthma control. Many of these are potentially “treatable traits” that can be pulmonary, extrapulmonary, behavioural or environmental factors. Whilst evidence-based guidelines lead clinicians in pharmacological treatment of pulmonary and many extrapulmonary traits, multiple comorbidities increase the burden of polypharmacy for the patient with asthma. Many of the treatable traits can be addressed with non-pharmacological approaches. In the current healthcare model, these are delivered by separate and often disjointed specialist services. This leaves the patients feeling lost in a fragmented healthcare system where clinical outcomes remain suboptimal even with the best current practice applied in each discipline. Our review aims to address this challenge calling for a paradigm change to conceptualise difficult-to-treat asthma as a multimorbid condition of a "Difficult Breathing Syndrome" that consequently needs a holistic personalised care attitude by combining pharmacotherapy with the non-pharmacological approaches. Therefore, we propose a roadmap for an evidence-based multi-disciplinary stepped care model to deliver this.

How Does Mild Asthma Differ Phenotypically from Difficult-to-Treat Asthma?

“…Comorbidity in difficult asthma is strongly associated with poorer asthma control, greater symptom burden, frequent exacerbations, mOCS dependency and non-adherence to asthma treatment. [29][30][31]33,34 We found that severity of comorbidities based on questionnaire scores was lower and HRQoL was better in mild asthma compared to difficult disease. To et al found 6% of hospitalisations were related to asthma and asthma comorbidity in their population-based cohort study of 12 million residents in Ontario, Canada.…”

“…It has recently been proposed that we shift our focus to the concept of complex asthma as a multimorbidity “Difficult Breathing Syndrome” rather than a severe asthma-centric state, recognising the constellation of conditions with multiple “treatable traits” contributing to difficult asthma. 34 Whether such notions are relevant to mild asthma too is worth consideration.…”

Integrative Approach to Risk Factors in Simple Chronic Obstructive Airway Diseases of the Lung or Associated with Metabolic Syndrome—Analysis and Prediction

“…The potential association between bronchial obstructive disorders and MS has acquired profound significance in this context. MS comprises several pathological conditions, conferring this association a unique and noteworthy character [ 13 , 14 ].…”

The “Asthma-Polycystic Ovary Overlap Syndrome” and the Therapeutic Role of Myo-Inositol

“…Most asthmatic patients have multiple comorbidities including rhinitis, sinusitis with or without nasal polyps, airway infections, gastro-esophageal reflux disease, obesity, sleep-related breathing disorders, anxiety and depression, and polycystic ovary syndrome (PCOS). Adequate treatment of comorbidities is essential to achieve satisfactory asthma control [ 8 ].…”