The Difficult-to-Control Asthmatic: A Systematic Approach

Abstract

With the judicious use of inhaled corticosteroids, β2 agonists, and leukotriene modifiers, most patients with asthma are easily controlled and managed. However, approximately 5% of asthmatics do not respond to standard therapy and are classified as "difficult to control." [1] Typically, these are patients who complain of symptoms interfering with daily living despite long-term treatment with inhaled corticosteroids in doses up to 2,000 μg daily. Many factors can contribute to poor response to conventional therapy, and especially for these patients, a systematic approach is needed to identify the underlying causes. First, the diagnosis of asthma and adherence to the medication regimen should be confirmed. Next, potential persisting exacerbating triggers need to be identified and addressed. Concomitant disorders should be discovered and treated. Lastly, the impact and implications of socioeconomic and psychological factors on disease control can be significant and should be acknowledged and discussed with the individual patient. Less conventional and novel strategies for treating corticosteroid-resistant asthma do exist. However, their use is based on small studies that do not meet evidence-based criteria; therefore, it is essential to sort through and address the above issues before reverting to other therapy.

Controlled diesel exhaust and allergen coexposure modulates microRNA and gene expression in humans: Effects on inflammatory lung markers

“…Nevertheless, further research is urgently needed to enhance prevention and improve treatment of allergic diseases because current therapies are of limited efficacy due to issues such as poor compliance, corticosteroid resistance, and ineffective control of exacerbating factors, including air pollution. 67 Key messages…”

Vocal Cord Dysfunction after an Inhalation Exposure

“…The prevalence of VCD was 22% for persons requiring repeated emergency room visits due to sudden-onset shortness of breath [38]. The condition was observed in about 10% of patients seeking evaluation of asthma unresponsive to aggressive therapy [39,40]. VCD was mistaken for refractory asthma [33].…”

Accreditation of specialized asthma units for adults in Spain: an applicable experience for the management of difficult-to-control asthma

“…Uncontrolled severe asthma accounts for ~15% of all asthma patients but is associated with a higher morbidity and mortality as well as an important impact on health care costs and the consumption of resources. 15 The AsmaCost study 16 based on data of a prospective cohort of 627 patients throughout Spain with asthma diagnosed according to the guidelines of the Global Initiative for Asthma (GINA) 17 and the adapted Spanish criteria (Guía Española de Manejo del Asma [GEMA]) 9 and followed up for 12 months revealed that the total societal cost for asthma was 1,726€ per patient annually (1,533€ to the National Health Service), with higher costs for patients older than 65 years and for those with a more severe disease (2,635€ for severe asthma). Based on these findings, the total annual cost of asthma in Spain was estimated to be 1,480 million euros.…”

“…On the other hand, 70% of total costs were attributed to the poor control of the disease, which further reinforces the need to achieve clinical stability of the patients as it has been repeatedly emphasized in clinical practice guidelines. 9 , 17…”

“…Although much progress has been made in the understanding of difficult-to-control asthma, with consensus documents and clinical practice guidelines focused on severe uncontrolled asthma with proposals for a stepwise diagnostic procedure and phenotype-targeted treatment, 9 , 10 improvements in clinical practice are still limited. In addition, involvement of pulmonology services in the specialized approach for difficult-to-control asthma is insufficient.…”