Patients With Difficult-To-Treat Asthma Require Different Intervention Methods Based on Comorbidities

Asthma’s medical complexity can cause patients to have difficulty managing their condition, particularly those with severe forms. Previous work analyzed severe asthma and its endotypes, but not the less standardized management of difficult-to-treat asthma based solely on clinical features. Authors of an analysis published in the Journal of Allergy and Hypersensitivity Diseases identify the reasons behind adult and pediatric patients’ difficult-to-treat asthma, and what therapeutic or diagnostic approaches would be best to help manage their condition.

For this analysis, data were collected from 42 consecutive patients followed at the University Hospital of Montpellier in the outpatient clinic of the respiratory diseases department and referred for difficult asthma. Asthma had to be defined as “difficult-to-treat” with diagnoses being made by an allergist or respiratory allergy specialist. Additionally, patients with chronic obstructive pulmonary disease (COPD) and other respiratory obstructive diseases as well as asthma-COPD overall syndromes were excluded from the analysis.

Qualitative analyses were performed for each patient with an emphasis on specific individual characteristics. Each record was assigned to 1 or more groups of intervention to potentially explain the difficulty for controlling patients’ asthma symptoms, according to the authors. The distribution of a patient to 1 or more specific group was determined after discussions between allergy and respiratory medicine specialists.

Of the 42 patients enrolled, 25 were adults and the remaining 17 were children. Additionally, 57.1% of the patients were female. The average age of asthma diagnosis in adults was 18.6 years ± 20.7 years and in children was 5.5 years ± 2.2 years. Comorbidities were also present in approximately 92% of adults and 29% of children. In adults, the most common comorbidities were weight (overweight or obese, 55%), atopy (32%), and concomitant gastroesophageal reflux disease (GERD, 24%), and in children, the most common were atopy (65%) and GERD (11.8%). Additionally, 20% of adults were active smokers and 16% had quit smoking, and approximately 30% of children were exposed to passive smoking.

The analysis differentiated 9 groups of intervention, with each method correlating with a specific issue that could be managed to reach either a good or better control of asthma in patients. For example, patients with untreated or refractory metabolic comorbidities—such as obesity or non-T2 inflammation—were given dietary advice and discussed pulmonary rehabilitation with providers, and those with a different untreated or refractory comorbidity—such as GERD or scoliosis—were suggested to use proton pump inhibitors or physical rehabilitation. Other suggested intervention methods include the following: nasal corticosteroids and ear, nose, and throat (ENT) consultation for untreated or refractory ENT comorbidities; smoking cessation with or without specific consultation for uncontrolled non-allergic respiratory environment (eg, smoking, occupational exposure); and therapeutical trials and an increase in treatment for untreated or untreated patients whose diagnoses were not yet established.

The authors note that some patients were unvoluntary or voluntary non-compliant in some groups. Although non-compliance isn’t an issue specific to asthma, it can have significant consequences and the differences between adult and children populations need to be considered separately, according to the authors. Additionally, the investigators note that important skills providers must have when helping patients manage their difficult-to-treat asthma is the navigation of obstacles and ability to find related incentives (eg, job-related factors, age).

Further, the investigators emphasize the importance of communication between health care professionals and their patients. Health care providers must explain to patients how the interventions or different drugs work, why they are prescribed, and what follow-ups are necessary to properly manage their asthma. Additionally, providers must be able to recognize when readjustments need to be made to interventions. This communication and education can help patients with compliance and willingness to be active participants in their treatments, the authors note.

Limitations of the study include its qualitative design, missing data during retrospective analyses, and patient assessments not being entirely based on the G2A questionnaire. Additionally, the number of cases of difficult-to-treat asthma is not easily assessed from the outset; however, the data were considered sufficient to meet the study’s primary purpose. The investigators suggest that a prospective study could further confirm the proposed intervention methods for patients with difficult-to-treat asthma.

REFERENCE

Demoly P, Gamez A, Bourdin A, Caimmi D. Precision medicine targeting groups of intervention in difficult-to-treat asthma. JAHD. 2024:100013. doi:10.1016/j.jahd.2024.100013