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Although a minority of asthma patients suffer from severe asthma, they represent a major clinical challenge in terms of poor symptom control despite high-dose treatment, risk of exacerbations, and side effects. Novel biological treatments may benefit patients with severe asthma, but are expensive, and are only effective in appropriately targeted pa...
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Context 1
... a patient with a suspicion of or proven severe asthma should be referred to the local severe asthma center or team. As the number of patients with adult and/or adult-onset asthma is high and the burden from these patients is high [156], we propose a two- step model, where the generalist may initially refer the patient to a respiratory specialist, if there is a strong suspicion of or a proven severe asthma, the patient is subsequently referred to the severe asthma center/team (Figure 4). However, depending on the local situation, direct referral from the GP office to the severe asthma center or team may be preferable . ...
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Citations
... Severe asthma is a highly burdensome condition affecting approximately 5-10% of asthma patients who remain uncontrolled despite of high-dose controller therapy, and where other causes including lack of adherence, inadequate inhaler technique, and influence of untreated comorbidities have been ruled out [1][2][3][4] . Severe asthma is associated with high morbidity, loss of quality of life and iatrogenic side effects to treatment, most notably from oral corticosteroids (OCS) prescribed either intermittently to treat exacerbations or as maintenance therapy (mOCS) 5,6 . ...
... A statistically significant relationship between findings of elevated leucocyte or neutrophil counts and diagnosed CRS could not be demonstrated, but among patients with asthma, the elevated neutrophil count was more common than among non-asthmatics. This finding does not necessarily indicate that a large proportion of asthma in these patients has associated with airway neutrophilic inflammation, as it can only be reliably assessed from airway samples [29]. A previous finding among these patients was that 23% of the 30 new-onset asthma cases had signs of type 2 inflammation (increased FeNO and/or levels of blood eosinophils) [28]. ...
The mechanisms of health effects of moisture damage (MD) are unclear, but inflammatory responses have been suspected. The usefulness of laboratory and allergy tests among patients in secondary healthcare with symptoms associated with workplace MD were examined. Full blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), total serum immunoglobulin E (IgE), fractional exhaled nitric oxide (FeNO), and skin prick testing were assessed and analyzed in relation to multiple chemical sensitivity (MCS) and perceived stress in 99 patients and 48 controls. In analysis, t-tests, Mann-Whitney tests, and chi-squared tests were used. Minor clinically insignificant differences in blood counts were seen in patients and controls, but among patients with asthma an elevated neutrophil count was found in 19% with and only in 2% of patients without asthma (p = 0.003). CRP levels and ESR were low, and the study patients’ FeNO, total IgE, or allergic sensitization were not increased compared to controls. The level of stress was high among 26% of patients and 6% of controls (p = 0.005), and MCS was more common among patients (39% vs. 10%, p < 0.001). Stress or MCS were not significantly associated with laboratory test results. In conclusion, no basic laboratory or allergy test results were characteristic of this patient group, and neither inflammatory processes nor allergic sensitization were found to explain the symptoms among these patients. While the value of basic laboratory tests should not be ignored, the use of allergy tests does not seem necessary when symptoms are indicated to be workplace-related.
... In Denmark, the decision to start an asthma patient on biological therapy is made by an asthma specialist. Initiation of biological treatment should be preceded by a systematic assessment to differentiate severe asthma from difficult-to-treat asthma [33]. According to the Danish Medicines Council, anti-IL-5 therapy is indicated for patients with severe asthma with lack of disease control together with evidence of eosinophilic inflammation. ...
... Documentation of smoking data in patients with ex-smoking or current smoking history In the assessment of asthma, the knowledge on the smoking status can be considered highly important especially if the patient is ex-smoker or current smoker 40 . Out of all 603 scheduled contacts, 45.9% (n = 277) were contacts in which the patient was either current or ex-smoker. ...
Smoking among asthmatics is common and associates with poorer asthma control, more rapid lung function decline and higher health care costs in dose-dependent manner. No previous real-life studies exist, however, on how smoking status and pack-years are documented in scheduled asthma contacts in primary health care (PHC) during long-term follow-up, and how often patients are advised to quit smoking. In this real-life 12-year follow-up study, we showed that out of all scheduled PHC asthma contacts ( n = 603) smoking was mentioned only in 17.2% and pack-years only in 6.5%. Smoking data was not recorded even once in 70.9% of never smokers, 64.7% of ex-smokers and 27.3% of current smokers. Smoking including pack-years were mentioned more often if nurse took part on the scheduled contact. For current smokers, smoking cessation was recommended only in 21.7% of their scheduled contacts. Current smokers used more antibiotics and had more unscheduled health care contacts during follow-up.
... If these issues have been addressed and the symptom burden is still marked, asthma is considered severe. 18 Severe asthma may reportedly begin in childhood or adulthood, but the molecular findings of bronchial inflammation seem to differentiate between them, more symptomatic disease associating especially with eosinophilic bronchial inflammation. 3,19,20 Most of the few studies on asthma symptom burden between early-and late-onset asthma have resulted in only little or no difference. ...
Background
Although asthma may begin at any age, knowledge about relationship between asthma age of onset and the prevalence and character of different symptoms is scarce.
Objectives
The aim of this study was to investigate if adult-diagnosed asthma is associated with more symptoms and different symptom profiles than child-diagnosed asthma.
Methods
A FinEsS postal survey was conducted in a random sample of 16 000 20-69-year-old Finnish adults in 2016. Those reporting physician-diagnosed asthma and age at asthma diagnosis were included. Age 18 years was chosen to delineate child- and adult-diagnosed asthma.
Results
Of responders (N = 8199, 51.5%), 842 (10.3%) reported asthma diagnosis. Adult-diagnosed asthma was reported by 499 (59.3%) and child-diagnosed by 343 (40.7%). Of responders with adult-diagnosed and child-diagnosed asthma, 81.8% versus 60.6% used asthma medication (p < 0.001), respectively. Current asthma was also more prevalent in adult-diagnosed asthma (89.2% versus 72.0%, p < 0.001). Risk factors of attacks of breathlessness during the last 12 months were adult-diagnosis (OR = 2.41, 95% CI 1.64–3.54, p < 0.001), female gender (OR = 1.49, 1.07–2.08, p = 0.018), family history of asthma (OR = 1.48, 1.07–2.04, p = 0.018) and allergic rhinitis (OR = 1.49, 1.07–2.09, p = 0.019). All the analysed asthma symptoms, except dyspnea in exercise, were more prevalent in adult-diagnosed asthma in age- and gender-adjusted analyses (p = 0.032-<0.001) which was also more often associated with 5 or more asthma symptoms (p < 0.001) and less often with non-symptomatic appearance (p < 0.001) than child-diagnosed asthma.
Conclusion
Responders with adult-diagnosed asthma had more often current asthma and a higher and multiform asthma symptom burden, although they used asthma medication more often compared to responders with child-diagnosed asthma.
... The obesity-related asthma phenotype is often complicated with the presence of several obesity-related comorbidities such as diabetes or ischaemic heart disease [17,18]. It is also known that, for example, obstructive sleep apnoea syndrome and gastro-esophageal reflux, which are common comorbidities particularly in severe asthma [37], may impact the association between BMI and lung function. Smoking also has adverse effects on lung function among adults with asthma [4] and was more common among the overweight/obese than those with normal weight in our study. ...
Background
: With increasing prevalence of overweight and obesity, it is important to study how BMI change may affect lung function among subjects with asthma. There are few prospective studies on this topic, especially with separate analyses of those with normal and high BMI.
Aim
: To prospectively study the association between annual BMI change and annual lung function decline, separately among those with normal initial BMI and overweight/obesity, in an adult asthma cohort.
Methods
: A population-based adult asthma cohort was examined at study entry between 1986–2001 and at follow-up between 2012–2014 (n=945). Annual BMI change was analysed in association to annual decline in FEV 1 , FVC and FEV 1 /FVC separately in those with normal weight (BMI=18.5–24.9) and overweight/obesity (BMI≥25) at study entry. Regression models were used to adjust for sex, age, smoking, ICS use and occupational exposure to gas, dust, or fumes.
Results
: Subjects with overweight/obesity had lower FEV 1 and FVC but slower annual FEV 1 and FVC decline compared to those with normal weight. After adjustment through regression modelling, the association between BMI change with FEV 1 and FVC decline remained significant for both BMI groups, but with stronger associations among the overweight/obese (FEV 1 B [Overweight/obese] =−25 ml versus B [normal weight] =−15 ml). However, when including only those with BMI increase during follow-up, the associations remained significant among those with overweight/obesity, but not in the normal weight group. No associations were seen for FEV 1 /FVC.
Conclusions
: BMI increase is associated with faster FEV 1 and FVC decline among overweight and obese adults with asthma in comparison with their normal weight counterparts.
... In Denmark, the decision to start an asthma patient on biological therapy is made by an asthma specialist. Initiation of biological treatment should be preceded by a systematic assessment to differentiate severe asthma from difficult-to-treat asthma [33]. According to the Danish Medicines Council, anti-IL-5 therapy is indicated for patients with severe asthma with lack of disease control together with evidence of eosinophilic inflammation. ...
Background
Phase III regulatory trials show that anti-IL 5 biologics efficiently reduce exacerbations and use of maintenance oral corticosteroids (mOCS) in patients with severe eosinophilic asthma. However, patients eligible for these trials differ significantly compared to real life severe asthma populations. Therefore, our aim was to explore efficacy in a real-life setting. The Danish Severe Asthma Register (DSAR) is a complete, nationwide register that comprises all Danish patients on biological therapy for severe asthma.
Methods
This prospective study identified patients in DSAR who were complete responders to anti IL5 biologics after one year of treatment. A complete response was defined as resolution of the parameter setting the indication, i.e. recurrent exacerbations and/or use of mOCS.
Results
A total of 289/502 (58%) were complete responders to anti-IL5 biologics after 12 months. Complete responders had greater improvements in FEV1 and Asthma Control Questionnaire (ACQ) compared to non-complete responders (Δ 210 mL versus Δ 30 mL, p<0.0001) and (Δ-1.04 versus Δ-0.68, p=0.016), respectively. A complete response was predicted by age at onset, less severe disease at baseline ( i.e. no mOCS and lower ACQ score) and higher blood eosinophils.
Conclusion
More than half of Danish patients treated with anti-IL5 biologics for severe asthma achieve a complete response to treatment thereby becoming free from asthma exacerbations and need for mOCS. Complete responders also achieved superior effects on lung function and symptoms compared to non-complete responders.
... 1,2 The majority of patients with asthma have mild-to-moderate disease, with possible severe asthma comprising a minority (5-10%) of patients. [3][4][5] However, poor asthma control is common, 6 and 60-80% of patients with sub-optimal disease control and/or possible severe asthma are managed in primary care. 4,5,7 As such, a large unmet need for improving asthma control exists. ...
Introduction
The impact of asthma and disease control on job absenteeism in young adults is sparsely investigated and conflicting evidence exist. Based on a nationwide cohort, the present study aims to describe the overall job absenteeism across asthma severities and describe the possible influence of asthma control.
Methods
REASSESS is a nationwide cohort of Danish asthma patients aged 18–45 using controller medication between 2014 and 2018, followed retrospectively for up to 15 years using national databases. Impact of asthma was investigated using negative binomial regression adjusted for age, sex, Charlson score and level of education and presented as adjusted incidence rate ratios with 95% confidence intervals.
Results
A total of 60,534 patients with asthma (median age 33 (25, 39), 55% female, 19% uncontrolled disease and 5.7% possible severe asthma) were followed for 12.7 (6.5–14.8) years. The prevalence of any absenteeism was more common in both mild-to-moderate and possible severe asthma compared to the background population (67%, 80% and 62%, respectively; p < 0.0001). Compared to the background population, mild-to-moderate and possible severe asthma were more likely to have temporary sick leave (1.37 (1.33–1.42); 1.78 (1.62–1.96)), unemployment (1.11 (1.07–1.14); 1.26 (1.15–1.38)) and obtain disability benefits (1.67 (1.66–1.67); 2.64 (2.63–2.65)). Uncontrolled asthma had increased temporary sick leave (1.42 (1.34–1.50)), unemployment (1.40 (1.32–1.48)) and disability (1.26 (1.26–1.27)) when compared to controlled disease. Significant increases in absenteeism could be measured already at ≥100 annual doses of rescue medication (1.09 (1.04–0.1.14)), patients’ first moderate or severe exacerbation (1.31 (1.15–1.49) and 1.31 (1.24–1.39), respectively). Further increases in absenteeism were observed with increasing rescue medication use and severe exacerbations.
Conclusion
Across severities, job absenteeism is increased among patients with asthma compared to the background population. Increases in absenteeism was seen already at ≥100 annual doses of rescue medication, representing a substantial, and probably preventable, reduction in productivity among young adults.
... 1-A semi-structured questionnaire was used depending on previous studies regarding sociodemographic, work characteristics, and asthma symptoms: -Age, sex, smoking, occupational process, PPE, and duration -Symptoms (cough, dyspnea, wheeze), symptoms resolve after work or in holidays or not, completely or partially trigger of asthma, asthma symptoms leading to night awaking, family history of atopy, childhood asthma, occupational periodic examination, diagnosed as occupational asthma, work replacement or compensation for occupational asthma (Nicholsonet al., 2001;Ladics et al., 2014;Porsbjerg et al., 2018). 2-Clinical examination. ...
Cleaning products are mixtures of many chemical ingredients that are known to contain sensitizers, disinfectants, and fragrances, as well as strong airway irritants which associated with lower respiratory tract and asthma symptoms.
The aim of this study is to assess the prevalence and possible risk factors of occupational asthma and its effect on quality of life among workers in detergent and cleaning products industries in El Asher men Ramadan city.
This cross-sectional study was conducted on 780 workers. All participants were personally interviewed at their workplaces and were subjected to a questionnaire regarding sociodemographic, work characteristics and asthma symptoms, clinical examination, chest X-ray, spirometer, and bronchodilator test.
The prevalence of occupational asthma among the studied workers was 35.4%. Multivariate logistic regression analysis revealed that female gender [odds ratio 1.397; 95% CI 1.09–1.96], manually working participants [odds ratio 3.067; 95% CI 1.72–5.46], and history of atopy [odds ratio 1.596; 95% CI 1.09–2.33] were risk factors for development of occupational asthma. The total mean score of asthma-specific quality of life was significantly lower in asthmatic (5.10 ± 0.49) than non-asthmatic workers (5.89 ± 0.46) (P < 0.01) indicating impairment of quality of life among asthmatic group.
Workers in detergent and cleaning products industry are at higher risk for developing occupational asthma that adversely affects their general health and quality of life.
... Asthma is a major health risk in developed or highincome countries [56]; Nordic countries are no exception to this, with asthma remaining a risk factor for mortality [57,58]. Patients with severe asthma have poor symptom control despite high-dose treatment with corticosteroids and additional controller therapy, and represent a major clinical challenge [59]. A large proportion of patients with difficult-to-control asthma also have at least one comorbidity [60,61], and these have a great impact on healthcare costs and healthrelated quality of life (HRQoL). ...
... A large proportion of patients with difficult-to-control asthma also have at least one comorbidity [60,61], and these have a great impact on healthcare costs and healthrelated quality of life (HRQoL). Novel biologic treatments may benefit patients with severe asthma, but they must be targeted appropriately [59]. ...
Eosinophils have a broad range of functions, both homeostatic and pathological, mediated through an array of cell surface receptors and specific secretory granules that promote interactions with their microenvironment. Eosinophil development, differentiation, activation, survival and recruitment are closely regulated by a number of type 2 cytokines, including interleukin (IL)-5, the key driver of eosinophilopoiesis. Evidence shows that type 2 inflammation, driven mainly by interleukin (IL)-4, IL-5 and IL-13, plays an important role in the pathophysiology of eosinophilic airway diseases, including asthma, chronic rhinosinusitis with nasal polyps, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome. Several biologic therapies have been developed to suppress type 2 inflammation, namely mepolizumab, reslizumab, benralizumab, dupilumab, omalizumab and tezepelumab. While these therapies have been associated with clinical benefits in a range of eosinophilic diseases, their development has highlighted several challenges and directions for future research. These include the need for further information on disease progression and identification of treatable traits, including clinical characteristics or biomarkers that will improve the prediction of treatment response. The Nordic countries have a long tradition of collaboration using patient registries and Nordic asthma registries provide unique opportunities to address these research questions. One example of such a registry is the NORdic Dataset for aSThmA Research (NORDSTAR), a longitudinal population-based dataset containing all 3.3 million individuals with asthma from four Nordic countries (Denmark, Finland, Norway and Sweden). Large-scale, real-world registry data such as those from Nordic countries may provide important information regarding the progression of eosinophilic asthma, in addition to clinical characteristics or biomarkers that could allow targeted treatment and ensure optimal patient outcomes.
