Monica Kraft, MD: Finding, Fighting Comorbidities in Severe Asthma

Comorbid conditions are highly prevalent in patients with asthma, with allergy and inflammation-based symptoms developing over years. But for patients with severe, uncontrolled, or type 2 asthma, comorbidities can be particularly difficult to handle.

In an interview with MD Magazine® while attending the 2018 CHEST Annual Meeting in San Antonio, TX, Monica Kraft, MD, Deparment of Medicine Chair at the University of Arizona College of Medicine — Tuscon, detailed the ways in which comorbid conditions often manifest in this at-need patient population, and why digging deeper into patient symptoms is critical for care.

MD Mag: What are the comorbidities associated with severe asthma?

Kraft: The comorbidities that are most common would be allergic rhinitis, sinusitis with nasal polyps, gastroesophageal reflux disease—and it can be acid or non-acid reflux. Plus, upper airway dysfunction—we call it intermittent loringeal obstruction or vocal chord dysfunction, it has a few different names.

Obstructive sleep apnea is a big one. Depression often comes along with chronic, and especially severe, asthma. It's really important to address that. In some cases, where obesity is an issue, because we see a fair amount of patients that are obese, you worry about metabolic syndrome, diabetes, heart disease, all the things you would worry about in any patient with obesity. That could add to the symptom-medication burden.

MD Mag: How are comorbidities addressed in patients with type 2 asthma?

Kraft: I think the key factors in addressing comorbidities is in taking a really good look at their history. Allergies is a good example—you want to make sure there's a good clinical history of allergy, and then you can do the skin testing, the blood testing, to look for allergen-specific antibodies. But you've got to put it together with the clinical history—is there a seasonal component? Is there allergic rhinitis? Do they have other manifestations of allergic disease, like atopic dermatitis? It's important to get a really good history to go along with your skin tests or other tests for allergy.

I think the same holds true for reflux. Some patients don't have obvious reflux symptoms, but they may have throat closure, sore throat, or change in voice. That actually might be reflux, they manifest in different ways. They might have a hernia that promotes reflux. They may have a family history of heartburn.

You really want to delve in and decide if a patient has a comorbidity. Sleep apnea— do they have morning headaches? Do they have daytime fatigue, do they fall asleep easily during tasks? Are they overweight, which would also predispose to sleep apnea?

So those kinds of questions, really delving into each of them, so you feel assured that it's something real, and especially if you're going to be doing some testing, it'll give you the evidence you need to pursue testing to make the diagnosis.

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