Patients with Severe Asthma Symptoms Require Improvements in Assessment and Diagnosis

A nationwide real-life study assessing diagnostics and treatment adherence in patients with severe asthma revealed that only 50% of patients who were treated for severe asthma in a specialist setting had been objectively diagnosed with asthma, and many had not been properly assessed for adherence to treatment or inhaler technique.

Danish researchers from the respiratory units at Bispebjerg University Hospital, Naestved Hospital, the University of Southern Denmark, Roskilde Hospital, Aalborg University Hospital and Arhus University Hospital led by Anna von Bülow, MD, PhD student (photo), from the Department of Respiratory Medicine at Bispebjerg hospital in Copenhagen, Denmark, sought to "describe the diagnostic work-up in a complete population of patients with severe asthma including: objective confirmation of the asthma diagnosis, and identification of potential treatment barriers, such as poor adherence and poor inhaler technique."

The study included data from the complete population (patients aged 18-65 years) of 5 respiratory outpatient clinics in Denmark. All of the patients were originally diagnosed with asthma or "suspected" asthma between 2009 and 2010 and were re-evaluated 2 years after their original referral.

After analyzing patient record forms from 2013-2014, including diagnosis and treatment data for each of the patients, the team discovered that of the 2,023 patients referred to the respiratory outpatient clinics in Denmark, only 6.8% fulfilled the treatment-criteria for severe asthma as outlined by international ERS/ATS guidelines, and only 98 had a complete dataset.

The team explained that issues with asthma control in patients with severe asthma could develop from several confounding factors and comorbidities. According to the authors, "Patients receiving high-dose asthma treatment are recommended to undergo a proper systematic assessment in a specialist setting to confirm the diagnosis of asthma and identify and address potential aggravating comorbidities, for adherence and environmental triggers before being classified as having severe asthma.”

Often a diagnosis of asthma is based on the presence of asthma-like symptoms, but von Bülow and colleagues warn that diagnoses based on symptoms alone can lead to a misdiagnosis of asthma and "potential overtreatment" for patients.

But, according to the Global Initiative for Asthma (GINA) program, asthma diagnoses could be based on the presence of typical asthma symptoms combined with an objective test for asthma demonstration of expiratory airflow limitation to differentiate asthma from other respiratory issues.

Researchers found that 83.7% had undergone at least one attempt of confirming the diagnosis of asthma. However, only 54.1% (n =53) had a confirmed diagnosis defined as having at least one positive objective test for asthma

Demonstration of airflow limitation might be challenging in these patients receiving high-dose inhaled corticosteroids. However, a total of 1/3 of the non-confirmed asthma group had not completed testing for airflow obstruction. Further, of those patients with bronchial challenges — patients with a normal PEF variability and/or a negative reversibility test, and who had a lung function that allowed for a bronchial challenge test – only 23.1% had such a test performed.

In general, the study found that those patients with confirmed asthma had undergone more significant diagnostic testing than those with unconfirmed asthma.

An evaluation of inhaler technique and adherence to treatment data showed that only 19.4% of patients with confirmed asthma and 30.6% of patients with unconfirmed asthma had received assessment in these areas according to the patient records. According to results, “apart from atopy and rhinitis, examination of other potential comorbidities/alternative diagnosis was relatively rare" for both confirmed and unconfirmed asthma populations.

The team suggested patients with severe asthma should be evaluated in specialist care for at least 3 to 6 months. The study highlighted that despite guidelines, many patients are being inadequately tested and assessed in clinical settings. Researchers were concerned about the lack of assessment and data that revealed misdiagnosis in roughly 30% of patients having symptom-based diagnosis of asthma.

Additionally, von Bülow pointed out that treatments for severe asthma such as high-dose ICS and oral steroids have severe side effects. Some misdiagnosed patients with non-specific respiratory disorders may be ineffectively treated with these asthma-specific regimens and could benefit more from other treatments.

An assessment of these patients is time consuming and complex; nonetheless, systematic assessment of these patients is becoming even more important due to the emergence of and increased availability of novel promising therapies for subsets of patients with severe asthma.

The team explained that there is an increased need for systematic and standardized assessments for patients with severe asthma, which could affect quality of life for patients with asthma and those being improperly diagnosed.

The article "The Level of Diagnostic Assessment in Severe Asthma; A Nationwide Real-Life Study" was published in the March 2017 issue of Respiratory Medicine.

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