Introduction: Significant intraindividual and temporal variability in symptom control is a feature of asthma that requires careful monitoring and the need to periodically review and adjust therapy Both NHLBI/NAEPP and GINA offer helpful algorithms for a stepping approach to asthmaAreas covered: The problems arisen in applying the stepwise approach to the treatment of asthma proposed by NHLBI/NAEPP and GINA algorithms and their possible alternativesExpert opinion: The current therapeutic stepping approach to asthma, which takes into account lung function, symptoms and quality of life, is certainly useful, but it does not consider the underlying mechanisms Furthermore, patient's overestimation or underestimation of the severity of the disease and differences in the opinions on the level of asthma control required between patients and physicians and also between physicians in both primary care and specialist settings are common and may negatively affect asthma control and future risks A reassessment of the conventional stepping approach to management of asthma is now needed A pragmatic approach that sets therapeutic goals for each individual and associates them with the treatable traits of asthma which, when therapeutically targeted, will in many cases help to achieve the goals, seems more reasonable than the present stepping approach

Step-up and step-down approaches in the treatment of asthma.

CS Murray. M Thomas. K Richardson. DB Price. SW Turner. J Allergy Clin Immunol Pract. 2017;5(4):1082–1090.e7

Current guidelines offer a number of different choices for step-up treatment of uncontrolled asthma in children on low-dose inhaled corticosteroids (ICSs). In this study, the authors compared the relative effectiveness of step-up treatment to fixed-dose combination (FDC) ICSs and long-acting β2-agonists as opposed to an increased dose of inhaled corticosteroids (i-ICSs) or adding a leukotriene receptor antagonist (LTRA).

This matched cohort study included children with uncontrolled persistent asthma aged 5 to 12 years from 2 UK primary-care databases who were receiving …

Comparative Effectiveness of Step-up Therapies in Children With Asthma Prescribed Inhaled Corticosteroids: A Historical Cohort Study

BACKGROUND AND OBJECTIVE
Comorbidities can influence asthma control and promote asthma exacerbations (AE). However, the impact of multimorbidity in AE, through long-term follow-up in patients with asthma of different severity has been scarcely studied in real-life conditions. Objective: To describe the epidemiological and clinical characteristics and predictive factors of AE in patients who had presented at least one AE in the last year among patients recruited in the MEchanism of Genesis and Evolution of Asthma (MEGA) project.


METHODS
We carried out a detailed clinical examination, pulmonary function testing, fractional exhaled nitric oxide (FeNO), blood counts, induced sputum, skin prick-tests, asthma questionnaires, and multimorbidity assessment. For each subject, the number of moderate-severe AE in the preceding year was registered.


RESULTS
486 patients with asthma were included (23.7% mild, 35% moderate, 41.3% severe). 41.9% remained uncontrolled. 47.3% presented ≥1 moderate-severe AE, with mean annual exacerbation rate of 0.47±0.91 vs 2.11±2.82 in mild and severe asthma, respectively. 56.4% (66.6% among severe asthmatics) presented some comorbidity. Bronchiectasis, chronic rhinosinusitis with nasal polyps, atopy, psychiatric illnesses, hyperlipidaemia and hypertension were significantly related with AE. No associations were found for FeNO, blood eosinophils and total serum IgE. Sputum eosinophilia and a high-T2 inflammatory pattern were significantly associated with AE. Multivariable regression analysis showed significant association with asthma severity, uncontrolled disease and low pre-bronchodilator FEV1/FVC.


CONCLUSION
The MEGA cohort found a high AE rate, which was strongly associated with multimorbidity, asthma severity, poor asthma control, airflow obstruction, higher sputum eosinophils and a very high T2-inflammatory pattern.

Exacerbations among patients with asthma are largely dependent on the presence of multimorbidity.

INTRODUCTION AND OBJECTIVE Introduction: Clinical practice guidelines recommend regular adjustment of treatment to achieve control of asthma. A step-up approach based on the degree of disease control should be followed. Objective: To perform a real-life analysis of the factors that affect the success or failure of this therapeutic strategy and of the criteria applied by clinicians when applying a step-up approach in a representative sample of patients diagnosed with moderate-severe asthma. MATERIAL AND METHODS We performed a multicenter retrospective cohort study involving 226 Spanish specialist physicians (98 allergologists, 127 pulmonologists, and 1 family physician). We included 1254 patients (787 women) diagnosed with moderate-severe asthma who underwent step-up therapy during 2016. RESULTS Step-up was successful in 44% of cases. The factors associated with success were presence of 3 to ≤6 months, >6 to ≤12 months) was more likely to be successful. CONCLUSION The factors that determine whether or not this therapeutic strategy manages to control asthma are time since onset of clinical impairment, previous grade of severity, number of comorbid conditions, previous exacerbations, and frequency of symptoms.

/pdf/factors-affecting-the-success-of-step-up-therapy-in-patients-2nroyjp0kd.pdf

Factors Affecting the Success of Step-up Therapy in Patients With Moderate-Severe Asthma: A Real-Life Study.

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Factors Affecting the Success of Step-up Therapy in Patients With Moderate-Severe Asthma: A Real-Life Study.