Photo Credit: Liliia Bila

Researchers recently identified five extrapulmonary treatable traits in asthma that are clinically relevant and have a clear diagnostic process.

Asthma is often complicated by extrapulmonary, behavioral, and lifestyle risk factors. In a recent paper for the Journal of Allergy and Clinical Immunology in Practice, Vanessa McDonald, PhD, and coauthors investigated the effect of these non-pulmonary traits on asthma. Specifically, the researchers looked at the impact of atopic dermatitis, anxiety, depression, chronic rhinosinusitis with nasal polyps, and GERD.

In an interview with Physician’s Weekly, Dr. McDonald says, “Treatable traits offer a model of care for patients and clinicians to work in partnership to deliver personalized approaches to the management of asthma and COPD that leads to important improvements in patient outcomes.”

Identifying Treatable Traits in Asthma

The researchers narrowed the scope of their literature analysis to five traits: atopic dermatitis, anxiety, depression, chronic rhinosinusitis with nasal polyps, and GERD.

“These traits frequently co-exist with asthma,” Dr. McDonald says. “They can lead to worse asthma symptom control and attacks and, when treated, can result in improved asthma outcomes.”

The researchers assessed each of these traits based on three criteria:

• Clinical relevance.
• Ability to measure and identify.
• Responsive to one or more treatments.

Atopic Dermatitis

Atopic dermatitis met all three criteria. For criteria one, the researchers stated that it affects 26% of people with asthma, and 25.7% of patients with atopic dermatitis also have asthma. Previous studies have also linked atopic dermatitis to asthma’s development.

Various diagnostic tools satisfy criteria two. These include validated scoring systems to judge the severity of the condition, such as the SCORing Atopic Dermatitis and the Eczema Area and Severity Index.

Atopic dermatitis also has multiple effective treatment options, satisfying criteria three. Treatments include topical anti-inflammatory agents, skin moisturizers, and education programs on avoiding triggers. Systemic treatments are prescribed for more severe atopic dermatitis.

Anxiety & Depression

Anxiety and depression are both considered clinically relevant to asthma. Anxiety is present in 24% to 38% of people with asthma, and depression in 10% to 25%. Anxiety and depression are common comorbidities of asthma that are often left untreated. Both conditions are associated with reduced asthma control, lung function, and a worse overall QOL.

Myriad screening tools for anxiety and depression satisfy criteria two. Common screening tools include the Hospital Anxiety and Depression Scale, Kessler Psychological Distress Scale, Depression Anxiety Stress Scale, Hamilton Anxiety Scale, and Hamilton Depression Scale.

The researchers identified multiple treatment options, including lifestyle interventions, medications, psychological interventions, and social support systems.

Chronic Rhinosinusitis With Nasal Polyps

Chronic rhinosinusitis with nasal polyps met all three major criteria. This condition only impacts 2% to 4% of the general population but 30% to 70% of patients with asthma.

Diagnosis occurs when a patient experiences symptoms for 12 weeks or longer and when the physician detects sinonasal inflammation and nasal polyps. Both can be measured by nasal endoscopy and sinus-computed tomography. There are multiple validated tests to assess severity, with the 22-item Sinonasal Outcomes Test being one of the most popular.

Some treatments include intranasal or oral corticosteroids, nasal saline irrigation biologics, and endoscopic sinus surgery.

GERD

GERD also met the criteria. To start, 46.5% to 52.7% of patients with asthma also have GERD. Multiple studies have demonstrated that GERD has an impact on asthma symptoms and is associated with worse asthma outcomes.

GERD has a complex diagnostic process that consists of a combination of therapeutic responses, objective tests, and characteristic symptoms. Questionnaires are often used to collect self-reported data, and these diagnostic tools can also be used to assess GERD’s severity.

GERD usually requires a multi-pronged but well-established treatment approach. Treatment options include lifestyle interventions, medication, surgical, and endoscopic therapies. The researchers referred to proton pump inhibitors as the “cornerstone of medical treatment for GERD.” These medications may also relieve asthma symptoms.

A Call for a Multidimensional Assessment

Dr. McDonald and coauthors concluded that these five treatable traits in asthma should be treated alongside pulmonary traits of asthma. To treat asthma and one or more of these comorbidities, clinicians should conduct a multidimensional assessment that considers extrapulmonary factors, behavioral traits, and lifestyle risk factors. Clinicians should also consider treatment options for all present conditions.

“Thinking about traits from the perspective of prevalence, impact, treatability, and size of treatment effect is a useful way to identify traits to target,” Dr. McDonald says.