Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia.
School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
Allergy. 2023 Sep;78(9):2418-2427. doi: 10.1111/all.15719. Epub 2023 Mar 27.
Multidisciplinary systematic assessment improves outcomes in difficult-to-treat asthma, but without clear response predictors. Using a treatable-traits framework, we stratified patients by trait profile, examining clinical impact and treatment responsiveness to systematic assessment.
We performed latent class analysis using 12 traits on difficult-to-treat asthma patients undergoing systematic assessment at our institution. We examined Asthma Control Questionnaire (ACQ-6) and Asthma Quality of Life Questionnaire (AQLQ) scores, FEV , exacerbation frequency, and maintenance oral corticosteroid (mOCS) dose, at baseline and following systematic assessment.
Among 241 patients, two airway-centric profiles were characterized by early-onset with allergic rhinitis (n = 46) and adult onset with eosinophilia/chronic rhinosinusitis (n = 60), respectively, with minimal comorbid or psychosocial traits; three non-airway-centric profiles exhibited either comorbid (obesity, vocal cord dysfunction, dysfunctional breathing) dominance (n = 51), psychosocial (anxiety, depression, smoking, unemployment) dominance (n = 72), or multi-domain impairment (n = 12). Compared to airway-centric profiles, non-airway-centric profiles had worse baseline ACQ-6 (2.7 vs. 2.2, p < .001) and AQLQ (3.8 vs. 4.5, p < .001) scores. Following systematic assessment, the cohort showed overall improvements across all outcomes. However, airway-centric profiles had more FEV improvement (5.6% vs. 2.2% predicted, p < .05) while non-airway-centric profiles trended to greater exacerbation reduction (1.7 vs. 1.0, p = .07); mOCS dose reduction was similar (3.1 mg vs. 3.5 mg, p = .782).
Distinct trait profiles in difficult-to-treat asthma are associated with different clinical outcomes and treatment responsiveness to systematic assessment. These findings yield clinical and mechanistic insights into difficult-to-treat asthma, offer a conceptual framework to address disease heterogeneity, and highlight areas responsive to targeted intervention.
多学科系统评估可改善治疗困难的哮喘患者的结局，但目前尚缺乏明确的应答预测指标。采用可治疗特征框架，我们根据特征谱对接受系统评估的治疗困难的哮喘患者进行分层，评估系统评估对临床结局和治疗应答的影响。
我们对在我院接受系统评估的治疗困难的哮喘患者进行了 12 项特征的潜在类别分析。我们在基线和系统评估后评估了哮喘控制问卷（ACQ-6）和哮喘生活质量问卷（AQLQ）评分、FEV1、发作频率和维持口服皮质激素（mOCS）剂量。
在 241 例患者中，分别以早发伴变应性鼻炎（n=46）和成年发病伴嗜酸性粒细胞增多/慢性鼻-鼻窦炎（n=60）为特征的两个气道特征谱，其特征为最小的合并症或心理社会特征；三个非气道特征谱分别以合并症（肥胖、声带功能障碍、呼吸功能障碍）占主导（n=51）、心理社会（焦虑、抑郁、吸烟、失业）占主导（n=72）或多领域损害（n=12）为主。与气道特征谱相比，非气道特征谱的基线 ACQ-6（2.7 比 2.2，p<0.001）和 AQLQ（3.8 比 4.5，p<0.001）评分更差。经过系统评估，该队列的所有结果均显示出总体改善。然而，气道特征谱的 FEV1 改善更多（5.6%比 2.2%预计值，p<0.05），而非气道特征谱的发作减少趋势更大（1.7 比 1.0，p=0.07）；mOCS 剂量减少相似（3.1mg 比 3.5mg，p=0.782）。
治疗困难的哮喘中存在不同的特征谱与不同的临床结局和对系统评估的治疗应答相关。这些发现为治疗困难的哮喘提供了临床和机制上的见解，为解决疾病异质性提供了概念框架，并突出了对靶向干预有反应的领域。
