Workup of difficult-to-treat asthma: implications from treatable traits

Qing Zhang; Wen Wen Wu; Lei Li; Vanessa M McDonald; Yu Cheng Chen; Gang Wang; Peter G Gibson

doi:10.1093/pcmedi/pbad003

Workup of difficult-to-treat asthma: implications from treatable traits

Precis Clin Med. 2023 Feb 24;6(1):pbad003. doi: 10.1093/pcmedi/pbad003. eCollection 2023 Mar.

Authors

Qing Zhang^{1

2}, Wen Wen Wu^{1

2}, Lei Li^{1

2}, Vanessa M McDonald^{3

4}, Yu Cheng Chen⁵, Gang Wang^{1

2}, Peter G Gibson^{3

4

6}

Affiliations

¹ Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China.
² Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu 610041, Sichuan, China.
³ Center of Excellence in Severe Asthma and Priority Research Center for Asthma and Respiratory Disease, the University of Newcastle, Newcastle 2308, Australia.
⁴ National Health and Medical Research Council Center for Research Excellence in Severe Asthma and Treatable Traits, the University of Newcastle, Newcastle 2308, Australia.
⁵ Cardiology Division, Department of Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China.
⁶ Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle 2305, Australia.

Abstract

Traditional stepwise approach usually adjusts the treatment regimen based on changes in asthma symptoms and severity to achieve good asthma control. However, due to the generalized heterogeneity and complexity of asthma, its therapeutic efficacy in difficult-to-treat asthma is limited. Recently, a precision medicine approach based on the identification and intervention of treatable traits of chronic airway disease has been proposed and appears to be of greater benefit to asthmatics. We reported a 71-year-old male with uncontrolled asthma and multiple exacerbations over the past year. He complained of persistent dyspnea despite high-dose of inhaled corticosteroids plus other controllers. Does this patient have some potential treatable traits contributing to difficult-to-treat asthma? Through a multidimensional assessment of three domains including pulmonary, extrapulmonary, and behavioral/risk factors, 15 treatable traits were identified in the patient, mainly including airflow limitation, eosinophilic airway inflammation, small airway dysfunction, exacerbation prone, dilated cardiomyopathy, diabetes mellitus, inhaler device polypharmacy, smoking, and the absence of an asthma action plan. After targeted treatment for these treatable traits, the patient experienced significant improvement in dyspnea and he could maintain good asthma control with low-dose inhaled corticosteroids and long-acting β₂-agonist. This study shows that, in response to the limitation of a stepwise approach to therapy, treatable traits is a new strategy where patients are individually assessed for a specified set of treatable problems, and an individualized treatment program is developed and implemented based on this multidimensional assessment, especially for difficult-to-treat asthma.

Keywords: comorbidity; difficult-to-treat asthma; multidimensional assessment; stepwise approach; treatable traits.