The multicomponent nature of difficult asthma

Background: Difficult Asthma poses significant management challenges. Better clinical understanding of the nature of this state could facilitate better care. Aim: To aid understanding of Difficult Asthma, we characterised patients in our Adult Difficult Asthma Clinic. Methods: Retrospective data for all patients seen during a calendar year were collated including demographic factors, comorbidities, asthma severity (BTS steps), and spirometry. Results: The clinic saw 185 patients (mean age 48.2 years), who were mainly female (66.1%). Most were atopic (73.2%) with mean total IgE of 769.8. Mean FEV 1 was 2.16 (68.5%) and FEV 1 /FVC 68.9%. Most patients were at Step 4 BTS management (57.9%), with equal proportions at Steps 5 (21.3%) and 3 (19.1%). One fifth were on maintenance prednisolone, 2.7% on oral steroid sparing agents, 4.9% on antifungal therapy and 11.0% on Omalizumab. Asthma hospital admission occurred in 25%. Comorbidities included rhinitis (80.7%), GORD (58.5%), obesity (43.2%), dysfunctional breathing (41.5%), salicylate sensitivity (32.6%), and psychological comorbidity (20.8%). Coexistent COPD was noted in 13.3% and bronchiectasis in 10.5%. Current smoking was present in 13.3%. Comorbidities were usually addressed by appropriate pharmacotherapy or behavioural therapy. Conclusion: Our Difficult Asthma population had high treatment needs but most patients were managed without need for Step 5 BTS therapy or Omalizumab and avoided hospitalisation. Our data suggest a multicomponent nature to Difficult Asthma with high prevalence of aggravating comorbidities that merit attention alongside asthma therapy. Addressing such comorbidity may offer avenues to improve the “difficult breathing syndrome” experienced by these patients.