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  • Co-Morbidities
    • Overview
    • Pulmonary & Upper Airways
      • Allergic & Non-Allergic Rhinitis
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      • Obesity
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  • Living with Severe Asthma
    • Overview
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  • Paediatrics
    • Overview
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Overview

Home Co-Morbidities Overview

Comorbidities in severe asthma are common, they complicate management and effect patient outcome. Comorbidities may frequently interact, contribute to poor disease control and mimic symptoms of asthma. They may also increase the cost of treatment for people with severe asthma and lead to overtreatment. It is therefore recommended that comorbidities be addressed in severe asthma (Chung et al. 2014). Multidimensional assessment of severe asthma allows for the recognition of these comorbidities and has been shown to improve patient outcomes (Clark et al. 2017). In this module, we deal with the most common comorbidities associated with severe asthma, we present their prevalence and impact and provide recommendations for assessment and management.

LAY OVERVIEW

People with severe asthma often have other medical problems. These comorbidities can make a person’s asthma worse and more difficult and expensive to manage and treat. People may end up taking too many medications. When people have a multidimensional assessment of severe asthma, their other medical problems and treatments are taken into account and this improves asthma outcomes.

Comorbidities are Common

Many comorbidities are more prevalent in people with severe asthma than in mild-moderate asthma, or in the healthy population. Their prevalence in a difficult-to-treat asthma cohort (most of whom had severe asthma) is shown below.

  • Percentage of patients
Prevalence of individual comorbidities in a difficult to treat asthma cohort. Data represented from (Radhakrishna et al. 2016) with permissions from Elsevier

Comorbidities Are Under-Diagnosed

While respiratory physicians are adept at recognising some comorbidities (such as obstructive sleep apnoea, bronchiectasis and COPD), others often go undiagnosed even in specialist practice (such as dysfunctional breathing and vocal cord dysfunction) (Radhakrishna et al. 2017).

Comorbidities Worsen Asthma Outcomes

There is data to indicate that the presence of comorbidities is associated with worse asthma outcomes for patients. For example, the presence of chronic rhinosinusitis is a strong risk factor for frequent exacerbations (ten Brinke et al. 2005, Tay et al. 2016, Denlinger et al. 2017). Other risk factors for exacerbations, poor asthma control, and impaired quality of life include gender, body mass, dysfunctional breathing and vocal cord dysfunction (Tay et al. 2016).

Comorbidity Worsens Asthma
Odds ratios and linear regression coefficients of comorbidities for frequent exacerbations, asthma control and asthma quality of life among 90 patients with difficult-to-control asthma (Tay et al. 2016) with permissions from John Wiley & Sons.

Treatment of Comorbidities Is Associated with Improved Asthma Outcomes

Based mainly on observational studies, treatment of many comorbidities appears to improve asthma outcomes (Porsbjerg et al. 2017, Tay et al. 2017).

Clinical approaches to severe asthma comorbidities

The multitude of patient comorbidities to be considered during severe asthma evaluation presents a clinical challenge. An unstructured approach is likely to miss several issues. On the other hand, exhaustive evaluation with every possible diagnostic test would be costly in resources and time. A third option is to employ a stratified approach, shown below.

Clinical-approaches-to-severe-asthma-comorbidities-1
A stratified approach to comorbidity detection and treatment from (Tay et al. 2017) with permissions from John Wiley & Sons.

This commences with the use of validated screening questionnaires for each comorbidity. An overview of validated screening tools is included below. As an example, the following scored and validated questionnaires and there sensitivity / specificity are proposed for screening by (Radhakrishna et al. 2017)

  • Sinonasal Questionnaire (SNQ) for sino-nasal disease
  • Score for Allergic Rhinitis (SFAR) for allergic rhinitis
  • Nijmegen Questionnaire for dysfunctional breathing
  • Pittsburgh Vocal Cord Dysfunction Index (PVCDI) for vocal cord dysfunction
  • Berlin Questionnaire for obstructive sleep apnoea
  • Hospital Anxiety and Depression Scale (HADS) for anxiety & depression
  • Gastroesophageal Reflux Disease Questionnaire (GERD-Q) for gastro-oesophageal reflux disease

For further details see the Comorbidity Components Resources section of this website.

Such an approach has been shown to increase detection of comorbidities compared to clinical consultation alone (Radhakrishna et al. 2017). Positive questionnaires guide the clinician to confirm the likelihood of comorbidities being present, and prompt appropriate further management.

A systematic approach to addressing severe asthma comorbidities in patients is clinically effective. A recent meta-analysis of three severe asthma programs which addressed comorbidities systematically as part of their protocol demonstrated improvements in asthma control, asthma quality of life and exacerbation rate (Clark et al. 2017).

Comorbidity
Effects of multidimensional assessment and targeted treatment based on meta-analysis of 3 studies (n=451 participants). Bars represent standardised mean difference with 95% confidence intervals. Data represented from (Clark et al. 2017).
Comorbidities are Frequently Considered in Two Domains: Pulmonary and Extrapulmonary

Pulmonary & Upper Airways

  • Allergic & Non-Allergic Rhinitis
  • Chronic Rhinosinusitis
  • Dysfunctional Breathing
  • Vocal Cord Dysfunction
  • Chronic Obstructive Pulmonary Disease
  • Bronchiectasis
  • Obstructive Sleep Apnoea

Extra-Pulmonary

  • Obesity
  • Anxiety & Depression
  • Gastro-oesophageal Reflux Disease (GORD)
  • Osteoporosis
  • Cardiovascular Disease & Metabolic Disease
Read more
Click here to download a printable version of the infographic below.

Access the full suite of infographics here.

asthma comorbidity infographic

Last Updated on September 19, 2019

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  • Overview
  • Pulmonary & Upper Airways
    • Allergic & Non-Allergic Rhinitis
    • Chronic Rhinosinusitis
    • Dysfunctional Breathing
    • Vocal Cord Dysfunction
    • Chronic Obstructive Pulmonary Disease
    • Bronchiectasis
    • Obstructive Sleep Apnoea
  • Extra-Pulmonary
    • Obesity
    • Anxiety & Depression
    • Gastro-oesophageal Reflux Disease (GORD)
    • Osteoporosis
    • Cardiovascular Disease & Metabolic Disease
For considerations relevant to the paediatric and adolescent population, please see Alternative Diagnoses & Co-Morbidities in Paediatrics or Asthma in the Adolescent Population

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