A Prospective Study of the Natural History of Asthma: Remission and Relapse Rates

doi:10.1378/chest.90.4.480

Chest

Volume 90, Issue 4, October 1986, Pages 480-484

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In this longitudinal study of a general population sample, remissions of asthma were common only during the second decade of life and were especially unusual in subjects ages 30 to 60 years on enrollment. Asthmatic subjects with severe symptoms, with reduced ventilatory function, or with a concomitant diagnosis of chronic bronchitis or emphysema on entry to the study were very unlikely to be in remission nine years later. Relapses of disease were common in subjects with a past history of asthma who were considered to be quiescient on enrollment to the study. Relapse rates tended to increase with age, at least up to the age of 70. Relapses were especially frequent among those “ex-asthmatics” who had persisting respiratory symptomatology on entry to the study.

Section snippets

MATERIALS AND METHODS

The population under study is a random stratified cluster sample of non-Mexican white American households in Tucson, Ariz. Details of the selection of the population and general methods have been published.¹⁵ Initial self-completion questionnaires were obtained from 3, 454 subjects. The present study examined only those who completed questionnaires in the first (1972 to 1973) and seventh (1981 to 1983) surveys. Because the surveys take slightly longer than one year, the mean follow-up was 9.4

Remission of Asthma

Of the 2, 300 subjects in the study, 136 had active asthma in the first survey. In the seventh survey, 30 of these 136 subjects were in remission, a 22 percent remission rate.

Figure 1 shows the rate of remission of active asthma by the age of the subjects at entry into the study. The total number at risk for a remission in each decade of age is indicated at the bottom of Figure 1. The remission rate was highest in the group aged 10 to 19 years, with 65 percent (13/20) having a remission, and

DISCUSSION

In this study, a high remission rate (65 percent; 13/20) was noted only in the group aged 10 to 19 years. Previous studies have also shown this decade to be characterized by frequent remissions. Williams and McNicol and associates7, 8, 9, 10 prospectively studied 331 children from 7 to 21 years old who had asthma or wheezy bronchitis when enrolled. Remissions of at least one-year duration were noted in 70 to 75 percent of these children at the age of 14 years, and 55 percent of those who had a

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Advances in asthma and allergic disease genetics: Is bigger always better?
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The trajectory of asthma symptoms is highly variable, with many subjects with an asthma diagnosis in childhood undergoing remission. Remission rates are higher in children with an asthma diagnosis than in adults with an asthma diagnosis.54,55 Vonk et al56 performed GWASs of clinical remission and complete remission of asthma in 178 and 55 subjects, respectively, after a median follow-up of 15.5 years among a cohort of 790 asthma cases.
This review focuses on genome-wide association studies (GWASs) of asthma and allergic diseases published between January 1, 2018, and June 30, 2019. During this time period, there were 38 GWASs reported in 19 articles, including the largest performed to date for many of these conditions. Overall, we learned that childhood-onset asthma is associated with the most independent loci compared with other defined groups of asthma and allergic disease cases; adult-onset asthma and moderate-to-severe asthma are associated with fewer genes, which are largely a subset of those associated with childhood-onset asthma. There is significant genetic overlap between asthma and allergic diseases, particularly with respect to childhood-onset asthma, which involves genes that reflect the importance of barrier function biology, and to HLA region genes, which are the most frequently associated genes overall in both groups of diseases. Although the largest GWASs in African American and Latino/Hispanic populations were reported during this period, they are still significantly underpowered compared with studies reported in populations of European ancestry, highlighting the need for larger studies, particularly in patients with childhood-onset asthma and allergic diseases, in these important populations that carry the greatest burden of disease.
Clinical onset of atopic eczema: Results from 2 nationally representative British birth cohorts followed through midlife
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Atopic eczema onset is described primarily in early childhood, and the frequency and characteristics of adult-onset disease remain controversial.
We sought to determine the proportion of subjects who report atopic eczema symptoms between birth and midadulthood and to examine demographic, immunologic, and genetic factors associated with period of symptom onset.
We conducted a longitudinal study using data from 2 nationally representative community-based birth cohorts from the United Kingdom: the British Cohort Studies 1958 and 1970. Subjects were followed from birth through age 42 to 50 years. The primary outcome was the age period of self-reported atopic eczema symptom onset based on repeated measures of self-reported atopic eczema at each survey wave.
The annual period prevalence of atopic eczema ranged from 5% to 15% in 2 cohorts of more than 17,000 participants each followed from birth through middle age. There was no clear trend in prevalence by age, and among adults reporting active atopic eczema during a given year, only 38% had symptom onset reported in childhood. When compared with subjects whose eczema started in childhood, those with adult-onset disease were more likely to be women, from Scotland or Northern England, of lower childhood socioeconomic group, smokers in adulthood, and less likely to have a history of asthma. In a subanalysis using data from the 1958 cohort only, genetic mutations previously associated with atopic eczema, including filaggrin-null mutations, and allergen-specific IgE were more common among those with childhood-onset disease.
Rates of self-reported atopic eczema remain high after childhood, and adult-onset atopic eczema has different risk factor associations than childhood-onset eczema.
A review on the pathophysiology of asthma remission
2019, Pharmacology and Therapeutics
Citation Excerpt :
As such, episodes with little or no disease activity can alternate with periods of more disease symptoms and renewed dependence on medication use. Consequently, patients in remission of the disease have a certain risk of relapse (Bronnimann & Burrows, 1986; Butland & Strachan, 2007; Carpaij et al., 2017; Vonk et al., 2004). This resembles “remission” of cancer (National Cancer Institute, 2018), in which the disappearance of signs and symptoms does not ensure that the disease is cured.
Asthma is a chronic respiratory condition, which is highly prevalent worldwide. Although no cure is currently available, it is well recognized that some asthma patients can spontaneously enter remission of the disease later in life. Asthma remission is characterized by absence of symptoms and lack of asthma-medication use. Subjects in asthma remission can be divided into two groups: those in clinical remission and those in complete remission. In clinical asthma remission, subjects still have a degree of lung functional impairment or bronchial hyperresponsiveness, while in complete asthma remission, these features are no longer present. Over longer periods, the latter group is less likely to relapse. This remission group is of great scientific interest due to the higher potential to find biomarkers or biological pathways that elicit or are associated with asthma remission.
Despite the fact that the definition of asthma remission varies between studies, some factors are reproducibly observed to be associated with remitted asthma. Among these are lower levels of inflammatory markers, which are lowest in complete remission. Additionally, in both groups some degree of airway remodeling is present. Still, the pathological disease state of asthma remission has been poorly investigated. Future research should focus on at least two aspects: further characterisation of the small airways and airway walls in order to determine histologically true remission, and more thorough biological pathway analyses to explore triggers that elicit this phenomenon. Ultimately, this will result in pharmacological targets that provide the potential to steer the course of asthma towards remission.
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Assessment of prognosis of asthma may be based on measurements on asthma remission, severity or lung function. Definition of asthma remission varies [13,27,28]. Most often, remission is defined as a period of at least one year without symptoms of asthma and without any usage of asthma medication.
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We undertook a systematic review to identify studies that evaluated the long-term prognosis of new-onset asthma diagnosed at adult age. Criteria used (set 1) were: 1. adult-onset asthma, 2. physician diagnosed asthma (including objective lung-functions) < 1 year before the first visit, 3. follow-up time of at least 5 years, 4. objective lung function measurements used at follow-up and 5. not a comparative trial. Another set of studies (set 2) with less strict criteria were gathered.
The main result of this systematic review is that the amount of evidence on the prognosis of new-onset asthma diagnosed at adult age is very limited. Only one study (n = 250) fulfilled the criteria (set 1) and it suggests that the five-year prognosis of new-onset asthma diagnosed at adult age may not be favorable, the proportion of patients being in remission was less than 5%. Furthermore, six additional follow-up studies (n = 964) were identified including mainly patients with adult-onset asthma (set 2). These studies had variable endpoints and the results could not be combined.
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2015, Annals of Allergy, Asthma and Immunology
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The present findings, in parallel with the European study, suggest that patients who do not gain weight have a better chance of attaining a totally controlled status or even a remission state. Studies of children have shown that better lung function is significantly associated with better prognosis during adulthood.19,20 Higher FEV1 values at the first visit and during remission have been reported to be important predictive factors for children with asthma who develop clinical remission.21
Studies on adult-onset asthma and the contributing factors for its prognosis are few in the literature.
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Two hundred patients with a diagnosis of adult-onset asthma in 2006 were included in this study. Of these, 160 were contacted in 2013 and participated in the study. Their demographic features, family history, clinical symptoms, pulmonary function test results, and Asthma Control Test scores were re-evaluated. Patients' asthma control status was determined. Patients who had total control and had not used any asthma treatment for at least 2 years were classified as in remission.
The study group consisted of 160 patients (144 women and 16 men, mean age 52.9 ± 10.3 years). Nearly 70% of patients had adult-onset asthma before 40 years of age. According to asthma control status, 21.9% of patients had uncontrolled asthma, 29.4% had partially controlled asthma, and 48.8% had totally controlled asthma. Remission was observed in 11.3% of the entire study group. The mean age of the remission group was significantly younger. Disease duration was shorter and the proportion of patients with atopy was larger in the totally controlled and remission groups. Except in the remission group, patients showed weight gain from 2006 through 2013.
According to these 7-year follow up data, the remission rate of asthma was 11.3%. Patients with younger age, younger onset, atopy, allergic rhinitis, and few comorbidities seemed to have a greater possibility of remission.

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Supported by Specialized Center of Research grant HL-14136 from the National Heart Lung, and Blood Institute.

†American Thoracic Society/American Lung Association Research Training Fellowship awardee at the time of the study

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Chest

Clinical InvestigationsA Prospective Study of the Natural History of Asthma: Remission and Relapse Rates

Section snippets

MATERIALS AND METHODS

Remission of Asthma

DISCUSSION

J Allergy Clin Immunol

Chest

Epidemiological aspects

Epidemiology and natural history

Some aspects of the natural history of asthma

Ann Allergy

Asthma in children

N Engl J Med

Prevalence, natural history, and relationship of wheezy bronchitis and asthma in children

Br Med J

Spectrum of asthma in children: 1. clinical and physiological components

Br Med J

Spectrum of asthma in children: 2. allergic components

Br Med J

Clinical Investigations
A Prospective Study of the Natural History of Asthma: Remission and Relapse Rates