Chest
Volume 103, Issue 6, June 1993, Pages 1662-1669
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Clinical Investigations
Difficult-to-Control Asthma: Contributing Factors and Outcome of a Systematic Management Protocol

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To our knowledge, there are no published results of protocols for managing difficult to control asthma (DTCA) or of the spectrum and frequencies of reasons why asthma can be difficult to control (DTC). To assess the usefulness of a systematic management protocol and determine the reason(s) why asthmatics are DTC, we developed a protocol that systematically considered multiple factors that may make asthma worse and prospectively evaluated the outcomes of therapeutic interventions for these factors and of inhaled corticosteroids (ICS) and azathioprine. We studied 42 consecutive and unselected DTCAs (19 men and 23 women) whose age was 48 ± 15.9 years. They had a diagnosis of asthma for 15.1 ± 15.8 years, were DTC for 4.8 ± 7.8 years, and were followed up by us in the study for a total of 3.5 ± 1.9 years. Initially, the dose of prednisone was 30.2 ± 22 mg/d. Following utilization of the protocol, 74 percent were no longer DTC. It took 1.8 ± 1.7 years for them to no longer be DTC; they remained so for 1.8 ± 1.5 years. In these patients, 2.7 ± 1.2 factors appeared to be responsible for the DTC state; 80 percent had ≥2. Improvemen t was more likely if gastroesophageal reflux (GER) was a factor (p=0.014); it correlated with the addition of ICS (p=0.04) and treatment for GER (p=0.02). Failure to reverse DTCA correlated with the suspicion (p=0.004) and admission of nonadherence (p=0.04). In 14 patients given azathioprine, prednisone dose decreased from 45 ± 25.3 to 13.3 ± 21.6 mg/d (p=0.003); 6 of 14 achieved no longer DTC status; and substantial morbidity occurred. The reason(s) for DTCA could be determined in most instances by utilizing a systematic protocol; multiple factors were responsible in the majority of cases; treatment for GER and ICS were the two most helpful interventions; nonadherence was the most likely reason suspected for maintaining DTCA; and azathioprine acted as a corticosteroid-sparing agent that should not be prescribed routinely.

(Chest 1993; 103:1662-69)

Section snippets

Patients

Patients who were referred to our pulmonary outpatient clinic because their asthma was difficult to control were selected for participation in this study. A patient with asthma who required more than 10 mg of prednisone every other day for at least three consecutive months per year to remain functional was defined as having difficult-to-control asthma. From January 5, 1982 to October 1, 1990, 42 consecutive and unselected patients prospectively met this definition and served as our study

Outcome of Systematic Protocol

The results of the protocol before and after evaluation and intervention are shown in Figure 1. By closely managing and monitoring the patients and their daily corticosteroid doses over an average of 3.5 years, it was determined that 74 percent of subjects were no longer difficult to control. At the end of the study, this favorable outcome had lasted an average of 1.8 ± 1.5 years. The remaining 26 percent of patients persistently remained difficult to control. The characteristics of these two

DISCUSSION

To our knowledge, this is the first study to assess systematically the usefulness of a specific protocol in treating difficult-to-control asthmatics and to determine the reasons why asthmatics are difficult to control. From the results of our prospective, descriptive study, five findings have emerged that are pertinent to managing the difficult-to-control asthmatic. Future controlled studies will determine whether these findings can be extrapolated to all difficult-to-control asthmatics.

First,

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Presented in part at the Annual Meeting, American Thoracic Society, Anaheim, Calif, May 15, 1991 (Am Rev Respir Dis 1991; 143, Part 2: A632).

Manuscript received July 9; revision accepted October 7.

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