Perils of asthma research in vulnerable groups

Abstract

To coincide with the annual European Respiratory Society meeting, in Barcelona, on Sept 18–22, The Lancet today focuses on asthma and respiratory diseases. WHO estimates that asthma affects 300 million people worldwide, and vulnerable groups—particularly children and elderly people—can be especially difficult to treat. Two Reviews in this issue focus on these groups, for which asthma is associated with substantial morbidity and mortality, and is characterised by scarce data from research.With an ageing population, the prevalence of asthma in elderly people will soar in the next few years; yet diagnosis is often overlooked because of comorbidity, under-reporting of symptoms, insufficient use of lung-function testing, and overlap with chronic obstructive pulmonary disease. Peter Gibson and colleagues explore these issues and take an integrated approach to the understanding and management of asthma in this age group. Research into new treatments is needed for progress to be made; however, patients older than 65 years are often not eligible for inclusion in clinical trials because of age restriction, substantial comorbidity, or smoking history. Thus clinicians treating elderly people are unable to know the extent to which results from trials apply to their patients.At the other end of the age spectrum, Andrew Bush and Sejal Saglani focus on the management of severe paediatric asthma that is unresponsive to treatment. For these patients there are similar barriers to high-quality research as for the barriers faced by elderly patients: most of the data on which to base therapy options are from trials of children with less severe forms of asthma or adults. Furthermore, severe asthma is often misdiagnosed and adherence to treatment is poor.Although asthma is one of the most enigmatic chronic diseases, evidence for new treatments in vulnerable populations is scarce and is compounded by the exclusion of such groups from randomised trials. 2010 has been declared the Year of the Lung. To live up to this title, more research is needed that focuses specifically on these difficult-to-treat patients. To coincide with the annual European Respiratory Society meeting, in Barcelona, on Sept 18–22, The Lancet today focuses on asthma and respiratory diseases. WHO estimates that asthma affects 300 million people worldwide, and vulnerable groups—particularly children and elderly people—can be especially difficult to treat. Two Reviews in this issue focus on these groups, for which asthma is associated with substantial morbidity and mortality, and is characterised by scarce data from research. With an ageing population, the prevalence of asthma in elderly people will soar in the next few years; yet diagnosis is often overlooked because of comorbidity, under-reporting of symptoms, insufficient use of lung-function testing, and overlap with chronic obstructive pulmonary disease. Peter Gibson and colleagues explore these issues and take an integrated approach to the understanding and management of asthma in this age group. Research into new treatments is needed for progress to be made; however, patients older than 65 years are often not eligible for inclusion in clinical trials because of age restriction, substantial comorbidity, or smoking history. Thus clinicians treating elderly people are unable to know the extent to which results from trials apply to their patients. At the other end of the age spectrum, Andrew Bush and Sejal Saglani focus on the management of severe paediatric asthma that is unresponsive to treatment. For these patients there are similar barriers to high-quality research as for the barriers faced by elderly patients: most of the data on which to base therapy options are from trials of children with less severe forms of asthma or adults. Furthermore, severe asthma is often misdiagnosed and adherence to treatment is poor. Although asthma is one of the most enigmatic chronic diseases, evidence for new treatments in vulnerable populations is scarce and is compounded by the exclusion of such groups from randomised trials. 2010 has been declared the Year of the Lung. To live up to this title, more research is needed that focuses specifically on these difficult-to-treat patients. Asthma in older adultsAsthma in older people is common and is characterised by underdiagnosis and undertreatment. Ageing is associated with unique issues that modify expression, recognition, and treatment of the disease. In particular, asthma and chronic obstructive pulmonary disease (COPD) both overlap and converge in older people. This concurrence, together with absence of precise diagnostic methods, makes diagnosis complex. A multidimensional assessment that addresses airway problems, comorbidities, risk factors, and management skills will draw attention to key needs for intervention. Full-Text PDF Management of severe asthma in childrenChildren who are referred to specialist care with asthma that does not respond to treatment (problematic severe asthma) are a heterogeneous group, with substantial morbidity. The evidence base for management is sparse, and is mostly based on data from studies in children with mild and moderate asthma and on extrapolation of data from studies in adults with severe asthma. In many children with severe asthma, the diagnosis is wrong or adherence to treatment is poor. The first step is a detailed diagnostic assessment to exclude an alternative diagnosis (“not asthma at all”), followed by a multidisciplinary approach to exclude comorbidities (“asthma plus”) and to assess whether the child has difficult asthma (improves when the basic management needs, such as adherence and inhaler technique, are corrected) or true, therapy-resistant asthma (still symptomatic even when the basic management needs are resolved). Full-Text PDF