Asthma Control Questionnaire Score Research Articles

Exhaled Nitric Oxide as a Predictor of Response to Anti-inflammatory Treatment in Asthma

RATIONALE: Inhaled steroïds (ICS) are the first line treatment recommended for chronic asthma. However, heterogeneity in response to ICS has been documented among asthma patients. In the present study, we investigated, in a real life context, whether exhaled nitric oxide assessment may predict ICS response in asthma patients, as defined by a significant improvement in the Asthma Control Questionnaire (ACQ) score from >1.5 (uncontrolled asthma) to < 0.75 (well controlled asthma). METHODS: FEV1 eNO and ACQ scores were recorded at two successive visits in 105 patients suffering from uncontrolled asthma (ICS naïve (n =42) and ICS treated (n=63)). At first visit, ICS treatment was initiated or dosage was increased. (mean dose 675 μg/day−1 eq. Beclomethasone). RESULTS: 35 patients achieved well controlled asthma on the second visit. Using the ROC curve technique, we show that initial eNO value greater than 50 ppb predicts ICS response with sensitivities of 67% and 60% in ICS naive and ICS treated patients respectively. No predictive cut-off value was identified for FEV. CONCLUSION: Exhaled N0 may be used to predict ICS response in a real life asthma management: 2 out of 3 patients suffering from uncontrolled asthma and achieving well controlled asthma after ICS initiation or ICS dose adjustment display initial eNO value superior to 50 ppb.

What Is Worse for Asthma Control and Quality of Life: Depressive Disorders, Anxiety Disorders, or Both?

The high burden of asthma appears to be related to poor asthma control. Although previous studies have reported associations between depressive disorders (DDs) and anxiety disorders (ADs) and worse asthma control and quality of life, the relative impact of these disorders on asthma control and quality of life has not been explored. This study evaluated the relative impact of having a DD and/or AD on asthma control and quality of life. Five hundred four consecutive adults with confirmed, physician-diagnosed asthma underwent a brief, structured psychiatric interview using the Primary Care Evaluation of Mental Disorders. Asthma control and asthma-related quality of life were assessed using the Asthma Control Questionnaire (ACQ) and the Asthma Quality of Life Questionnaire (AQLQ). All patients underwent standard spirometry. Thirty-one percent of patients (n = 157) met the diagnostic criteria for one or more psychiatric disorders (8% had DD only, 12% had AD only, and 11% had both). Analyses revealed independent effects for DDs on total ACQ scores (p < 0.01), and for DDs and ADs on total AQLQ scores and all four AQLQ subscales (p < 0.05). There were no interaction effects. Results suggest that DDs and ADs are associated with worse asthma-related quality of life, but only DDs are associated with worse asthma control. Interestingly, having both a DD and an AD did not confer additional risk for worse asthma control or quality of life. Physicians may want to consider the differential impact of negative mood states when assessing levels of asthma control and quality of life.

Combination therapy with a long-acting beta-agonist and a leukotriene antagonist in moderate asthma.

Long-acting beta-agonists (LABAs) and inhaled corticosteroids administered together appear to be complementary in terms of effects on asthma control. The elements of asthma control achieved by LABAs (improved lung function) and leukotriene receptor antagonists (LTRAs; protection against exacerbations) may be complementary as well. We sought to determine whether the combination of the LTRA montelukast and the LABA salmeterol could provide an effective therapeutic strategy for asthma. In a randomized, placebo-controlled, crossover study of 192 subjects with moderate asthma, we compared the clinical efficacy of regular treatment over 14 weeks with the combination of montelukast and salmeterol to that with the combination of beclomethasone and salmeterol in moderate asthma. The primary efficacy outcome was time to treatment failure. Three months after the randomization of the last subject, the Data and Safety Monitoring Board determined that the primary research question had been answered and terminated the trial. The combination of montelukast and salmeterol was inferior to the combination of beclomethasone and salmeterol as judged by protection against asthma treatment failures (p = 0.0008), lung function (26 L/min difference in a.m. peak expiratory flow rate, p = 0.011), asthma control score (0.22 difference in Asthma Control Questionnaire score, p = 0.038), and markers of inflammation and airway reactivity. Patients with moderate asthma similar to those we studied should not substitute the combination of an LTRA and an LABA for the combination of inhaled corticosteroid and an LABA.

Asthma Control following Initial Inhaled Corticosteroid Monotherapy in Mild to Moderate Asthma: A 4- to 8-Week Observational Study

Background: There is an increasing trend for the use of combination therapy of inhaled corticosteroids (ICS) and long-acting β₂-agonists as initial treatment for asthma. Objective: To assess the efficacy of initial monotherapy with ICS for achieving asthma control in steroid-naive mild to moderate asthmatics. Method: During an observational survey, steroid-naive patients received ICS in a dosage of 400–2,000 µg/day. After 4–8 weeks’ treatment, achievement of asthma control, defined according to the Global Initiative for Asthma (GINA) guidelines, was assessed and the Asthma Control Questionnaire (ACQ) was completed. Results: Among 537 selected patients, 21 were excluded because of severe asthma and 96 because of inadequate ICS daily dosage. Four hundred and twenty patients were analyzed, 396 (94%) of whom completed the survey. Mean ICS dosage, in equivalent beclomethasone, was 479 ± 62 µg/day for mild asthma (group A) and 1,115 ± 306 µg/day for moderate asthma (group B). Asthma control was achieved for 71 and 65% of the patients, mean ACQ score improved from 1.1 ± 0.6 to 0.5 ± 0.5 (p < 0.001) and from 2.0 ± 0.8 to 0.8 ± 0.7 (p < 0,001), and FEV₁ (% predicted) improved from 93 ± 9 to 96 ± 13 (p < 0.05) and from 85 ± 15 to 91 ± 15 (p < 0.001) for groups A and B, respectively. Conclusion: Asthma control can be achieved by ICS monotherapy for two thirds of steroid-naive patients with mild to moderate asthma. For these patients, we suggest that ICS alone could be started as initial therapy and that additional therapy should be considered after 4–8 weeks for patients who do not achieve control.

ABS74: Large variations in asthma control between UK general practices participating in the asthma control, concordance and tolerance (ACCT) Initiative

Despite availability of effective asthma, outcomes remain suboptimal. The issue of whether different practices achieve different results in terms of asthma control is currently unknown although much discussed. To evaluate variation in asthma control using patient reported outcomes and routine practice recorded data. Subjects and method: Practices participating in the ACCT initiative evaluated asthma control using the asthma control questionnaire (ACQ) and other patient reported outcomes for adults prescribed preventative asthma therapy. Routine anonymous data was also extracted from practice computer systems including current asthma treatment and recorded exacerbations. Practices with full data on more than 30 adult patients only were included in this analysis. Proportions with evidence of poor asthma control using practice reported oral steroid usage and high ACQ scores (>1.5) are reported [1]. Data from 36 practices met the study criteria. Median practice proportion of patients receiving at least one course of oral steroids was 14.2% (IQR 7.3% to 19.6%) and median proportion with an ACQ score of >1.5 was 36.5% (IQR 27.0% to 48.1%). The absolute range for oral steroids from 0% to 37.8% of patients and for high ACQ score from 12.3% to 78.3%. This data suggests vast variation exists between practices in terms of achieved asthma control as evidenced by oral steroid usage and high ACQ scores. Conflict of interest and funding The ACCT programme is supported by an unrestricted educational grant by Altana pharma.

ABS31: AKL1, a herbal treatment for asthma: a randomised controlled cross-over trial

Despite effective treatments, asthma outcomes remain suboptimal. Interest exists in herbal remedies. To evaluate AKL 1, an herbal mixture, in a randomised double blinded placebo controlled cross-over trial. 32 asthmatics (8 male, median (range) age 40.5 (22–73) yrs., median (range) FEV1% predicted 87.5 (33–126)%, median (range) daily ICS dose 800 (0–4000) mcg beclomethasone) completed a 36 week trial consisting of; four week baseline, twelve-week treatment with AKL or identical placebo, eight week washout and further twelve-week crossover treatment period. The change occurring over treatment periods was observed for lung function, Asthma Control Questionnaire (ACQ), Asthma Quality of Life Questionnaire (AQLQ), Leicester Cough Questionnaire (LCQ) scores. The mean (95% Confidence Interval) individual patient changes between active minus placebo periods was calculated. No significant differences in lung function (active–placebo) were found (FEV1: mean (95% CI) difference = 0.01 (−0.12 to 0.14)L, p = 0.9. PEF: −4.08 (−35.03 to 26.89) L/min, p= 0.8). Trends to clinical improvements favouring active treatment were however consistently seen in the patient-centred outcomes: ACQ mean difference (active-placebo)=−0.35 (−0.78 to 0.07, p = 0.10, AQLQ difference 0.42 (−0.08 to 0.93, p = 0.09), LCQ difference 0.49, (−0.18 to 1.16, p = 0.15). With a change in ACQ and AQLQ score of 0.5 signifying a clinically relevant changes in control or health status, on the ACQ, 28% were unchanged, 22% better on placebo and 50% better on AKL, and on the AQLQ 29% had no change, 29% were better on placebo and 42% better on AKL. Nine exacerbations occurred during placebo treatment and five whilst on AKL. No significant adverse events were noted. AKL1 treatment was well tolerated. Consistent trends to symptom and quality of life improvements were observed, although no improvements in lung function seen. Further studies. Conflict of interest and funding None. Funding: The study was funded by Bridgehead Technologies Ltd.

Asthma Control Test: Reliability, validity, and responsiveness in patients not previously followed by asthma specialists

The development of the Asthma Control Test (ACT), a short, simple, patient-based tool for identifying patients with poorly controlled asthma, was recently described in patients under the routine care of an asthma specialist. We sought to evaluate the reliability and validity of the ACT in a longitudinal study of asthmatic patients new to the care of an asthma specialist. Patients (n=313) completed the ACT and the Asthma Control Questionnaire (ACQ) at 2 physician visits (4-12 weeks apart). Pulmonary function was measured, and asthma specialists rated asthma control. Internal consistency reliability of the ACT was 0.85 (baseline) and 0.79 (follow-up). Test-retest reliability was 0.77. Criterion validity was demonstrated by significant correlations between baseline ACT scores and baseline specialists' ratings of asthma control (r=0.52, P<.001) and ACQ scores (r=-0.89, P<.001). Discriminant validity was demonstrated, with significant (P<.001) differences in mean ACT scores across patients differing in asthma control, pulmonary function, and treatment recommendation. Responsiveness of the ACT to changes in asthma control and lung function was demonstrated with significant correlations between changes in ACT scores and changes in specialists' ratings (r=0.44, P<.001), ACQ scores (r=-0.69, P<.001), and percent predicted FEV1 values (r=0.29, P<.001). An ACT score of 19 or less provided optimum balance of sensitivity (71%) and specificity (71%) for detecting uncontrolled asthma. The ACT is reliable, valid, and responsive to changes in asthma control over time in patients new to the care of asthma specialists. A cutoff score of 19 or less identifies patients with poorly controlled asthma. In a clinical setting the ACT should be a useful tool to help physicians identify patients with uncontrolled asthma and facilitate their ability to follow patients' progress with treatment.

Asthma Control and Exhaled Nitric Oxide in Real Life

RATIONALE: Exhaled nitric oxide (eNO), a marker of airway inflammation, has been shown to reflect asthma status in controlled studies. We examined this eNO ability in a real life context. METHODS: Asthma control questionnaire (ACQ) , eNO and FEV1 were evaluated on several occasions in 100 non-smoking patients suffering from asthma and treated according to the international guidelines. The ability of eNO and FEV1 to detect an improvement in asthma control as assessed by the ACQ score was evaluated using the Roc curve technique. RESULTS: We evaluated 199 pairs of consecutive visits. When considering patients treated with low doses of ICS (= 500 μg BDP equivalent), a 10 ppb decrease in eNO level displayed higher sensitivity and specificity to detect any change in ACQ score compared with a 6% increase in FEV1 (e.g. 75% and 79,3% as compared to 30.6% and 84,4% respectively for an ACQ score decreasing by 0.50 which is considered as a cut-off value for a significant change). In the high ICS dose group, eNO and FEV1 showed similar characteristics (sensitivity: 64.9% and 67.6%; specificity: 69,1% and 79.5% for a decrease of 0.5 in the ACQ score). At visit 1, FEV1 averaged 92.5 %pred in the low dose group versus 70.4%pred only in the high dose group. CONCLUSIONS: It is concluded that eNO is a useful marker of asthma control in the real life context, especially in patients treated by low doses of ICS, in whom asthma control is poorly reflected by a close to normal FEV1.

A Proton Pump Inhibitor, Lansoprazole, Ameliorates Asthma Symptoms in Asthmatic Patients with Gastroesophageal Reflux Disease

Aspiration of acid to the airway causes airway inflammation, and acid stress to the airway caused by gastroesophageal reflux disease (GERD) has been known as a potential mechanism of deteriorated asthma symptoms. However, the efficacy of the acid suppressive drugs, H(2)-receptor blockers (H(2) blocker) and proton pump inhibitors, on asthma symptoms and pulmonary functions remains controversial. We therefore designed the randomized prospective study to determine the efficacy of an H(2) blocker (roxatidine, 150 mg/day) and a proton pump inhibitor (lansoprazole, 30 mg/day) on asthma symptoms of 30 asthmatic patients with GERD. These patients were divided in the two groups (15 patients for each group) and treated with either roxatidine or lansoprazole. The diagnosis of GERD was established by the method of Los Angeles classification including mucosal minimum change of Grade M and questionnaire for the diagnosis of reflux disease (QUEST) score. The efficacy of acid suppressive drugs was evaluated by peak expiratory flow (PEF), asthma control questionnaire (ACQ) that evaluates the improvement of asthma symptoms, and forced expiratory volume in 1 second (FEV(1.0)). Lansoprazole, but not roxatidine, significantly improved PEF and ACQ scores (p < 0.05) with the improved QUEST scores. However, these acid suppressive drugs did not change the pulmonary function of FEV(1.0) in asthmatic patients. In conclusion, treatment with a proton pump inhibitor, lansoprazole, appears to be useful in improvement of asthma symptoms in asthmatic patients with GERD.

Are psychiatric disorders associated with worse asthma control and quality of life in asthma patients?

Achieving good asthma control has become the major goal of asthma treatment. Studies have reported a high rate of psychiatric disorders among asthma patients, though the impact of these disorders on asthma control and quality of life remains unexplored. This study evaluated the prevalence of psychiatric disorders in 406 adult asthma patients, and associations between psychiatric status, levels of asthma control, and asthma-related quality of life. Consecutive asthma patients presenting to the asthma clinic underwent a brief, structured psychiatric interview, completed the Asthma Control Questionnaire (ACQ) and Asthma Quality of Life Questionnaire (AQLQ), and reported the frequency of bronchodilator use in the past week. All patients underwent standard pulmonary function testing. A total of 34% (n=136) of patients had one or more psychiatric diagnosis, including major depression (15%), minor depression (5%), dysthymia (4%), panic disorder (12%), generalized anxiety disorder (5%), and social phobia (4%). Though there were no differences in pulmonary function, patients with versus without psychiatric disorders had worse ACQ and AQLQ scores and reported greater bronchodilator use, independent age, sex and asthma severity. Results suggest that psychiatric disorders are prevalent among asthmatics and are associated with worse asthma control and quality of life. Physicians should be aware of the potential risk of poorer asthma control and functional impairment in this population.

Improvement of asthma control with beclomethasone extrafine aerosol compared to fluticasone and budesonide

Qvar Autohaler efficacy on asthma control, assessed with E. Juniper asthma control questionnaire (ACQ), was compared with fluticasone and budesonide. An open randomized study, stratified (2:1) on the intake of long-acting beta2-mimetics (LAbeta2), was performed in patients with moderate to severe poorly controlled asthma (defined by at least one nocturnal discomfort in the last 5 days or a mean of 2 puffs of short-acting beta2-mimetics in the last 7 days or exercise dyspnea) despite treatment with beclomethasone < or = 1000 microg/day (or equivalent). 460 patients received Qvar Autohaler 800 microg/day (n = 149), fluticasone Diskus 1000 microg/day (n = 149) or budesonide Turbuhaler 1600 microg/day (n = 162) during 12 weeks. Asthma control improved in all groups, with no difference between groups. For patients treated with LAbeta2 (n = 286) a significantly greater improvement of the ACQ score was obtained with Qvar Autohaler versus fluticasone (1.0 +/- 1.0 vs. 0.6 +/- 0.9; P = 0.019), but not versus budesonide (0.9 +/- 0.9). Pulmonary function test improvements were similar in the 3 groups. The significant improvement in asthma control in patients receiving LAbeta2 suggests potential advantages for extrafine aerosols as part of anti-inflammatory treatment optimization.

Clinicians tend to overestimate improvements in asthma control: an unexpected observation

The original purpose of this study was to determine the Minimal Important Difference for the Asthma Control Questionnaire (ACQ) but an unexpected tendency of clinicians to overestimate improvements in asthma control thwarted the endeavour. We describe the observed clinician bias and discuss its implications for clinical practice and research. Ninety-four adults with inadequately controlled asthma received a full clinical consultation with one of nine asthma specialists. Medications were adjusted according to clinical needs. Four weeks later the same clinician estimated change in asthma control on a 15-point scale (-7 = a very great deal worse, 0 = no change, +7 a very great deal better). All patients completed the ACQ before each consultation but responses were not shown to the clinician. Clinicians consistently recorded that patients improved more than their change in ACQ scores suggested (p = 0.018). Clinicians should be aware of potential biases that may occur when estimating change in asthma control compared with measuring absolute status at each visit.

Childhood asthma: Exhaled markers of airway inflammation, asthma control score, and lung function tests

Exhaled markers of airway inflammation become increasingly important in the management of childhood asthma. The aims of the present study are: 1) to compare exhaled markers of inflammation (nitric oxide, carbon monoxide, and acidity of breath condensate) with conventional asthma measures (lung function tests and asthma control score) in childhood asthma; and 2) to investigate the detectability of albumin, CRP, IL-6, IL-8, TNF-alpha, sICAM-1, and sTNF-R75 in the exhaled breath condensate (EBC) of asthmatic children. Thirty-two children with mild to moderate persistent asthma and healthy controls aged 6-12 years were studied. We measured exhaled NO and CO, and subsequently EBC was collected. Inflammatory mediators in EBC were measured using an enzyme-linked immunosorbent assay. Respiratory symptoms and asthma control were assessed using the asthma control questionnaire (ACQ) of Juniper et al. (Eur Respir J 1999;14:902-907). Exhaled NO showed a significant correlation with exhaled CO (r = 0.59, P < 0.05) and FEV1 (r = -0.59, P < 0.05), but not with ACQ score (r = 0.48, P = 0.06). Exhaled CO was correlated with prebronchodilator FEV1 (r = -0.45, P < 0.05), but not with asthma control (r = 0.18, P = 0.35). Acidity of EBC was significantly lower in asthmatic children than in healthy controls (P < 0.05), but did not correlate with any of the conventional asthma measures. We were not able to demonstrate the presence of CRP, IL-6, IL-8, TNF-alpha, sICAM-1, and sTNF-R75 in EBC. Albumin was found in two EBC samples of asthmatic children. We conclude that exhaled NO had a better correlation with lung function parameters and asthma control than exhaled CO and acidity of EBC, in mild to moderate persistent childhood asthma. However, exhaled NO, CO, and deaerated pH of EBC did not differ between asthmatic children and controls, possibly because of a too homogeneous and well-controlled study population. To further evaluate the clinical utility of exhaled markers in monitoring childhood asthma, more studies are required on a wider range of asthma severity, and preferably with repeated measurements of markers and of asthma control.

Profiles of asthma control in 12,488 patients in 30 practices in East Anglia

Introduction:Since the introduction of the British Thoracic Society Guidelines for Asthma Management in 1993, updated in 1997 and 2003, there have been substantial shifts in asthma management in general practice with improved patient care, but many reports indicate that for some patients, it is still difficult to maintain good control and improve quality of life. The ELEVATE study investigates asthma control and quality of life for adults in practices in East Anglia.Methods:Searches of computerised records of all active registered adult (age 16-80 years) patients at 30 practices participating in the ELEVATE study were performed using the search and report system in each practice's software. Patients who had prescriptions for inhaled salbutamol or terbutaline and who did not have prescriptions for Ipratropium containing products in the past 2 years received a screening questionnaire by post.The Asthma Control Questionnaire (ACQ) and Mini-Asthma Quality of Life Questionnaire (MiniAQLQ) were sent by the practices to each patient with a stamped return envelope. Cut-off points of scores =1 for the ACQ (0=well controlled, 6=extremely poor control) and =6 for the MiniAQLQ (7=no impairment, 1= severe impairment) were set as markers of inadequate asthma control and asthma related quality of life respectively.In 12 of the practices a further search was made of the registry to identify patients with a prescription or refill issue for inhaled cortico-steroids (ICS) in the past 4 months. This was used to categorise the patients from the first search into those most likely to be at step 1, and those likely to be at step 2 or higher (“2+”).Results:12488 patients were identified and sent questionnaires. Return rates were 60.3% overall with a range among practices from 52 to 69%. The ACQ score was >1 for 49.4% of the 7094 valid responses. The MiniAQLQ score was <6 for 56.6% of the 6751 valid responses. Cases with a combination of both an ACQ score=1 and MiniAQLQ score =6 were 43.7% of the 6574 valid casesFor the 6488 patients categorised as likely being either step 1 (3873) or step 2+ (2615), the ACQ score was =1 for 59.2 and 61.7% respectively of the 2132 step 1 and 1683 step 2+ valid responses. The MiniAQLQ score was =6 for 49.9 and 66.8% respectively of the 2040 step 1 and 1628 step 2+ valid responses.Conclusion:Examination of indicators of asthma control and quality of life among adult patients in general practice settings show a substantial level of inadequate asthma control and impaired quality of life. Further work to characterise the factors which influence these problems is needed.