Worse Asthma Control Research Articles

Psychological Status in Uncontrolled Asthma Is not Related to Airway Hyperresponsiveness

Background. Airway hyperresponsiveness (AHR) is the characteristic functional abnormality of asthma, and previous studies have shown the potential for AHR to be influenced by psychological factors, yet the relationship between anxiety and/or depression and AHR remains unclear in patients with asthma. Objective. To explore the relationship between psychological status and AHR in asthma patients. Methods. In a cross-sectional study, 168 adult subjects were recruited with physician-diagnosed uncontrolled asthma and a positive result for AHR in methacholine (Mch) challenge test. Psychological status, asthma control, and asthma quality of life were assessed using Zung self-rating anxiety/depression scale, asthma control test (ACT), and asthma quality of life questionnaire (AQLQ), respectively. AHR severity was evaluated and quantified by the provocative concentration of Mch, which evoked a given decrease of 20% in FEV1. Results. A total of 70.23% of recruited patients (n = 118) met the diagnostic criteria for anxiety and/or depression. There was a trend between negative psychological status and AHR in asthma patients that did not reach statistical significance, but no independent effects of negative mood states (anxiety, depression, or both) on AHR were established. Further, analyses revealed that only anxiety is associated with worse asthma control (p = 0.029), and a significant interaction effect of depression and anxiety accounted for lower asthma-related quality-of-life scores (p < 0.001). Conclusions. AHR and psychological status are loosely related to each other even if in uncontrolled asthma.

The Relationship between Perceived Stress and Morbidity among Adult Inner-City Asthmatics

Background. Psychological stress has been linked in some studies to asthma prevalence and outcomes in children. The authors sought to evaluate the relationship between perceived stress and morbidity among inner-city adults with asthma. Methods. The authors interviewed a prospective cohort of 326 moderate-to-severe asthmatics receiving care at two large, urban, hospital-based general medicine clinics in New York City and New Jersey. Psychological stress was assessed at baseline using the Perceived Stress Scale (PSS), a validated 4-item instrument. Outcomes included the Asthma Control Questionnaire (ACQ), the Asthma Quality of Life Questionnaire (AQLQ), and the Medication Adherence Reporting Scale (MARS) measured at baseline, 1, 3, and 12 months of enrollment. Results. Higher perceived stress was significantly correlated with worse asthma control (ACQ scores; r = .30 to .37, p < .0001), poor quality of life (AQLQ scores; r = −.49 to − .35, p < .0001), and decreased medication adherence (MARS scores; r = −.25 to −.15, p < .028) at baseline and across the follow-up interviews. In multivariate analyses, increased stress remained a significant predictor of worse ACQ (p < .0001), AQLQ scores (p < .0001), and MARS (p < .0001) after adjusting for age, sex, income, number of years with asthma, and comorbidities. Conclusions. Among inner-city asthmatics, higher perceived stress is strongly associated with increased asthma morbidity across a 1-year follow-up. Further research is needed to identify mechanisms mediating the association between stress and asthma morbidity in adults.

Environmental tobacco smoke and childhood asthma

= Abstract = In recent years, environmental tobacco smoke (ETS) has become an important worldwide public health issue. Children are particularly vulnerable to ETS because they are still developing. ETS exposure causes a wide range of adverse health ef- fects on childhood asthma. There is convincing evidence that ETS exposure is causally associated with an increased pre- valence of asthma, increased severity of asthma and worsening asthma control in children who already have the disease, even though a causal relationship with asthma onset is not yet established for asthma incidence. Mechanisms underlying these adverse effects of ETS are not clearly elucidated but e studies on this issue suggest that genetic susceptibility, im- paired lung function, and augmented airway inflammation and remodeling may be involved. Children with asthma are just as likely to be exposed to ETS as children in general and there is no risk-free level of exposure. Therefore, providing a smoke-free environment may be of particular importance to the asthmatic children exposed to ETS who have adverse asthma outcomes, as well as to children with genetic susceptibility who are at increased risk of developing asthma upon exposure to ETS in early childhood. (Korean J Pediatr 2010;53:121-128)

Individual-level socioeconomic status is associated with worse asthma morbidity in patients with asthma.

BackgroundLow socioeconomic status (SES) has been linked to higher morbidity in patients with chronic diseases, but may be particularly relevant to asthma, as asthmatics of lower SES may have higher exposures to indoor (e.g., cockroaches, tobacco smoke) and outdoor (e.g., urban pollution) allergens, thus increasing risk for exacerbations.MethodsThis study assessed associations between adult SES (measured according to educational level) and asthma morbidity, including asthma control; asthma-related emergency health service use; asthma self-efficacy, and asthma-related quality of life, in a Canadian cohort of 781 adult asthmatics. All patients underwent a sociodemographic and medical history interview and pulmonary function testing on the day of their asthma clinic visit, and completed a battery of questionnaires (Asthma Control Questionnaire, Asthma Quality of Life Questionnaire, and Asthma Self-Efficacy Scale). General Linear Models assessed associations between SES and each morbidity measure.ResultsLower SES was associated with worse asthma control (F = 11.63, p < .001), greater emergency health service use (F = 5.09, p = .024), and worse asthma self-efficacy (F = 12.04, p < .01), independent of covariates. Logistic regression analyses revealed that patients with <12 years of education were 55% more likely to report an asthma-related emergency health service visit in the last year (OR = 1.55, 95%CI = 1.05-2.27). Lower SES was not related to worse asthma-related quality of life.ConclusionsResults suggest that lower SES (measured according to education level), is associated with several indices of worse asthma morbidity, particularly worse asthma control, in adult asthmatics independent of disease severity. Results are consistent with previous studies linking lower SES to worse asthma in children, and add asthma to the list of chronic diseases affected by individual-level SES.

THE RELATIONSHIP BETWEEN SMOKING AND BODY MASS INDEX AND LEVEL OF PRESCRIBED INHALED CORTICOSTEROIDS IN ASTHMA PATIENTS

PURPOSE: Smoking and obesity are modifiable risk factors that have been associated with a higher prevalence of asthma, more severe asthma, and worse asthma control. These two risk factors have also been found to be associated with a reduction in the effectiveness of inhaled corticosteroids (ICS), potentially leading higher prescribed doses. To our knowledge, no study has assessed the joint impact of smoking and obesity on ICS dose The present study assessed the interaction of smoking and obesity on prescribed ICS dose in adult asthmatics.

Obstructive Sleep Apnea Syndrome and Asthma: What Are the Links?

Recent data suggest that obstructive sleep apnea syndrome (OSAS) is an independent risk factor for asthma exacerbations. Neuromechanical reflex bronchoconstriction, gastroesophageal reflux, inflammation (local and systemic), and the indirect effect on dyspnea of OSAS-induced cardiac dysfunction have been suggested as mechanisms that lead to worsening asthma control in patients with concomitant OSAS. Vascular endothelial growth factor-induced airway angiogenesis, leptin-related airway changes, and OSAS-induced weight gain also may play a common mechanistic role linking both disorders. Several studies have confirmed that asthmatic patients are more prone to develop OSAS symptoms than are members of the general population. The common asthmatic features that promote OSAS symptoms are nasal obstruction, a decrease in pharyngeal cross sectional area, and an increase in upper airway collapsibility. Clarifying the nature of the relationship between OSAS and asthma is a critical area with important therapeutic implications.

Effect of low-dose theophylline plus beclometasone on lung function in smokers with asthma: a pilot study

Smoking is common in asthma and is associated with worse asthma control and a reduced therapeutic response to corticosteroids. The present authors hypothesised that treating smokers with asthma with low-dose theophylline added to inhaled corticosteroids would enhance steroid sensitivity and thereby improve lung function and symptoms. In a double-blind, parallel group exploratory trial, 68 asthmatic smokers were randomised to one of three treatments for 4 weeks: inhaled beclometasone (200 microg day(-1)), theophylline (400 mg day(-1)) or both treatments combined. Outcome measures included change in lung function and Asthma Control Questionnaire (ACQ) scores. At 4 weeks, theophylline added to inhaled beclometasone produced an improvement in peak expiratory flow (39.9 L min(-1), 95% confidence intervals (CI) 10.9-68.8) and ACQ score (-0.47, 95% CI -0.91- -0.04) and a borderline improvement in pre-bronchodilator forced expiratory volume in one second (mean difference 165 mL, 95% CI -13-342) relative to inhaled corticosteroid alone. Theophylline alone improved the ACQ score (-0.55, 95% CI -0.99- -0.11), but not lung function. In the present pilot study, the combination of low-dose theophylline and inhaled beclometasone produced improvements in both lung function and symptoms in a group of smokers with asthma. Larger trials are required to extend and confirm these findings.

Pediatric Dyspnea Scale for use in hospitalized patients with asthma

Asthma is a leading cause of pediatric hospitalizations across the country, yet no clinical instrument exists that incorporates the child's perception of dyspnea in determining discharge readiness. We sought to develop the Pediatric Dyspnea Scale (PDS) to support discharge decision making in hospitalized asthmatic patients and to compare the performance of the PDS with traditional markers of asthma control in predicting outcomes after discharge. Asthmatic children aged 6 to 18 years hospitalized for an exacerbation were included in the study. The PDS score, demographics, asthma severity, spirometric results, peak expiratory flow rate, and fraction of exhaled nitric oxide were assessed at the time of discharge. A telephone call 14 days after discharge determined relapse, activity limitation, asthma control, and asthma-related quality-of-life outcomes. Eighty-nine patients were enrolled, of whom 70 completed the telephone follow-up. Eight patients had a relapse, and 29 complained of limited activity. A PDS score of greater than 2 on the 7-point scale was a significant predictor of these poor outcomes, with each additional point of the PDS doubling the risk. A higher score on the PDS also correlated with worse asthma control and poor asthma-specific quality of life. The PDS performed better than FEV(1), peak expiratory flow rate, or fraction of exhaled nitric oxide in predicting the outcomes of interest. The PDS, which is easy to use in children as young as 6 years of age, might be able to predict adverse outcomes after hospitalization for an asthma exacerbation and should be used as a tool to help guide inpatient discharge decisions.

Inhaled corticosteroids for asthma: impact of practice level device switching on asthma control

BackgroundAs more inhaled corticosteroid (ICS) devices become available, there may be pressure for health-care providers to switch patients with asthma to cheaper inhaler devices. Our objective was to evaluate impact on asthma control of inhaler device switching without an accompanying consultation in general practice.MethodsThis 2-year retrospective matched cohort study used the UK General Practice Research Database to identify practices where ICS devices were changed without a consultation for ≥5 patients within 3 months. Patients 6–65 years of age from these practices whose ICS device was switched were individually matched with patients using the same ICS device who were not switched. Asthma control over 12 months after the switch was assessed using a composite measure including short-acting β-agonist and oral corticosteroid use, hospitalizations, and subsequent changes to therapy.ResultsA total of 824 patients from 55 practices had a device switch and could be matched. Over half (53%) of device switches were from dry powder to metered-dose inhalers. Fewer patients in switched than matched cohort experienced successful treatment based on the composite measure (20% vs. 34%) and more experienced unsuccessful treatment (51% vs. 38%). After adjusting for possible baseline confounding factors, the odds ratio for treatment success in the switched cohort compared with controls was 0.29 (95% confidence interval [CI], 0.19 to 0.44; p < 0.001) and for unsuccessful treatment was 1.92 (95% CI, 1.47 to 2.56; p < 0.001).ConclusionSwitching ICS devices without a consultation was associated with worsened asthma control and is therefore inadvisable.

Rhinosinusitis and asthma: the missing link

Disease of the nose and sinuses is the most common comorbidity associated with asthma. Rhinitis, sinusitis and asthma may represent part of one disease process with manifestations at different sites. The purpose of this review is to highlight significant new findings on the epidemiological and pathophysiological link between the upper and lower airway. Finally, we will review recent data assessing the impact of treating sinonasal disease on both the development of asthma and asthma control. Studies illustrate that rhinitis is very common in asthma, and associated with worse asthma control. Rhinitis typically precedes the development of asthma. Even in patients with rhinitis without asthma, there is evidence of subclinical change in the lower airways as measured by physiological changes and the presence of inflammatory mediators. There is much interest on the impact of treating allergic rhinitis on the development of asthma. Rhinitis, sinusitis and asthma are likely part of one disease process. Treatment of established rhinitis may have some impact on measures of airway obstruction, but an effect on lower airway inflammation is yet to be established. Prospective studies are required to determine whether treatment of rhinitis can prevent the development of asthma, or decrease airway inflammation to improve asthma outcomes in those with established asthma or both.

The Impact of Alexithymia on Asthma Patient Management and Communication with Health Care Providers: A Pilot Study

Background and objectives. Alexithymia is a personality trait associated with difficulty identifying and verbalizing feelings. It has been associated with poorly controlled asthma and near-fatal asthma. The primary objectives were to () determine the prevalence of alexithymia in a group of moderate to severe asthmatics who attended an Outpatient Clinic; and () investigate the relationship between alexithymia and asthma control, management, and communication. Methods. Twenty-five moderate to severe asthma patients were recruited from the Royal Adelaide Hospital Outpatient Respiratory Clinic. Participants were either mailed the questionnaire pack or completed it after a clinic appointment. Existing validated questionnaires were used to collect data. The primary outcome measures were alexithymia, asthma control, adherence to medication; patient satisfaction with communication with health care providers and health-related quality of life. Data were analyzed using Pearson correlations, linear regression and analysis of variance (ANOVA) in SPSS. A p value ≤ 0.05 was required for statistical significance. Results. A total of 11 male (44%) and 14 female (56%) patients with moderate to severe persistent asthma (mean age 44 years ± 11) participated. Alexithymia scores ranged between 23.0-76.0 ( = 48.3, SD = 13.2); 12% of participants reported high alexithymia scores, 32% reported borderline alexithymia scores, and 56% reported low alexithymia scores. Alexithymia mean scores were not statistically different across sociodemographic variables. A higher alexithymia score was associated with worse asthma control score (r = 0.57, p < 0.01) (where higher asthma control scores indicate worse asthma control); poor adherence (p = 0.03), and worse quality of life (r = - 0.65, p < 0.01). Alexithymia score was not correlated with satisfaction with communication (r = − 0.27, p = 0.2).), or the number of hospitalizations for asthma (p = 0.25). Conclusions. This is the first study to investigate relationships between alexithymia, asthma control, asthma management and communication with health care professionals. The study reaffirms associations between alexithymia and asthma control, but a larger sample size is needed to determine the impact of alexithymia on self-management and provision of clinical care for asthma.

Predicting worsening asthma control following the common cold

The asthmatic response to the common cold is highly variable, and early characteristics that predict worsening of asthma control following a cold have not been identified. In this prospective multicentric cohort study of 413 adult subjects with asthma, the mini-Asthma Control Questionnaire (mini-ACQ) was used to quantify changes in asthma control and the Wisconsin Upper Respiratory Symptom Survey-21 (WURSS-21) to measure cold severity. Univariate and multivariable models were used to examine demographic, physiological, serological and cold-related characteristics for their relationship to changes in asthma control following a cold. Clinically significant worsening of asthma control was observed following a cold (mean+/-SD increase in mini-ACQ score of 0.69+/-0.93). Univariate analysis demonstrated that season, centre location, cold duration and cold severity measurements were all associated with a change in asthma control. Multivariable analysis of the covariates available within the first 2 days of cold onset revealed that the day 2 and cumulative sum of day 1 and 2 WURSS-21 scores were significant predictors of the subsequent changes in asthma control. In asthmatic subjects, cold severity within the first 2 days can be used to predict subsequent changes in asthma control. This information may help clinicians prevent deterioration in asthma control following a cold.

Original article: Frequency and impact of allergic rhinitis in asthma patients in everyday general medical practice: a French observational cross‐sectional study

Background: Allergic rhinitis (AR) and asthma are inflammatory conditions of the airways that often occur concomitantly. This observational, cross‐sectional, national study was undertaken to describe the frequency and severity of AR in asthmatic patients. The impact of AR on the quality of life and the therapeutic management of patients in everyday general medical practice were also assessed.Methods: From April to October 2005, 1906 French general practitioners (GP) participated in the study. Each physician had to fill out a questionnaire (including the Juniper Asthma Control Questionnaire and a Rhinitis Questionnaire) for up to 10 consecutive adult asthmatic patients. The first three patients with a confirmed diagnosis of AR (Allergic Rhinitis and its Impact on Asthma classification) were asked to complete the Juniper Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ).Results: A total of 14 703 patient questionnaires and 4335 auto‐questionnaires were analysed. Patients presented with intermittent (45%), mild (25%), moderate (25%) and severe (4%) persistent asthma. The frequency of AR in asthmatic patients was 55.2% (CI: 95%, 54.4–56.0%). Allergic rhinitis was mild for 54% and moderate/severe for 46% of patients. The frequency and severity of AR increased with the severity of asthma (P &lt; 0.001). Moreover, AR was associated with worse asthma control whatever be the severity of asthma (P &lt; 0.001). The global RQLQ scores of AR patients worsened with the severity of asthma (P &lt; 0.001). Prescription of anti‐asthma treatments significantly increased with the severity of AR. The majority of AR patients (81%) were treated for rhinitis.Conclusions: This survey suggested that AR was associated with more severe asthma, more difficulty to control asthma and substantial impairment of quality of life. The high frequency of AR in asthma patients requires that these conditions should be recognized and managed by GP.

Effects of LABA Discontinuation in Poorly Controlled Asthmatics with the 16 Arg-Arg Genotype of the Adrenergic β2 Receptor Gene (ADRB2)

Recent studies have suggested that regular use of a LABA worsens asthma control in patients with ADRB2 16Arg-Arg genotype. Whether discontinuation of LABA in such patients previously maintained on a LABA/ICS formulation improves their lung function is unclear. Nine pediatric patients (3 Caucasian and 6 African American) with poorly controlled asthma, the 16 Arg-Arg ADRB2 genotype and use of combination LABA/ICS were studied. LABA therapy was discontinued and ICS continued. Primary Outcomes were changes in lung function parameters, including FEV1 and FEV1/FVC over the next 18 months. Improvement was defined as a ≥5% increase in FEV1 % predicted over baseline. In addition, a subgroup analysis of lung function values at 0-6 month and 6-12 month after stopping LABA was subjected to one-way ANOVA analysis. 6 of 9 subjects demonstrated a sustained improvement in FEV1% predicted over an 18 month time period, and none of the subjects worsened. Further analysis did not reveal a significant change in % predicted FEV1/FVC or FEV1 when compared to baseline values in the 0-6 month and 6-12 month subgroups (p-value 0.90 and 0.37, respectively), probably due to the small sample size. Overall, there was no significant change in lung function after discontinuation of LABA over time in this open label study of patients with the 16Arg/Arg ADRB2 genotype, although most patients demonstrated a small increase in lung function. Whether clinical outcomes were altered is the subject of ongoing investigation.

Clinical characteristics and treatment of acute asthma exacerbations during pregnancy

To study the clinical characteristics of acute asthma during pregnancy, focusing on management of pregnant women presenting with an acute exacerbation. A prospective observational study was conducted in 30 cases of acute exacerbations during pregnancy. The prognosis of 25 patients with mild or moderate asthma was good for both mother and fetus; none had severe complications. Among 5 women who had severe exacerbations, there were 4 pulmonary co-infections, 1 with respiratory acidosis, 1 with respiratory acidosis plus metabolic alkalosis, and 4 with fetal growth-restriction. This study highlights that pregnancy can worsen asthma control in some women. Effective management and prevention of asthma exacerbations during pregnancy is key to ensuring the safety of the mother and the fetus.

Does Current Asthma Control Predict Future Health Care Use Among Black Preschool-aged Inner-City Children?

Factors predictive of future asthma must be identified among young inner-city children, who suffer disproportionately from asthma. We investigated whether current asthma control predicts future asthma-related health care use among inner-city preschool-aged children with asthma. A total of 150 inner-city preschool-aged children with asthma were followed prospectively for 6 months. At baseline, symptom frequency and reliever-medication use were assessed to classify children into National Asthma Education and Prevention Program-derived control categories. Long-term controller-medication use was also assessed, as well as asthma-related health care use at baseline and at 3 and 6 months. The mean age was 4.4 years, 92% were black, and 39% reported long-term controller use. At baseline, 37% were classified as having mild-intermittent, 17% had mild-persistent, 21% had moderate-persistent, and 25% had severe-persistent asthma control. Significant changes in asthma control were observed over time, including 46% of children originally categorized with mild-intermittent asthma who had worsened asthma control by 3 months. Asthma control significantly predicted future health care use 3 months later but not 6 months later. Multivariate analyses showed that, once control status was known, reported use of long-term controller medication added little additional predictive value. Among inner-city preschool-aged children, significant fluctuations in asthma control occur as early as 3 months after assessment. Poor control but not long-term controller-medication use is an independent predictor of future asthma-related health care use at 3 months but is not significantly predictive of 6-month outcomes. Therefore, clinicians caring for inner-city children with asthma should consider reassessing asthma control at least every 3 months to identify those at highest future risk and to provide early interventions.

The role of environmental tobacco smoke in the origins and progression of asthma

Exposure to environmental tobacco smoke (ETS) is a major source of indoor air pollution and causes adverse effects on the respiratory health of individuals with asthma. At least one third of children and adults with asthma are exposed to ETS on a regular basis. There is convincing evidence for a causal relationship between exposure to ETS and development of asthma in children and in nonsmoking adults. Exposure to ETS also worsens asthma control in children and nonsmoking adults who have established asthma. The mechanism by which ETS causes these harmful effects is not established but may involve genetic predisposition, impairment of lung development, and altered lung inflammatory responses. Workplace smoking restrictions and reduced smoking in the home may lower the prevalence of asthma, improve asthma control, and reduce the use of medical services in both children and adults who are exposed to ETS.

Lack of association between indoor allergen sensitization and asthma morbidity in inner-city adults

Sensitivity and exposure to indoor allergens is associated with increased asthma morbidity in inner-city children. However, it is unknown whether sensitization is associated with worse asthma in adults. To evaluate the relationship between sensitization and asthma morbidity in urban adults. We prospectively studied 245 adults with persistent asthma recruited from an inner-city clinic. Sensitization to indoor allergens was evaluated by specific IgE antibodies measured at enrollment. Data on asthma control, asthma-related emergency department visits, hospitalizations, and oral steroid use were collected at baseline and at 1-month and 3-month follow-up contacts. Univariate, stratified, and multiple regression analyses were used to compare asthma morbidity in sensitized and nonsensitized patients after controlling for self-reported exposure and other potential confounders. The study cohort consisted predominantly of low income, minority patients with high rates of resource utilization. The prevalences of sensitization to cockroach, dust mite, cat, mold, and mouse were 60%, 43%, 41%, 21%, and 14%. On univariate analyses, patients sensitized to each allergen did not have worse asthma control or higher resource utilization compared with nonsensitized individuals. Stratified and multivariate analyses also showed no association between sensitization and several measures of asthma morbidity even after controlling for self-reported exposure to indoor allergens and other potential confounders. Sensitization to indoor allergens does not appear to be associated with increased asthma morbidity in inner-city adults. These findings suggest that efforts to improve asthma control among urban populations should focus on other modifiable risk factors for morbidity.

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

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

Treatment and Outcomes in Patients with Asthma and Allergic Rhinitis in the United Kingdom

Background: Since allergic rhinitis in asthma patients is associated with worse asthma control, the treatment of the comorbid condition may improve outcomes. Methods: A 1-year retrospective study using the UK Mediplus® database (2001–2004) included asthmatic patients aged 15–55 with allergic rhinitis. Patients starting therapy based on the Global Initiative for Asthma guidelines, defined as an increase in inhaled corticosteroids (high-dose inhaled corticosteroids, hdICS), or the addition of montelukast (ICS+MON) or long-acting β-agonists (ICS+LABA) to ICS, were studied. Univariable and multiple logistic regressions evaluated asthma-related outcomes. Results: Among 2,596 asthma and allergic rhinitis patients, 83.2% initiated ICS+LABA, 12.1% hdICS and 4.7% ICS+MON. The mean age was 34 years and 60% were female. ICS+MON patients had more moderate-severe asthma (p = 0.04). Approximately 84% of the ICS+LABA patients experienced an asthma control failure compared to 50% in the other groups (p < 0.0001). The proportions of patients requiring treatment change were 73.8, 22 and 27.3% in the ICS+LABA, hdICS and ICS+MON groups, respectively (p = 0.001). Asthma-related resource use was similar among all groups. The ICS+MON group received fewer mean prescriptions for oral corticosteroids (p = 0.024) than the other groups (p = 0.026). Conclusions: In asthma and allergic rhinitis, treatment with ICS+MON or hdICS was associated with lower rates of asthma control failure and fewer treatment changes than the ICS+LABA group. MON users also required fewer oral corticosteroids.