Respiratory experts urge rethink of 'outdated' asthma categorisation

September 12, 2017 by Ryan O'hare, Imperial College London
Credit: Imperial College London

A group of respiratory medicine experts have called for an overhaul of how asthma and other airways diseases are categorised and treated.

The team, which includes researchers from the University of Oxford and Imperial College London, says the current approach is outdated and does not reflect advances in treating these conditions.

Outlining their views in a specially commissioned article in The Lancet, the 23 international experts – co-chaired by University of Oxford Professor of Respiratory Medicine Ian Pavord, and Andy Bush, Professor of Paediatric Respirology at Imperial –  say that progress in treating asthma has slowed in the past 10 years despite increased spending on treatments, and has not matched that enjoyed in other medical fields.

"We believe that the most important cause of this stagnation is a continued reliance on outdated and unhelpful labels, treatment and research frameworks, and monitoring strategies, which have reached the stage of unchallenged veneration and have subsequently stifled new thinking," the experts in the Lancet Commission say.

Asthma is responsible for considerable global morbidity and health-care costs. A study by Asthma UK last year found that asthma costs the UK health service at least £1.1 billion each year, and that more than 270 people are admitted to hospital each day because of asthma attacks.

Slow progress

Professor Pavord, who leads the Respiratory Theme of the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), said: "Despite considerable progress being made against key outcomes such as mortality and hospital admissions in the 1990s and early 2000s, we've seen far too little progress in the past 10 years, despite escalating treatment costs and the availability of highly effective treatments."

"This Commission has sought to identify entrenched areas of asthma management and treatment in which progress has stalled, and to challenge current principles. It's a call to action for all clinicians involved in this field."

Writing in The Lancet, the authors argue that the physiology-based classification system for airways diseases is obsolete because it provides a limited view of the distinct causes of morbidity and mortality in patients with asthma.

Instead, they believe airways diseases should be deconstructed into traits that can be measured and, in some cases, modified.

A new approach

Looking at how this new approach can be made a reality in all healthcare settings, the commission calls for a fundamental rethink of the current guidelines, with greater emphasis on traits that can be measured and treated, and less emphasis on arbitrary disease labels.

This means that inhaled corticosteroids – the standard for controlling – would be used in a more targeted and efficient way, based on biomarkers, and should not be escalated unless the biomarker profile suggests treatment will be successful.

In addition, they call for a rethink around how asthma attacks are treated, arguing that should be considered as a prompt for "thorough re-evaluation of asthma management in the patient".

Finally, the respiratory experts call for an ambitious "revolution in thinking about asthma that is generalisable to all airways diseases". This would lead to the delivery of better and more precise care to each patient, separating airways diseases into component parts and addressing each in turn, stratified by risk.

Commenting on the findings, Professor Bush said: "Challenging how we think about asthma and how the condition is classified will, we believe, lead to an important step change in the management of the disease. 

"We want patients to be asking 'what sort of asthma do I have?', just as a patient with red, painful joints will ask 'what sort of arthritis do I have?', because we believe asthma is a clinical description of symptoms, for which there are many different causes.

He added: "Ultimately, by looking at the components of airway disease in each individual, rather than being satisfied with the umbrella term 'asthma', we believe  will enable treatment to be personalised allowing patients  of all ages living with asthma to lead fuller, healthier lives."

Professor Pavord concluded: "This commission feels it is time for a new era in , where it is more about getting the right to the right – so, a precision medicine approach rather than the one-size-fits-all approach we've been doing up until now."

Explore further: Study compares treatment and outcomes in asthma patients in two countries

More information: Ian D Pavord et al. After asthma: redefining airways diseases, The Lancet (2017). DOI: 10.1016/S0140-6736(17)30879-6

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