The first impression counts for lung function: One year to make a difference in asthma prognosis
Authors: Helena Pite, Silvia Sanchez‐Garcia, Mário Morais‐Almeida
Journal: Allergy (2019)

Despite being one of the most frequent chronic diseases, asthma patients live in times of hope. The introduction of regular treatment with inhaled corticosteroids (ICS) was crucial, impacting and changing the lives of several hundred million asthmatics. Advances with new molecules, whether alone or in combination, coupled with developments in inhaler technology, and the advent of biologics raise the aspiration of achieving control and normalizing (as opposed to optimizing) lung function, for every asthma patient. As a chronic disease without definite cure, the need for long-term real-life studies is imperative to assess clinical practice outcomes.1 In the current highlighted study by Kauppinen et al, published in this issue of the journal, the authors endeavoured to investigate long-term treatment results in newly diagnosed asthma in adults.2 This study has the advantage of being a real-life 25 years-long prospective study that included only ICS-naïve asthmatics, who were systematically evaluated, including lung function, asthma control and health-related (HR) quality of life (QoL) at the outset. The authors report that the forced expiratory volume in one second expressed as percentage (FEV1%) of predicted value at the end of the first year predicted long-term lung function results, with no significant changes over the next 25 years. Despite good asthma control, clinical remission (defined as controlled asthma and no medication use in the last 12 months) was reached by a minority of patients and the general HR-QoL remained unchanged. One key message that could be translated into clinical practice is the importance of the first year of the ICS-based asthma treatment strategy. These steroid-naïve newly diagnosed adult asthmatics were treated with high-dose ICS, which was then decreased, according to the Finnish Asthma Programme. A peak expiratory flow-based guided self-management programme, where patients change the ICS doses as needed, was followed. The majority of patients reported that they used ICS continuously at 25 years, albeit at lower doses. Nearly one quarter of the patients stopped using their asthma medication and a minority used ICS periodically. Interestingly, patients with controlled asthma reported using less than half of the daily doses of ICS compared with those with partly or uncontrolled asthma. This may serve to strengthen the view that properly educated patients acquired the skills to evaluate their treatment needs and adjust the ICS dose accordingly. Furthermore, those patients who were not using ICS continuously showed better specific HR-QoL that even improved to normal mean values at 25 years, while continuous ICS users remained with impaired HR-QoL. A statistically significant improvement in FEV1% predicted was also seen only in those patients with no or periodical ICS use. Conflicting evidence regarding long-term FEV1%-predicted values in asthma patients has been published.3, 4 However, it is important to emphasize that the majority of patients (59%) had normal FEV1% predicted at baseline and remained with normal lung function at one and 25 years of follow-up. Those with impaired lung function at baseline (FEV1 < 80% predicted at baseline) who attained normal values at the end of the first year of treatment, maintained normal lung function at 25 years. Only a small minority of patients (<7%) had worsened their FEV1% predicted from normal to < 80%, but this was also evident during the first year. Others (17%) remained always with reduced FEV1% predicted throughout the study. Being younger (<30 years old) at baseline and having normal FEV1% after the first year predicted long-term normal FEV1% and the latter was also an independent predictor of the discontinuation of treatment. The evidence from this real-life study of ICS-based treatment should make us, physicians, think of 1. the critical importance of establishing control and normalising lung function during the first year of treatment, while 2. developing strategies to manage those patients who do not achieve control of symptoms or normalization of lung function by the end of one year, that clearly represent a group requiring specialist evaluation. Another important lesson to take from this long-term real-life study is that those patients whose condition deteriorated were all smokers or ex-smokers (different from other patients groups), and this was the only group where HR-QoL did not show any improvement. The ICS-based treatment strategy may not be adequate for every patient, namely for smokers/ex-smokers. Moreover, as the treatment during the first year achieved such relevance, this work shows the consequences in lung function if adequate asthma treatment is delayed.5 Finally, the importance of taking a holistic view of asthma patients is also highlighted. The association between asthma control, lung function and HR-QoL is not always straightforward, as is known, but has not been evaluated in such long-term basis. This study clearly shows that physicians need to address not only asthma symptoms and medication use but also lung function parameters and QoL regularly, as these reflect different dimensions of the disease that do not always correlate.6, 7 These differences may indeed reflect the discrepancy between physician and patient-reported outcomes. Patients reporting asthma control frequently have uncontrolled disease (according to the Global Initiative for Asthma (GINA) guidelines) or even low FEV1% values.8, 9 ‘Asthma control’ can have different meanings for patients and for physicians: for patients, it may simply mean that a person knows what to do if an asthma attack occurs, while this is substantially different from the definition used by the GINA guidelines-oriented physician. Therefore, the global question ‘Is your asthma well controlled’? is inadequate.7 The right, specific, clear and simple questions regarding each symptom, medication use and limitations need to be asked, in order to achieve concordant results. The study by Kauppinen et al brings valuable real-life evidence to suggest that the first year of ICS-based asthma treatment is crucial for long-term lung function prognosis and discontinuation of treatment. It also raises some of the most pressing current challenges in asthma care: the vast majority of patients did not achieve clinical and/or functional remission and continued with impaired QoL over the years. Thus, we should endeavour to evaluate each patient personally and holistically with the goal of attaining well-being. The authors have no conflicts of interest to declare in relation to this publication.