GINA missing several co-morbidities strongly linked with asthma


20 Mar 2023

Several co-morbidities strongly linked with asthma are missing from GINA guidelines on the management of the disease and should be included in future recommendations, a group of researchers say.

The finding is based on results of the first-ever meta-analysis to rank the association between co-morbidities and asthma against prevalence in the non-asthma population.

The analysis, based on a total of 5,493,776 subjects, provides real-world evidence that allergic conjunctivitis (OR 2.63), allergic rhinitis (OR 4.24), bronchiectasis (OR 4.89), hypertensive cardiomyopathy (OR 4.24) and nasal congestion (OR 3.30) are strongly linked with asthma, while COPD (OR 6.23) and other chronic respiratory diseases (OR 12.85) are very strongly associated, the researchers said.

For severe asthma, the investigators uncovered a strong association for panic attacks (OR 3.16), phobia (OR 3.56), bipolar disorders (OR 6.16) and hypertension (OR 3.35), and a very strong association for allergic rhinitis (OR 11.71), COPD (OR 19.27) and obesity (OR 4.06).

“The clinical assessment of those co-morbidities more strongly associated with asthma is crucial to achieve better asthma control and promote a change towards a patient-centred asthma management”, the authors stressed in their paper published in the European Respiratory Journal..

Indeed, the 2022 Global Initiative for Asthma (GINA) document emphasises the importance of actively managing co-morbid conditions because of the increased risk for reduced symptom control, poor quality of life, medicine interactions and increased healthcare utilisation.

However,  “paradoxically, the current GINA recommendations report only a few co-morbidities to be managed in asthmatic patients, namely obesity, GORD, anxiety and depression, food allergy and anaphylaxis, rhinitis, sinusitis and nasal polyps,” the authors noted.

“Evidently, several co-morbidities strongly to very strongly associated with asthma and severe asthma were missed in the section “Managing asthma with multimorbidity” of the GINA document, such as relevant co-morbidities in the domains of respiratory disorders (bronchiectasis), cardiovascular disorders (i.e. hypertension, hypertensive cardiomyopathy) and psychiatric and neuronal disorders (i.e. bipolar disorder, phobia, panic attack),” they said.

Therefore, “perhaps future recommendations for asthma management should include these disorders as co-morbidities to be managed in asthma.”

The analyses does have several limitations that need to taken into consideration, including “a substantial level” of heterogeneity across the studies included, including in the assessment of co-morbid disorders, and susceptibility for bias, the researchers conceded.

Need for personalised asthma management

However, they concluded that the findings highlight several co-morbidities strongly and very strongly linked with asthma and severe asthma, and therefore a need “to implement individualised strategies for asthma management that look beyond asthma”.

“This quantitative synthesis is a first step to help clinicians to better place each asthmatic patient in the context of their own co-morbidities according to disease severity. This is of interest because we have demonstrated that even non-severe patients may have a galaxy of concomitant disorders to be managed along with asthma,” they said.

“Correct diagnosis of these co-morbidities is pivotal to optimise asthma management by a multidimensional approach and to assess whether poor symptom control is related to uncontrolled asthma or to uncontrolled underlying co-morbidities.

“In turn, multidimensional assessment enables the detection of treatable traits, representing an effective approach for addressing the complexity of asthma”.

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