Becky McCall

December 07, 2010

December 7, 2010 (Dubai, United Arab Emirates) — The World Allergy Organization (WAO) 2010 International Scientific Conference centers on the theme of asthma and its comorbidities. Introducing the issue to delegates gathered at the annual conference, Richard Lockey, MD, president of the WAO and director of the Division of Allergy and Immunology at James A. Haley Veterans' Hospital in Tampa, Florida, emphasized the importance of managing both patients' comorbidities and their asthma.

"I don't believe you can take care of an asthmatic without addressing their comorbid conditions, and there are many of them. In my opinion, diagnosis and treatment guidelines should also address these comorbid conditions," Dr. Lockey said.

Comorbidities include rhinosinusitis, gastroesophageal reflux disease (GERD), vocal cord dysfunction, obesity, osteopenia and osteoporosis, psychological problems, sleep apnea, pregnancy, chronic obstructive pulmonary disease (COPD) with asthma, smoking cessation, infection, bronchiectasis, and cystic fibrosis.

"When I start with a patient, it's the history, the history, the history — not the test, the test, the test. History and thinking about comorbid conditions is essential in patients with asthma," Dr. Lockey stressed in his presidential keynote address.

He explained that most comorbidities have common risk factors. For example, he pointed out that GERD runs in families. After investigating the family history of disease, Dr. Lockey said he conducts a complete physical examination, psychological profile, sleep profile, and weight, smoking, drinking, diet, and activity level assessment.

"Do they need a [dual energy X-ray absorptiometry] bone scan, rhinoscopy, spirometry, and are their vaccinations up to date — flu, Pneumovax, Tdap, and pertussis? Pertussis is increasing in incidence in various parts of the world again. There are 5000 to 7000 cases each year in the United States," he said.

He supported his argument for increased attention to comorbid conditions by presenting data from a 2005 study (Eur Respir J. 2005;26:812-818), which investigated risk factors for difficult-to-treat asthma. Of 136 patients, 39 had 3 exacerbations per year and 29 had 1 exacerbation per year.

Conditions associated with 3 exacerbations were severe sinus disease (odds ratio [OR], 3.7), GERD (OR, 4.9), upper respiratory infections (OR, 6.9), psychological dysfunction (OR, 10.8), and obstructive sleep apnea (OR, 3.4). All patients with frequent exacerbations had 1 of these 5 comorbidities; 52% had 3 of the 5.

An introduction to a range of comorbidities was given. Dr. Lockey described his approach to teaching residents about rhinosinusitis, which is present in 70% of asthma patients. "I say, 'How goes the nose, so goes the chest'."

He stressed that physicians should investigate whether their asthma patients have symptoms of GERD. "They often feel like they have a cotton ball in their throat and try and clear it all the time, they have globus, they may hyperventilate, wheeze, and have chest pain and a chronic cough. Chronic cough is the third most common reason for chronic cough after rhinosinusitis and asthma."

He said that GERD in children is much more difficult to diagnose because a child can have an abnormal pH probe yet be asymptomatic. He added that history is more important in these patients.

Dr. Lockey referred to published studies that have shown that treating GERD leads to decreased exacerbations and improved quality of life for asthma patients (Chest. 2005;128:1128-1135; World J Gastroenterol. 2007;13:1706-1710; J Pediatr Gastroenterol Nutr. 2007;44:331-331; Tohoku J Exp Med. 2006;209:181-189; Eur Rev Med Pharmacol Sci. 2005;9:151-160).

Dr. Lockey also conducted a Cochrane database review of GERD treatment for asthma in adults and children (2006), which examined 12 randomized controlled trials for treating GERD in adults and children. He said the results showed "no overall improvement, but subgroups may gain benefit [and] albuterol use may be decreased."

"So does GERD make asthma patients worse? I think in certain patients, yes. In most patients probably not. But if you have GERD, you are not going to be a happy person, and we know psychological issues related to quality of life are very important in patients taking their medication."

He added that treating GERD alone will increase quality of life, that the prevalence of GERD is increasing in the Western world, and that GERD is often associated with chronic rhinosinusitis in children and adults. "It needs to be treated," Dr. Lockey asserted.

Although not covering any specific comorbidity in detail, he provided an overview of definitions, diagnostic criteria, treatment options, and some data for vocal cord dysfunction, obesity, osteoporosis and osteopenia, sleep apnea, pregnancy, COPD, infections, bronchiectasis and cystic fibrosis, and psychosocial problems. Individual speakers will address these in detail at the conference.

Dr. Lockey said that the WAO plans to publish on the topic of asthma and comorbid conditions after the conference.

In the meantime, he presented the audience with a list of his own recommendations for dealing with comorbidities:

  • How goes the nose, so goes the chest; treat nasal disease, especially polyps.

  • GERD can be severe and life-threatening and decrease quality of life; it can exacerbate asthma and asthma can exacerbate GERD. Treat appropriately.

  • Treat vocal cord dysfunction or concomitant vocal cord dysfunction.

  • Encourage weight reduction and refer overweight subjects to Weight Watchers.

  • Recommend calcium and vitamin D supplementation and encourage exercise for all patients.

  • Refer to psychiatric care, as necessary, as with any other disease.

  • Suspect, diagnose, and treat sleep apnea.

  • Provide 24-hour access to care to all patients with asthma, particularly pregnant women.

  • Maintain awareness that asthma and COPD can become the same disease.

  • Assist patients in smoking cessation.

  • Bronchiectasis must be suspected in severe asthma, as should diseases such as allergic bronchopulmonary aspergillosis and cystic fibrosis.

In conclusion, Dr. Lockey said that asthma is the most treatable of all chronic conditions and should be treated continuously to prevent symptoms and exacerbations. "Comorbid conditions must be identified and diagnosis and treatment of comorbid conditions should be included in the asthma guidelines," he asserted.

Finally Dr. Lockey added that physicians should "know when to refer for help, especially with comorbid conditions."

Dr. Lockey has disclosed no relevant financial relationships.

World Allergy Organization (WAO) 2010 International Scientific Conference: Keynote Lunch Symposium. Presented December 6, 2010.

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