Asthma may be said to be controlled when its signs and symptoms are absent or reduced to their utmost, allowing the patients to carry out their usual activities.1 In normal clinical practice, it can be observed that more than half of the patients with asthma are poorly controlled, although with a significant variability between different populations.2–5
Poor control of the disease has an increased impact on the patients, with a deteriorating the quality of life, increasing the incidence of work incapacity, loss of school days in children, an increased in the financial costs of the disease, as well as increasing the exacerbations and hospital admissions.5–7
Despite the advances achieved in the past few years, such as the availability of new diagnostic tests like the fractional exhaled nitric oxide (FeNO) test, new treatments like monoclonal antibodies, and the wide availability of management guidelines, the control of asthma is still far from being optimum.1
Several aspects may contribute to poor disease control, with a significant variability between different countries.
Several authors have analysed the factors associated with asthma control, which have led to identifying aspects that could be key factors for improving these results, although there are differences between the different studies.
It is well known that treatment adherence is low, a fact already mentioned by Hippocrates, but still applies, and to continues as such with no significant improvement in the last twenty years or so.8
Likewise, an over-estimation of the control of the disease by the patients, as well as their doctors, will lead to an under-treatment and worse outcome. In this study there also seems to be a significant disagreement between the perception of control self-assessed by the patients, and when it is assessed by their doctor, something that has been demonstrated in different populations.4
A recent study conducted on Spanish asthmatic patients followed-up in Primary Care identified as predictive factors of poor control the disease, forgetting the medication, living in a rural environment, the presence of a stressing event, poor therapeutic compliance, the underlying severity of the asthma, and the need for oral corticosteroids as baseline treatment.2 Other studies have corroborated the importance of some of these factors, as well as identifying other different ones that can also contribute to poor control of the asthma. Comorbidities include anxiety or depression, the excess secretion of mucous, exposure to some agents in the workplace, being older, active smoker, female gender, better doctor-patient relationship, obesity, lower socioeconomic level, previous hospital admissions, higher frequency of exacerbations in the previous year, need for treatment with anticholinergics or leukotriene receptor antagonists, and non-allergic asthma.9,10
Asthma is usually considered more difficult to treat in the elderly due to the characteristics of this population. There is usually a greater morbidity and mortality, poorer identification of symptoms, lower adhesion to the treatment, interactions due to intellectual or psychological impairment, more secondary effects due to taking multiple medications, and complications due to socio-economic difficulties.6,11 However, some studies indicate that with a proper diagnosis, treatment, and follow-up, these patients can achieve a level of control of the disease and exacerbations similar to other younger patients.12
Neither is there good agreement in the results obtained between the different methods available for determining disease control. The control of asthma has recently been evaluated in a population of asthmatic patients followed up in specialised clinics using the ACT (Asthma Control Test™) questionnaire and the Global Initiative for Asthma (GINA) guidelines, with agreement of 0.45 being obtained between both measurement methods.5
To improve asthma control does not seem to be straightforward, given its origin due to multiple factors as well as the variability between patients. This means that its many aspects have to be dealt with at the same time as individualising the approach to the problem and adapting it to each patient. In this sense, the health education of the patients that helps in understanding the disease, identifying the alert signs and symptoms, as well as improving self-management, is a key point.13,14
Lately, the incorporation of new technologies seems useful, at least for some patients, especially by means of applications that can help in the education and self-management of these patients. In order to optimise their use, the quality of the algorithms used in them should be guaranteed, given that they currently have a wide variability, and in many cases, very little control by the scientific societies.14,15
In conclusion, it appears there is still a need for an objective systematic evaluation of asthma control to try and identify the factors that can be associated with this situation.
Conflict of interestGonzalez-Barcala Francisco-Javier; Has received speaker fees, consulting fees or research grants from Chiesi, Menarini, Rovi, Bial, GlaxoSmithKline, Laboratorios Esteve, Teva, Gebro Pharma, ALK, Roxall, Stallergenes-Gree, Boehringer Ingelheim, Mundipharma, Astra and Novartis.
Rodríguez García Carlota; Has received speaker fees, consulting fees or research grants from Menarini, GlaxoSmithKline, Laboratorios Esteve, Teva, Gebro Pharma, Astra and Ferrer.
Lourido Cebreiro Tamara; Has received speaker fees from Chiesi
