Disease trajectory and treatment escalation in asthma: a retrospective analysis of data from the optimum patient care research database (OPCRD)

Background
Approximately 5% of patients with asthma have severe disease. Treatment escalation may occur despite symptoms not being due to asthma, leading to comorbidities occurring.

Objective
To explore factors associated with treatment escalation to Global Initiative for Asthma (GINA): step 4/5 in patients with asthma.

Methods
A nested case-control study of patients with asthma from the Optimum Patient Care Research Database. Study 1: patients who transitioned from GINA: steps 2/3 to steps 4/5 were compared with matched controls (GINA: step 2/3). Study 2: patients who transitioned from step 4 to step 5 were compared with matched controls (step 4).

Results
Study 1: Step 4/5 cases (n = 12,780) were older, obese, predominantly female, more comorbid (≥2) with increased exacerbations versus step 2/3 controls (n = 31,974) (P < .001). Exacerbations increased nearing treatment escalation in cases but not controls. Study 2: There was no difference in age, sex, or obesity levels in step 5 cases (n = 12,780) versus step 4 controls (n = 31,974). Cases were more comorbid (≥2) (54.0% vs 44.3%, P = .001), with increased mood disorder levels (depression/anxiety) (21.0% vs 13.7%, P = .002) and more exacerbations (81.4% vs 34.3%, P < .001), versus controls. Exacerbations and mood disorder were associated with treatment escalation (P < .001). Mood disorder and exacerbations were more common in cases than in controls, before study entry, but increased in cases alone nearing treatment escalation.

Conclusions
Treatment escalation is associated with mood disorder and asthma exacerbations. Obesity is highly prevalent in patients with asthma before treatment escalation. A symptom-based treatment approach potentially exposes patients to inappropriate treatment escalation.