Symptoms and exacerbations in asthma: an apparent paradox?

Jaymin B Morjaria, Alan S Rigby, Alyn H Morice, Jaymin B Morjaria, Alan S Rigby, Alyn H Morice

Abstract

Background: There is a dearth of data on prospectively recorded symptoms in patients with uncontrolled asthma. Asthma symptoms and exacerbation rate are commonly thought to be associated. The aim of this study was to analyse asthma symptoms of cough, wheeze, chest tightness and breathlessness in an uncontrolled asthma cohort. We also examined the effect of maintenance and reliever therapy (MART) on these symptoms and its effect on exacerbation rate.

Methods: Adults with uncontrolled asthma electronically recorded their asthma symptom severity scores twice-daily over a period of 48 weeks following randomisation to beclometasone/formoterol twice daily plus pro re nata (prn) salbutamol or MART. Subjects with symptom scores of ⩾2 (ranging from 0 to 3 for each symptom) were considered more symptomatic, whereas those below a score of 2 were considered less severe. The influence treatment on exacerbation frequency and symptom profiles were then correlated.

Results: Of the 1701 subjects in the analyses, 1403 were symptomatic with ⩾100 symptom episodes for one symptom. The remaining 298 subjects were classified as pauci-symptomatic. There was poor association between the frequency and symptom severity score for each symptom. Surprisingly, wheeze was the least reported symptom. Females were more likely to be polysymptomatic. MART compared with prn salbutamol markedly attenuated severe asthma exacerbations. This effect was most notable in subjects with fewer symptoms.

Conclusions: In uncontrolled asthma, there is a poor correlation between reported symptoms and exacerbation frequency. This post hoc analysis suggests that MART should not be reserved for symptomatic subjects but achieves the greatest benefit in pauci-symptomatic patients with asthma.

Trial registration: ClinicalTrials.gov identifier: NCT00861926.

Keywords: asthma; asthma symptoms; beclometasone/formoterol; breathlessness; chest tightness; cough; maintenance and reliever therapy; wheeze.

Conflict of interest statement

Conflict of interest statement: The author(s) declared following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JBM has received honoraria for speaking and financial support to attend meetings/advisory boards from Wyeth, Chiesi, Pfizer, MSD, Boerhinger Ingelheim, Teva, GlaxoSmithKline, Napp, Almirall, AstraZeneca, Trudell Medical International and Novartis Pharmaceuticals UK. ASR has no declarations. AHM has received for speaking and financial support to attend meetings/advisory boards and grants from Boerhinger Ingelheim, Chiesi, Novartis Pharmaceuticals UK, Almirall, Astra Zeneca, GlaxoSmithKline, Reckitt Benckiser, Nexus Communications Group, Pfizer Ltd, Bayer plc, Infirst Healthcare, Afferent Pharmaceuticals Inc, Philips Home Healthcare Solutions, Nycomed, Aerocrine AB, Roche, Genentech, ICON and Patara Pharma.

© The Author(s), 2019.

Figures

Figure 1.
Figure 1.
Venn diagram of the ITT population in the study (n = 1701) for the presence or absence of each symptoms reported. ITT, intention to treat.
Figure 2.
Figure 2.
Quartiles of symptom episode frequency and severity (a) cough, (b) wheeze, (c) breathless and (d) chest tightness. Cut-point severity ⩾2 indicated by dashed line. Pearson’s correlation coefficient (r) top right hand side.

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