No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Age-specific incidence of new asthma diagnoses in Finland
... 1,2 However, there is a lack of evidence regarding the incidence of asthma across different age groups, genders, and phenotypes. 3,4 The few studies that have investigated asthma incidence across a broad age range indicate that adult-onset asthma may be quite common. [4][5][6] These studies also reveal that asthma is more common in boys than in girls. ...
... 3,4 The few studies that have investigated asthma incidence across a broad age range indicate that adult-onset asthma may be quite common. [4][5][6] These studies also reveal that asthma is more common in boys than in girls. Although male dominance diminishes during puberty, the precise age at which sex shift occurs remains unclear. ...
... Additionally, the diagnosis of asthma in non-allergic individuals becomes more common with aging than allergic asthma. These findings support previously published results, [3][4][5]7 although the incidence of adult-onset asthma and the age of its predominance among women in our study was somewhat lower than in previous studies. In conclusion, our study suggests differences T A B L E 1 Characteristics of WSAS participants with and without asthma (N = 42,621). ...
Although asthma is more frequently diagnosed in childhood, a substantial proportion of cases manifests in adulthood. Nonetheless, few studies have comprehensively examined asthma incidence across different ages, genders, and asthma phenotypes. We conducted a retrospective evaluation of asthma incidence from birth to late adulthood, stratified by age, gender, and the presence or absence of allergies. Our analysis indicates that a significant number of asthma cases emerged in adulthood, particularly among middle‐aged women, with adult‐onset asthma surpassing childhood‐onset asthma after the age of 35 years. Additionally, allergic asthma was more common in younger than older individuals but decreases with age, ultimately leading to a higher proportion of non‐allergic asthma in older than younger individuals. These findings underscore the predominance of adult‐onset asthma among females and confirm the majority of allergic asthma in children, which declines with age. Additionally, increasing age is associated with increased incidence of non‐allergic asthma. Asthma heterogeneity should be considered in both clinical management and research.
... Asthma is often considered as mainly ailment of young children which becomes less common with increasing age. However, recent epidemiologic studies from Finland and the USA suggest that adult-onset asthma is common, especially among women aged 30-35 years and older [3][4][5]. Increasing knowledge on asthma phenotypes has shown that age at asthma onset is an important consideration in phenotypic categorization [6][7][8]. Age at asthma diagnosis helps in phenotyping asthma since allergic asthma more often begins in childhood or adolescence. ...
... A different way to assess the reliability of self-reported age at asthma diagnosis would be to compare it with health register data. This is possible in Finland as there are population-wide health registers and asthma diagnosis is based on objective pulmonary function tests [3,16] except in children under 3-5 years of age. Further, the date of asthma diagnosis can be derived from the registers. ...
... The SII has listed the reimbursed diseases, each with specific diagnostic criteria for reimbursement entitlement. In the case of asthma, the reimbursement covers 65% of the cost of their medication to treat asthma [3,19,20]. After receiving an asthma diagnosis, fulfilling at least one of the various diagnostic lung function criteria and after continuously using anti-inflammatory medication for a minimum of six months, the patients may apply for the special asthma medication reimbursement. ...
Introduction
In epidemiological studies, the age at asthma onset is often defined by patients’ self-reported age at diagnosis. The reliability of this report might be questioned. Our objective was to evaluate the agreement between self-reported and registered age at asthma diagnosis and assess features contributing to the agreement.
Methods
As part of the FinEsS respiratory survey in 2016, randomly selected population samples of 13,435 from Helsinki and 8000 from Western Finland were studied. Self-reported age at asthma diagnosis was compared to age at asthma diagnosis registered in the Finnish register on special reimbursement for asthma medication. The reimbursement right is based on lung function criteria according to GINA and Finnish guidelines. If the difference was less than 5 years, self-reported diagnosis was considered reliable. Features associated with the difference between self-reported and registered age at asthma diagnosis were evaluated.
Results
Altogether 197 subjects from Helsinki and 144 from Western Finland were included. Of these, 61.9% and 77.8%, respectively, reported age at diagnosis reliably. Median difference between self-reported and registered age at diagnoses was − 2.0 years (IQR − 9.0 to 0) in Helsinki and − 1.0 (IQR − 4.3 to 0) in Western Finland indicating earlier self-reported age at diagnosis. More reliable self-report was associated with non-allergic subjects and subjects who reported having asthma diagnosis more recently.
Conclusions
Agreement between self-reported and registered age at asthma diagnosis was good especially with adult-onset asthma patients. Poor agreement in early-onset asthma could be related to delay in registration due to reimbursement criteria.
... 7 Furthermore, one-third of males but only a minority of females with persistent medication-dependent asthma diagnosed by age 19 years had remitted by 24 years of age in a recent Finnish nation-wide register study. 8 Severe asthma at baseline, female gender, and allergic sensitization are most often reported predictors of persistence of childhood asthma up to adult age. 2,3,5,7,9 In contrast to child-onset asthma, only 3% to 17% of adultonset asthma have remitted 5 to 25 years after the diagnosis. ...
... In addition, gender modifies asthma incidence, persistence, and severity. 7,8,22,23,28 Therefore, this study aimed to evaluate the association between age at asthma diagnosis, asthma remission, and gender, and to assess diagnosis-age specific risk factors of nonremission in an adult general population sample. We hypothesized that asthma diagnosed later in adulthood would be least often in remission, and risk factors of nonremission would differ according to age at diagnosis. ...
... 25 Our remission estimates were low compared with studies with a symptom-based definition of asthma, 3 but very similar to studies that have included only physician-diagnosed or objectively confirmed asthma. 7,8 In addition, we found 2 risk factors of nonremission in early-diagnosed asthma: allergic rhinitis and female gender, similarly as in earlier reports. 3,7,9 Intermediate-diagnosed asthma (12-39 years) was in remission in 17.9% of subjects, which settles between earlier findings. ...
Background
Child-onset asthma is known to remit with high probability, but remission in adult-onset asthma is seemingly less frequent. Reports of association between remission and asthma age of onset up to late adulthood are scarce.
Objective
To evaluate association between asthma remission, age at diagnosis and gender, and assess risk factors of non-remission.
Methods
In 2016, a random sample of 16,000 subjects aged 20-69 years from Helsinki and Western Finland were sent a FinEsS-questionnaire. Physician-diagnosed asthma was categorized by age at diagnosis to early- (0-11 years), intermediate- (12-39 years), and late-diagnosed (40-69 years) asthma. Asthma remission was defined by not having had asthma symptoms and not having used asthma medication in the past 12 months.
Results
Totally 8199 (51.5%) responded, and 879 reported physician-diagnosed asthma. Remission was most common in early-diagnosed (30.2%), followed by intermediate-diagnosed (17.9%) and least common in late-diagnosed asthma (5.0%) (p<0.001), and the median time from diagnosis were 27, 18.5 and 10 years, respectively. In males, the corresponding remission rates were 36.7%, 20.0% and 3.4%, and females 20.4%, 16.6% and 5.9% (gender difference p<0.001). In multivariable binary logistic regression analysis, significant risk factors of asthma non-remission were intermediate- (OR=2.15, 95% CI 1.37-3.36) and late-diagnosis (OR=11.06, 4.82-25.37) compared to early-diagnosis, COPD (OR=5.56, 1.26-24.49), allergic rhinitis (OR=2.28, 1.50-3.46) and family history of asthma (OR=1.86, 1.22-2.85). Results were similar after excluding COPD.
Conclusion
Remission was rare in adults diagnosed with asthma after age 40 years in both genders. Late-diagnosed asthma was the most significant independent risk factor for non-remission.
... For instance, in the Tucson cohort 50% of subjects had experienced at least one episode of wheezing during preschool age and 9.6% had been diagnosed with asthma at 6 years of age [9], which stands for an average incidence of physician-diagnosed asthma of 16 for wheezing in childhood [7,[9][10][11]. After preschool age, the incidence declines [7,11,12], especially in boys [13,14]. ...
... Studies have varying age spans and the incidence in older subjects is less studied, although increasing incidence with age after mid-adulthood has been described [14,15,17]. Further, recent results from the US suggest that adult-onset asthma becomes the dominant phenotype in women quite early, at age 40 years [21], and novel data based on the entire population of Finland show similar results [13]. Nevertheless, further evidence is needed for verification of age-specific asthma incidence especially in subjects over 40 years of age. ...
... Prevalence of physician-diagnosed asthma was 11.2% and is similar with novel reports from Nordic studies [27,28]. Prevalence was higher in boys than girls but higher in women than men and the gender reversal occurred in adolescence, as previously described [10,13]. The prevalence of physician-diagnosed allergy was 17.8%, and a recent Finnish study estimated it somewhat higher, but it assessed self-reported allergy [27]. ...
Background:
Asthma is currently divided into different phenotypes, with age at onset as a relevant differentiating factor. In addition, asthma with onset in adulthood seems to have a poorer prognosis, but studies investigating age-specific incidence of asthma with a wide age span are scarce.
Objective:
To evaluate incidence of asthma diagnosis at different ages and differences between child- and adult-diagnosed asthma in a large population-based study, with gender-specific analyzes included.
Methods:
In 2016, a respiratory questionnaire was sent to 8000 randomly selected subjects aged 20-69 years in western Finland. After two reminders, 4173 (52.3%) subjects responded. Incidence rate of asthma was retrospectively estimated based on the reported age of asthma onset. Adult-diagnosed asthma was defined as a physician-diagnosis of asthma made at ≥ 18 years of age.
Results:
Among those with physician-diagnosed asthma, altogether, 63.7% of subjects, 58.4% of men and 67.8% of women, reported adult-diagnosed asthma. Incidence of asthma diagnosis was calculated in 10-year age groups and it peaked in young boys (0-9 years) and middle-aged women (40-49 years) and the average incidence rate during the examined period between 1946 and 2015 was 2.2/1000/year. Adult-diagnosed asthma became the dominant phenotype among those with physician-diagnosed asthma by age of 50 years and 38 years in men and women, respectively.
Conclusions:
Asthma is mainly diagnosed during adulthood and the incidence of asthma diagnosis peaks in middle-aged women. Asthma diagnosed in adulthood should be considered more in clinical practice and management guidelines.
... The prevalence of physician-diagnosed asthma varies globally. Among adults in Finland, it is approximately 11% [1,2], and the incidence of adulthood increases by age [3,4]. Poor asthma control is associated with more exacerbations and has negative influence on various aspects of quality of life [5,6]. ...
... *recommended treatment dose for beclomethasone dipropionate inhalation powder obtained from the Finnish Current Care Guideline [21] as it was not available from the GINA-report [8] study population was highest in the youngest age group [21] but asthma prevalence increases by age [3,4]. ...
Adherence to inhaled corticosteroids (ICS) has been described as poor. In adherence studies, if the actual prescribed dosing is not available, generic defined daily doses (DDD) are applied instead when assessing adherence. We evaluated asthma patients’ adherence in a large prospective follow-up survey. We also analysed whether World Health Organization (WHO) and Global Initiative for Asthma (GINA) reference doses give different results. The current study was cross-sectional and included respondents attending to HeSSup follow-up questionnaire in 2012. Altogether 1,141 of 12,854 adult participants answered positively to the question about having asthma. According to the Finnish Social Insurance Institutions’ medication register, 686 of them had purchased ICS medication during 2011. DDDs for ICS by WHO as well as medium doses from GINA report were used as reference doses to evaluate adherence. To estimate adherence to ICS, the proportion of days covered (PDC) over one year was calculated for every patient. If the lower limit of GINA medium ICS dose was used as a reference, 65% of the patients were adherent (PDC ≥ 80%). Use of WHO’s DDD as reference halved the proportion of adherent patients. Adherence was higher among those using a combination inhaler of corticosteroid and long-acting β2-agonist compared to those using steroid only inhalers. Use of WHO’s daily defined doses as reference values may lead to underestimation of adherence to inhaled corticosteroids. Thus, attention should be paid when choosing the reference doses for the evaluation of adherence to inhaled corticosteroids in asthma.
... During childhood, asthma is more common and severe in boys than in girls. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Then, a shift takes place around puberty from which time asthma becomes more common and severe in women than in men. [3][4][5]7, The switch in asthma from a male predominance in childhood to a female predominance from puberty onwards is clinically reflected in the fact that asthma that occurs in childhood (childhood-onset asthma) mainly affects boys, whilst asthma that occurs in adulthood (adult-onset asthma) mainly affects women. ...
... 10,40-45 Due to the low remission probability of adult-onset asthma together with the relatively high incidence among women, adult-onset asthma became the dominant phenotype among women with asthma early by age 32-40 years in a US study (adult-onset asthma defined as age at onset of ≥18 years), 46 and by age 30-38 years in two Finnish studies (age at onset of ≥15 or 18 years), 17,18 while childhood-onset asthma remained the dominant phenotype among men with asthma by age 50-54 years. 17,18 These studies indicate that adultonset asthma poses a marked burden to women's health, healthcare system and the larger society. ...
A gender-related disparity exists in asthma morbidity and mortality, which shifts at around puberty from a male predominance to a female predominance. This is clinically reflected in the fact that asthma that occurs in childhood (childhood-onset asthma) mainly affects boys, and that asthma that occurs in adulthood (adult-onset asthma) mainly affects women. Adult-onset asthma is often non-atopic, more severe, and associated with a poorer prognosis, thus posing a marked burden to women’s health and healthcare system. Many factors have been indicated to explain this gender-related disparity, including sociocultural and environmental factors as well as biological sex differences (genetic, pulmonary and immunological factors). It has long been suggested that sex hormones may be implicated in at least these biological sex differences. Overall, the evidence remains equivocal for the role of most sex hormones in asthma pathogenesis and clinical outcomes. Well-designed randomized clinical trials are required assessing the potential preventive or therapeutic effects of hormonal contraceptives on asthma in women, thereby helping to advance the evidence to inform future practice guidelines. The mechanisms underlying the role of sex hormones in asthma are complex, and our understanding is not yet complete. Additional mechanistic studies elucidating sex hormone signaling pathways and their interactions involved in the pathogenesis and clinical manifestations of asthma will help to identify potential sex hormone-driven asthma endotypes and novel therapeutic targets, providing the basis for a more personalized asthma management strategy.
... [21] After asthma diagnosis was confirmed and medication initiated the patients were managed by their personal physicians mostly in PHC according to the Finnish National Asthma Programme [22] unless asthma severity or other respiratory diseases required monitoring in specialized care. As described previously [2,4,15,21], after 12 years (mean 12.2, range 10.8-13.9) a total of 203 patients completed a follow-up visit where the participants gave written informed consent to the study protocol approved by the Ethics committee of Tampere University Hospital, Tampere, Finland (R12122). In addition to the data gathered at the diagnostic and follow-up visits, all data on asthma-related health care contacts during 12-year period was collected from PHC, occupational health care, private clinics and secondary care [2,4,15,21]. ...
... As described previously [2,4,15,21], after 12 years (mean 12.2, range 10.8-13.9) a total of 203 patients completed a follow-up visit where the participants gave written informed consent to the study protocol approved by the Ethics committee of Tampere University Hospital, Tampere, Finland (R12122). In addition to the data gathered at the diagnostic and follow-up visits, all data on asthma-related health care contacts during 12-year period was collected from PHC, occupational health care, private clinics and secondary care [2,4,15,21]. The SAAS-study protocol has been published previously [21]. ...
Background
Poor treatment compliance is a common problem in the treatment of asthma. To our knowledge, no previous long-term follow-up studies exist on how scheduled asthma follow-up contacts occur in primary health care (PHC) versus secondary care and how these contacts relate to adherence to medication and in participation to further scheduled asthma contacts. The aim of this study was to evaluate occurrence of scheduled asthma contacts and treatment compliance in PHC versus secondary care, and to identify the factors associated with non-participation to scheduled contacts.
Methods
Patients with new adult-onset asthma (n = 203) were followed for 12 years in a real-life asthma cohort of the Seinäjoki Adult Asthma Study (SAAS). The first contacts were mainly carried out in secondary care and therefore the actual follow-up time including PHC visits was 10 years.
Results
A majority (71%) of the patients had ≥ 2 scheduled asthma contacts during 10-year follow-up and most of them (79%) mainly in PHC. Patients with follow-up contacts mainly in PHC had better adherence to inhaled corticosteroid (ICS) medication during the whole 12-year period compared to patients in secondary care. In the study population, 29% of the patients had only 0–1 scheduled asthma contacts during the follow-up. Heavy alcohol consumption predicted poor participation in scheduled contacts.
Conclusions
Patients with mainly PHC scheduled asthma contacts were more adherent to ICS medication than patients in the secondary care. Based on our results it is necessary to pay more attention to actualization of asthma follow-up visits and systematic assessment of asthma patients including evaluation of alcohol consumption.
Trial registration Seinäjoki Adult Asthma Study is retrospectively registered at www.ClinicalTrials.gov with identifier number NCT02733016. Registered 11 April 2016.
... Recently, it has been suggested that a patient with fixed airway obstruction and smoking history compatible with COPD could be considered to have ACO if he/she has either a high reversibility of obstruction (> 400 mL BDR in FEV 1 ) or a diagnosis of asthma before the age of 40 years [7]. The revised criteria for ACO have already been criticized since the majority of asthma has been reported to be diagnosed after 40 years of age in women [13][14][15][16], and a BDR of ≥400 mL in FEV 1 in asthma has been shown to detect predominantly young males [17]. ...
... In addition, correlation analyses between age and BDR in FEV 1 did not show clinically meaningful correlation, further indicating that BDR remains stable despite increasing age of asthma onset. Increasing evidence shows that asthma starting at adult age is very common [14][15][16]. As compared with child-onset disease, adult-onset asthma patients are less often allergic and have poorer prognosis with low remission rate [24,38]. ...
Background:
Possible variation in bronchodilator response (BDR) according to age at the diagnosis of adult-onset asthma is unknown. Our aim was to assess if BDR in FEV1 is related to age at diagnosis of adult-onset asthma and how many subjects fulfill the 400 mL criterion of BDR, the suggested cut-off for asthma-like reversibility in asthma-COPD overlap (ACO).
Methods:
A total of 1030 patients with adult-onset asthma were included; 245 from SAAS (Seinäjoki Adult Asthma Study, Finland) and 785 from COREA (Cohort for Reality and Evolution of Adult Asthma in Korea) cohorts. BDR in FEV1 at the diagnosis of asthma was assessed. Patients were divided into groups based on age at asthma diagnosis: < 40, 40-59.9, and ≥ 60 years. The cohorts were analyzed separately.
Results:
BDR % in FEV1 did not differ between the groups of different age at asthma diagnosis and no correlation between BDR and age was found. Of patients aged ≥40 years, only 18% (SAAS-cohort) and 5% (COREA-cohort) reached the 400 mL BDR in FEV1. After exclusion of possible ACO patients, the results remained similar.
Conclusion:
By using two large cohorts of steroid-naive patients with asthma, we have shown that BDR at diagnosis of asthma is constant over large age span range, and the limit of 400 mL in BDR in FEV1 is rarely reached.
Trial registration:
Seinäjoki Adult Asthma Study is registered at ClinicalTrials.gov with identifier number NCT02733016 .
... The Global Initiative for Asthma (GINA) [7] guidelines classically use physiologic and inflammatory markers for phenotyping in all age groups, but recent studies in older asthma patients found concomitant morbidities and age at asthma onset also to be relevant for optimal treatment [1,8]. Onset of asthma in adulthood is not rare; an estimated one-third of all older patients with asthma develops the disease after the age of 40 [9,10], i.e. late-onset asthma, as opposed to early-onset asthma. Moreover, asthma in older adults differs from asthma in younger age groups with respect to genetic susceptibility, environmental exposures, pathogenic mechanisms, type of underlying airway inflammation, natural history of the disease, comorbidities, prognosis (i.e. ...
... In Portugal was the self-reported physiciandiagnosed asthma prevalence in subjects over 65 years 10.9% [32]. A Finnish report in subjects around seventy years of age [10] found an asthma prevalence around 7%. The asthma diagnosis was based on strict reimbursement criteria, and therefore more reliable than self-reported data. ...
Background
Little is known on the prevalence and characteristics of asthma in middle-aged and older adults, since previous studies mainly focused on children and young adults. Therefore, the aim was to investigate the prevalence of physician-diagnosed asthma and its comorbidities, in a population-based cohort of adults 45 years of age and over.
Methods
We identified participants with physician-diagnosed asthma in the Rotterdam Study; a prospective population-based cohort in the Netherlands. Pulmonary function measurements and comorbidities of the asthma cases were assessed at baseline and compared to those of the general population.
Results
Out of 14,621 participants (mean age 65.5 years; 59% women), 524 subjects (31.5%males) had physician-diagnosed asthma at study entry, implicating an asthma prevalence of 3.6% [95% Confidence Interval (CI) 3.3%–3.9%] (2.8% in males and 4.2% in females). Asthmatic subjects had a significantly higher prevalence of obesity and depressive symptoms (Odds Ratio [OR]: 2,02 [95% CI 1,66-2,47] and [OR]: 2,01 [95% CI 1,52-2,66] respectively). Longer duration of asthma and current smoking were associated with lower lung function in asthmatic subjects.
Conclusion
Four percent of middle-aged and older adults have physician-diagnosed asthma. These adult asthmatics suffer more frequently from obesity and depression than subjects without obstructive lung disease.
... Previous studies showed that "the adult-diagnosed asthma phenotype is common however insufficiently studied. Also, adult-diagnosed asthma in an over 50year-old is more probable than child-diagnosed" [9][10][11]. One possible explanation for these findings, from current and previous studies, could be attributed the hormonal disturbances during adulthood, especially menopause, as the latter is considered an important risk factor for development of asthma in women not receiving estrogen replacement therapy [12]. ...
Background: The main aim of asthma treatment is to ameliorate symptoms, improve patient's quality of life and minimize the use of bronchodilator drugs. In addition, one method for evaluation of asthma control is the assessment of its symptoms using a validated questionnaire. Therefore, the aim of current study was to use the Asthma Control Test to appraise disease control in a sample of Iraqi patients with bronchial asthma. Methods: A cross-sectional study that involved asthmatic patients attending the Respiratory Outpatient Clinic at Baghdad Teaching Hospital, Baghdad during the period from June 2023 to September 2023. Data were collected using the validated Asthma Control Test. Participants provided informed verbal consent to take part in the study. Collected data were presented as mean and standard deviation, numbers and percentages. Results: One hundred patients who are known cases of bronchial asthma did participate in current study. According to the scores of Asthma Control Test, the majority of participants (83%) had uncontrolled disease. Conclusion: Factors other than type(s) of drugs might influence control of symptoms in patients with bronchial asthma.
... Studies published in recent years have shown that a significant proportion of asthma cases are diagnosed in adulthood [32,33]. However, some previous studies have suggested that asthma onset in adulthood is mostly a relapse of childhood asthma, but again, these studies focus on asthma onset in young adulthood before the age of 26 years [14,15]. ...
Background
Childhood-onset allergic asthma is the best-known phenotype of asthma. Adult-onset asthma, also an important entity, is instead often shown to be more non-allergic. There is still a lack of studies concerning the association of allergies and age at asthma onset from childhood to late adulthood. The aim of the study was to assess the age at onset of asthma symptoms and age at asthma diagnosis among adults with allergic and non-allergic asthma.
Methods
Questionnaires were sent to 2000 randomly selected Finnish adults aged 18–80 years who were dispensed medication for obstructive airway diseases during the previous year. The corrected sample size was 1978 subjects after exclusion of non-analysable data. The response rate was 40.6%. Self-reported doctor-diagnosed asthma was considered allergic if a concomitant self-reported doctor-diagnosed pollen and/or animal allergy was reported with asthma symptoms upon allergen exposure.
Results
Of the 496 participants with asthma, 42.7% were considered to have allergic asthma. The median ages at asthma diagnosis and onset of asthma symptoms were 31 (IQR 17–46) and 20 (9.25–40) years in participants with allergic asthma and 49 (37.75–58) and 40.5 (30–50) years in participants with non-allergic asthma (p < 0.001), respectively. Of the participants with asthma diagnosed at ≥30 years of age, 18% of allergic and 7% of non-allergic participants reported having had asthma symptoms under 20 years of age.
Conclusions
Both the onset of symptoms and diagnosis occurred at a younger age among adults with allergic asthma than among those with non-allergic asthma. Only a minority of adults with non-allergic asthma had already had symptoms in younghood.
... COA was diagnosed at the median age of 5 years, which was the same as a study done by Lakshminarasappa [6], and AOA was diagnosed at the median age of 41 years, similar to studies done by Mirabelli [11] and Ilmarinem [12] in which the median age at onset was 38 years and 46 years, respectively. Our results are consistent with the literature that COA is more prevalent in males, while AOA is more prevalent in females [13][14][15][16][17]. This gender-related switch has been explained by many hypothesis like smaller airways in boys compared to girls [18] and increase in the activities of sex hormones in females starting from puberty [19,20]. ...
Background:
asthma, a chronic respiratory disease caused by inflammation and narrowing of the small airways in the lungs, is the most common chronic childhood disease. Prevalence of childhood asthma in the United States is 5.8%. In boys, prevalence is 5.7% and it is 6% in girls. Asthma is associated with other comorbidities such as major depressive disorder and anxiety disorder. This study explores the association between asthma and depression.
Methods:
we conducted a retrospective cross-sectional study using NHANES data from 2013 to 2018. Asthma and childhood onset asthma were assessed using questionnaires MCQ010 and MCQ025, respectively. Sociodemographic variables were summarized, and univariate analysis was performed to determine the association between asthma and major depressive disorder and its individual symptoms.
Results:
there were 402,167 participants from 2013-2018 in our study: no asthma in 84.70%; asthma in 15.30%. Childhood onset asthma (COA) included 10.51% and adult-onset asthma (AOA) included 4.79%. Median age of COA is 5 years and AOA is 41 years. Among the asthma groups, most AOA were females (67.77%, p < 0.0001), most COA were males (52.16%, p < 0.0001), and ethnicity was predominantly White in AOA (42.39%, p < 0001) and in COA (35.24%, p < 0.0001). AOA mostly had annual household income from 25,000-64,999 (36.66%, p < 0.0001). There was a significantly higher prevalence of MDD in COA (38.90%) and AOA (47.30%) compared to NOA (31.91%). Frequency of symptoms related to MDD were found to have a significantly higher prevalence and severity in the asthma groups compared to no asthma, and slightly greater and more severe in AOA than in COA. Symptoms include having little interest in doing things (COA 18.38% vs. AOA 22.50% vs. NOA 15.44%), feeling down, depressed, or hopeless (COA 20.05% vs. AOA 22.77% vs. NOA 15.85%), having trouble sleeping or sleeping too much (COA 27.38% vs. AOA 23.15% vs. NOA 22.24%), feeling tired or having little energy (COA 39.17% vs. AOA 34.24% vs. NOA 33.97%), having poor appetite or overeating (COA 19.88% vs. AOA 20.02% vs. NOA 15.11%), feeling bad about yourself (COA 13.90% vs. AOA 13.79% vs. NOA 10.78%), having trouble concentrating on things (COA 12.34% vs. AOA 14.41% vs. NOA 10.06%), moving or speaking slowly or too fast (COA 8.59% vs. AOA 9.72% vs. NOA 6.09%), thinking you would be better off dead (COA 3.12% vs. AOA 4.38% vs. NOA 1.95%) and having the difficulties these problems have caused (COA 21.66% vs. AOA 26.73% vs. NOA 19.34%, p < 0.0001).
Conclusion:
MDD and related symptoms were significantly higher and more severe in participants with asthma compared to no asthma. Between adult-onset asthma compared to childhood onset asthma, adult-onset asthma had slightly greater and more severe MDD and related symptoms compared to childhood onset asthma.
... While childhood-onset asthma constitutes a significant portion of asthma patients, adult-onset asthma has been shown to be even the dominant form of asthma in many Western countries. 6,7 Although many characteristics of adult-onset asthma have been under intensive research in recent years, the underlying inflammatory mechanisms and characteristics of possible clinically significant disease biomarkers are still poorly understood. ...
Background
Soluble urokinase plasminogen activator receptor (suPAR) has emerged as a novel biomarker for various inflammatory conditions and has been proposed to associate with the severity of asthma. However, the relationship between suPAR and clinical asthma features is poorly understood.
Objective
To examine associations of serum suPAR levels with clinical characteristics of asthma and to define the phenotype with high suPAR levels in patients with adult-onset asthma.
Methods
Serum suPAR levels were measured with ELISA from patients with adult-onset asthma participating in the 12-year follow-up visit in the Seinäjoki Adult Asthma Study.
Results
In total, 201 patients were divided into quartiles according to suPAR values. High suPAR patients had more severe asthma symptoms and poorer asthma control. They also had higher levels of interleukin 8 (IL-8), interleukin 6 (IL-6), matrix metalloproteinase 9 (MMP-9), and blood neutrophil counts than those with low suPAR levels. The use of high-dose inhaled and oral corticosteroids was more common in patients with elevated suPAR. Such patients also had visited healthcare more frequently during the follow-up period, had more comorbidities, and were physically less active than those with low suPAR levels. The above-mentioned results remained similar after excluding the patients with co-existing COPD; only association to hospitalizations was lost. In multivariable binary regression analyses, the highest suPAR quartile was associated with higher cumulative dispensed oral corticosteroid use, more severe symptoms, and uncontrolled asthma.
Conclusion
High suPAR levels occur in uncontrolled adult-onset asthma patients characterized by neutrophilic inflammation, high corticosteroid use, frequent healthcare visits, and multimorbidity with unhealthy lifestyle. This biomarker could be useful in determining asthma phenotypes and target new asthma treatments.
... Asthma diagnoses are based on objective lung function measurements and are reliable in Finland because of reimbursement policies. 53 The age at asthma diagnosis corresponded with the asthma reimbursement data, in which 24.7% had early-diagnosed asthma, 28.3% had intermediate-diagnosed asthma, and 47.0% had late-diagnosed asthma when an age distribution similar to that in this study was applied. 49 As a limitation of the present study, recall bias concerning the age at asthma diagnosis is possible, considering that the recall periods are long. ...
Purpose
Asthma is a heterogeneous disease, and factors associated with different asthma phenotypes are poorly understood. Given the higher prevalence of farming exposure and late diagnosis of asthma in more rural Western Finland as compared with the capital of Helsinki, we investigated the relationship between childhood farming environment and age at asthma diagnosis.
Methods
A cross-sectional population-based study was carried out with subjects aged 20–69 years in Western Finland. The response rate was 52.5%. We included 3864 participants, 416 of whom had physician-diagnosed asthma at a known age and with data on the childhood environment. The main finding was confirmed in a similar sample from Helsinki. Participants were classified as follows with respect to asthma diagnosis: early diagnosis (0–11 years), intermediate diagnosis (12–39 years), and late diagnosis (40–69 years).
Results
The prevalence of asthma was similar both without and with childhood exposure to a farming environment (11.7% vs 11.3%). Allergic rhinitis, family history of asthma, ex-smoker, occupational exposure, and BMI ≥ 30 kg/m² were associated with a higher likelihood of asthma. Childhood exposure to a farming environment did not increase the odds of having asthma (aOR, 1.10; 95% CI, 0.87–1.40). It did increase the odds of late diagnosis (aOR, 2.30; 95% CI, 1.12–4.69), but the odds were lower for early (aOR, 0.49; 95% CI, 0.30–0.80) and intermediate diagnosis of asthma (aOR, 0.75; 95% CI, 0.47–1.18).
Conclusion
Odds were lower for early diagnosis of asthma and higher for late diagnosis of asthma in a childhood farming environment. This suggests a new hypothesis concerning the etiology of asthma when it is diagnosed late.
... High FeNO levels have been shown to be associated with an excess decline in lung function both in long-standing disease and in adults with newlydiagnosed asthma (Table 1). Adult-onset asthma accounts for approximately half of new asthma diagnoses [30,31]. A prospective 5-year study in 200 individuals with adult-onset asthma measured several potential predictors for a decline in lung function at baseline and subsequent visits [29]. ...
Background:
Precision medicine means linking the right patient to the right management strategy including best possible pharmacological therapy, considering the individual variability of the disease characteristics, type of inflammation, genes, environment, and lifestyle. For heterogenous diseases such as asthma, reliable biomarkers are needed to facilitate the best possible disease control and reduce the risk of side effects. The present review examines fractional exhaled nitric oxide (FeNO) as a guide for the management strategy of asthma and predictor of its clinical course.
Method:
The literature included was identified by searching the PubMed database using specific key words and MeSH terms. Studies were not excluded based on their design alone. The search resulted in 212 hits, of which 35 articles were included in this review.
Results:
Several studies support a potential role for high FeNO levels as a prognostic biomarker for accelerated lung function decline in adults with newly diagnosed asthma. Furthermore, studies report an association between high FeNO levels and excess decline in FEV1 in adults with long-standing moderate to severe asthma despite optimised therapy, whereas the findings for patients with less severe disease are conflicting. Applying a FeNO-based management algorithm reduces the exacerbation rate in adults with asthma. Similar observations are seen in children, though based on fewer studies. The available studies provide evidence that the level of FeNO may be useful as a predictor of subsequent loss of asthma control in adults, though the evidence is somewhat conflicting in children and young adults.
Conclusion:
The present review provides evidence of the prognostic value of FeNO as a surrogate biomarker for type 2 inflammation in the airways. FeNO is likely to emerge as an important biomarker in monitoring and tailoring modern asthma treatment, either alone or in combination with other biomarkers.
... The prevalence of asthma and eczema increases from early childhood to adolescence-age, after which the prevalence of eczema declines and then plateaus after reaching adulthood (29). For asthma, the prevalence increases until young adulthood, and then decreases subsequently with increasing age during adulthood, but also contradicting data have been reported (30,31). Rhinitis, on the other hand, starts to become common during preschool-age followed by a continuous increase during teenage and young adulthood (32). ...
Background
Coexistence of asthma, rhinitis, and eczema has been studied in children, but data are lacking in adults. As new treatments emerge, epidemiological data on the coexistence are needed.
Aims
To study the prevalence of concomitant asthma, rhinitis and eczema in the general adult population and among those sensitized to aeroallergens, and to study associations between background characteristics and risks of phenotypes of asthma, rhinitis, and eczema.
Methods
In the West Sweden Asthma Study, phenotypes and sensitization profiles of 1103 randomly selected adults (16–75 years) were assessed. The methods included measures of serum-IgE and structured interviews on asthma, rhinitis, eczema, their associated symptoms, and relevant risk factors.
Results
Among all participants and in those sensitized, 2% and 6% had concomitant asthma, rhinitis, and eczema, respectively, and the condition did not differ by age or sex. Corresponding figures for asthma and rhinitis, but not eczema, was 8% and 19%, respectively. Determinants of coexistence of the three conditions were family history of asthma/allergy, body mass index, and occupational exposure to gas, dust and fumes.
Allergic sensitization in those with asthma, rhinitis and eczema was found in 78%, in those with asthma and rhinitis but not eczema in 65%, in those with asthma and eczema but not rhinitis in 40%, while only 5% were sensitized among those having asthma only.
Conclusions
In the general adult population about 2% have concomitant asthma, rhinitis, and eczema. Of sensitized adults, about 6% has coexistence of the three conditions.
... The age of asthma onset has been shown to be a significant factor in distinguishing the phenotypes of asthma [5,6]. Although a substantial proportion of asthma originates in childhood, recent data from the USA and Finland show that asthma diagnosed at adult age is common, and is in fact the dominant phenotype among women aged 35-40 years [7][8][9]. Patients with late-onset asthma are usually nonatopic and their response to corticosteroids is poorer than in patients with early-onset disease, and therefore they require more tailored medication [5,6]. Moreover, asthma rarely remits in patients with adult-onset asthma [5,6,10,11]. ...
Adherence to inhaled corticosteroids (ICS) has been suggested to be poor but long-term follow-ups are lacking. The objective of the present study was to assess adherence to ICS treatment in patients with adult-onset asthma during 12-year follow-up.
A total of 181 patients with clinically confirmed, new-onset adult asthma were followed for 12 years as part of the Seinäjoki Adult Asthma Study. Adherence to ICS was assessed individually as the percentage of true dispensed ICS in micrograms per true prescribed daily ICS in micrograms over 12 years.
Mean 12-year adherence to ICS was 69% (mean± sd dispensed 2.5±1.8 g and prescribed 3.6±1.5 g budesonide equivalent per patient for 12 years), annual adherence varying between 81% (year 1) and 67% (year 12). Patients with good 12-year adherence (≥80%) used oral corticosteroids more often, and had add-on drugs in use and asthma-related visits to healthcare more often. In addition, they showed less reversibility in forced expiratory volume in 1 s and had higher peripheral blood neutrophil counts. However, lung function decline was steeper in patients with poorer adherence (<80%) and this association remained in multiple linear regression analysis. No difference was found in symptom scores, blood eosinophil counts, exhaled nitric oxide or immunoglobulin E between the patients with different levels of adherence.
In patients with adult-onset asthma, adherence to ICS was moderate. Poorer adherence (<80%) to ICS was associated with more rapid decline in lung function but was not associated to symptoms or markers of inflammatory endotypes.
... Asthma prevalence is still increasing also in Finland 1,6 , and the most of asthma cases are diagnosed at adult age 7,8 . Remission of adult-onset asthma is rare 9,10 . ...
Primary health care (PHC) providers are at the front line of asthma management. To evaluate how planned asthma follow-up occurred in PHC and whether lung function tests were used, 203 patients were followed for 12 years as part of a real-life asthma cohort Seinäjoki Adult Asthma Study (SAAS). A total of 152 patients had visits in PHC attending on average to four planned contacts during 12-year follow-up corresponding to one visit every third year. National guideline recommends annual visits. Patients with ≥4 contacts seemed to have more difficult asthma and better adherence to inhaled corticosteroid medication. Lung function tests were performed on average in 87.5% of annual planned follow-up contacts. Spirometry was performed in 70%, 71% and 97% of all contacts depending on whether it was a contact to GP, nurse or both. Overall, the frequency of follow-up contacts was insufficient but PHC adherence to lung function testing was excellent.
... However, a recent U.S.-based study showed adult-onset asthma as being the dominant phenotype among women in middle age [27]. In Finland during 2012-2013, 70% of new asthma diagnoses were made in adults indicating that adult-onset asthma is a clinically relevant phenotype [28]. Nevertheless, studies on adult-onset asthma are still scarce. ...
Background:
Onset of allergic asthma has a strong association with childhood but only a few studies have analyzed incidence of asthma from childhood to late adulthood in relation to allergy. The purpose of the study was to assess age-specific incidence of allergic and non-allergic asthma.
Methods:
Questionnaires were sent to 8000 randomly selected recipients aged 20-69 years in Finland in 2016. The response rate was 52.3% (n = 4173). The questionnaire included questions on e.g. atopic status, asthma and age at asthma diagnosis. Asthma was classified allergic if also a physician-diagnosed allergic rhinitis was reported.
Results:
The prevalence of physician-diagnosed asthma and allergic rhinitis were 11.2 and 17.8%, respectively. Of the 445 responders with physician-diagnosed asthma, 52% were classified as allergic and 48% as non-allergic. Median ages at diagnosis of allergic and non-allergic asthma were 19 and 35 years, respectively. Among subjects with asthma diagnosis at ages 0-9, 10-19, 20-29, 30-39, 40-49, 50-59 and 60-69 years, 70, 62, 58, 53, 38, 19 and 33%, respectively, were allergic. For non-allergic asthma, the incidence rate was lowest in children and young adults (0.7/1000/year). It increased after middle age and was highest in older age groups (2.4/1000/year in 50-59 years old).
Conclusions:
The incidence of allergic asthma is highest in early childhood and steadily decreases with advancing age, while the incidence of non-allergic asthma is low until it peaks in late adulthood. After approximately 40 years of age, most of the new cases of asthma are non-allergic.
... Asthma with onset later in life is often non-allergic, related to life style and environmental factors, more severe, and has generally a poorer prognosis [1][2][3]. Majority of new asthma diagnoses are made in adults [4,5]. Adult-onset asthma is associated with negative effects on working career [6,7], but previous studies have not compared whether asthma onset in early or late adulthood has different impacts on working career. ...
Background:
Age at asthma onset is associated with severity and outcomes of the disease.
Objective:
We studied if age at asthma diagnosis is related to employment and outcomes in working career.
Patients and methods:
A questionnaire was sent to 2613 adults with asthma in Tampere, Finland, and a follow-up questionnaire was sent after six years. Asthmatics were divided into groups based on their employment status: working full-time or work disability. Logistic regression was used to study the association of age at asthma diagnosis with employment status at baseline and with the risk of exiting full-time work during follow-up period.
Results:
In cross-sectional analysis, asthma diagnosed in late adulthood (50 + years) was associated with higher OR for having work-disability compared to childhood onset asthma (OR [95% CI] 3.60 [1.43-9.06]). During follow-up, asthma diagnosed in late adulthood was associated with higher OR for exiting full time work compared to childhood-onset asthma (OR 10.87 [3.25-36.40]).
Conclusions:
Asthma diagnosed in late adulthood is a higher risk for poor employment than asthma diagnosed earlier in life. Adult-onset of asthma is an important factor in view of work ability and early rehabilitation procedures.
... In contrast, patients with disease onset at adulthood have often more severe asthma that rarely remits [7]. Recently, asthma diagnosed at adult-age has been shown to constitute a majority among all new cases of asthma [8], and it seems that several lifestyle factors such as cigarette smoking and obesity are major factors in adultonset asthma [6,9]. Since the concept of adult-onset phenotypes is rather new, only few studies exist on it and there is no clear consensus on the best therapy for these patients. ...
Background: There is a lack of knowledge on the association between daily physical activity and lung function in patients with asthma.
Objective: This study aims to examine the association between daily physical activity and asthma control, lung function, and lung function decline in patients with adult-onset asthma.
Design: This study is part of Seinäjoki Adult Asthma Study (SAAS), where 201 patients were followed for 12 years after asthma diagnosis. Daily physical activity was assessed at follow-up by a structured questionnaire and used to classify the population into subgroups of low (≤240 min) or high (>240 min) physical activity. Three spirometry evaluation points were used: 1. diagnosis, 2. the maximum lung function during the first 2.5 years after diagnosis (Max0-2.5), 3. follow-up at 12 years.
Results: High physical activity group had slower annual FEV1 (p<0.001) and FVC (p<0.018) decline. Additionally, the high physical activity group had higher FEV1 values at follow-up, and higher FEV1/FVC ratios at follow-up and diagnosis. There was no difference in BMI, smoking, medication, or frequency of physical exercise between high and low physical activity groups. Differences remained significant after adjustments for possible confounding factors.
Conclusion: This is the first demonstration of an association between long-term FEV1 decline and daily physical activity in clinical asthma. Low physical activity is independently associated with faster decline in lung function. Daily physical activity should be recommended in treatment guidelines in asthma.
... However, a patient with a suspicion of or proven severe asthma should be referred to the local severe asthma center or team. As the number of patients with adult and/or adult-onset asthma is high and the burden from these patients is high [156], we propose a twostep model, where the generalist may initially refer the patient to a respiratory specialist, if there is a strong suspicion of or a proven severe asthma, the patient is subsequently referred to the severe asthma center/team ( Figure 4). However, depending on the local situation, direct referral from the GP office to the severe asthma center or team may be preferable . ...
Although a minority of asthma patients suffer from severe asthma, they represent a major clinical challenge in terms of poor symptom control despite high-dose treatment, risk of exacerbations, and side effects. Novel biological treatments may benefit patients with severe asthma, but are expensive, and are only effective in appropriately targeted patients. In some patients, symptoms are driven by other factors than asthma, and all patients with suspected severe asthma (‘difficult asthma’) should undergo systematic assessment, in order to differentiate between true severe asthma, and ‘difficult-to-treat’ patients, in whom poor control is related to factors such as poor adherence or co-morbidities. The Nordic Consensus Statement on severe asthma was developed by the Nordic Severe Asthma Network, consisting of members from Norway, Sweden, Finland, Denmark, Iceland and Estonia, including representatives from the respective national respiratory scientific societies with the aim to provide an overview and recommendations regarding the diagnosis, systematic assessment and management of severe asthma. Furthermore, the Consensus Statement proposes recommendations for the organization of severe asthma management in primary, secondary, and tertiary care.
... Age at disease onset appears to be an important distinctive feature of these sub-phenotypes, as studies have shown that patients with adult-onset asthma differ in many respects from those in whom asthma started in childhood [3]. As adult-onset asthma covers more than 50% of new diagnoses of asthma [4,5] this is a clinically important phenotype. Adult-onset asthma is associated with more (persistent) eosinophilic airway inflammation and more chronic sinus disease [6,7]. ...
Little is known about the prognosis of adults with new-onset asthma. Cross-sectional studies suggest that these patients may exhibit accelerated decline in forced expiratory volume in 1 s (FEV 1 ). However, risk factors for accelerated decline in lung function have not yet been identified.
We aimed to identify these risk factors in a prospective 5-year follow-up study in 200 adults with newly diagnosed asthma. In the current study, clinical, functional and inflammatory parameters were assessed annually for 5 years. Linear mixed-effects models were used to identify predictors.
Evaluable lung function sets of 141 patients were available. Median (interquartile range) change in post-bronchodilator FEV 1 was −17.5 (−54.2 to +22.4) mL per year. Accelerated decline in FEV 1 was defined by the lower quartile of decline (>54.2 mL per year). Nasal polyps, number of blood and sputum eosinophils, body mass index, and level of exhaled nitric oxide were univariably associated with decline in lung function. Only the latter two were independently associated. Using cut-off values to identify patients at highest risk showed accelerated decline in FEV 1 in all patients with combined exhaled nitric oxide fraction ( FeNO ) ≥57 ppb and body mass index (BMI) ≤23 kg·m ⁻² .
We conclude that adults with new-onset asthma with both high levels of exhaled nitric oxide and low BMI are at risk of accelerated decline in lung function.
... We acknowledge that a recent consensus definition of ACOS has been published, in which a key suggested feature of ACOS should be the diagnosis of asthma or atopy before 40 years of age [10]. However, another recent study has shown that the majority of adult-onset asthma is actually diagnosed at an older age [43], which makes the proposed age limit of 40 somewhat low. The present study cohort included only patients with adult-onset asthma, and the age of onset of asthma in our cohort was on average 46.5 years, and in the ACOS group, 53.0 years. ...
Differences between asthma–COPD overlap syndrome (ACOS) and adult-onset asthma are poorly understood. This study aimed to evaluate these differences in a clinical cohort of patients with adult-onset asthma, as a part of the Seinäjoki Adult Asthma Study (SAAS).
188 patients were diagnosed with adult-onset asthma and re-evaluated 12 years after diagnosis. They were divided into three groups based on smoking history and post bronchodilator spirometry values: 1) never- and ex-smokers with <10 smoked pack-years; 2) non-obstructive (forced expiratory volume in 1 s (FEV 1 )/forced vital capacity (FVC) ≥0.7) patients with ≥10 pack-years; and 3) ACOS patients with ≥10 pack-years and FEV 1 /FVC <0.7.
ACOS patients had lower diffusing capacity ( DLCO /V A 86% predicted versus 98 or 96% predicted; p<0.001), higher blood neutrophil levels (4.50 versus 3.60 or 3.85×10 ⁹ L ⁻¹ ; p=0.008), and higher IL-6 levels (2.88 versus 1.52 or 2.10 pg·mL ⁻¹ , p<0.001) as compared to never- and ex-smokers with <10 pack-years, or non-obstructive patients with ≥10 pack-years smoking history, respectively. ACOS patients also showed reduced lung function, higher remaining bronchial reversibility and a higher number of comorbidities.
This study shows distinct differences in diffusing capacity, blood neutrophil and IL-6 levels, bronchial reversibility, lung function and comorbidities between ACOS and adult-onset asthma. The present findings should be considered in the comprehensive assessment of adult asthma patients.
Introduction
In epidemiological studies, the age at asthma onset is often defined by patients’ self-reported age at diagnosis. The reliability of this report might be questioned. Our objective was to evaluate the agreement between self-reported and registered age at asthma diagnosis and assess features contributing to the agreement.
Methods
As part of the FinEsS respiratory survey in 2016, randomly selected population samples of 13435 from Helsinki and 8000 from Western Finland were studied. Self-reported age at asthma diagnosis was compared to age at asthma diagnosis registered in the Finnish register on special reimbursement for asthma medication. The reimbursement right is based on lung function criteria according to GINA and Finnish guidelines. If the difference was less than 5 years, self-reported diagnosis was considered reliable. Features associated with the difference between self-reported and registered age at asthma diagnosis were evaluated.
Results
Altogether 197 subjects from Helsinki and 144 from Western Finland were included. Of these, 61.9% and 77.8%, respectively, reported age at diagnosis reliably. Median difference between self-reported and registered age at diagnoses was −2.0 years (IQR −9.0 to 0) in Helsinki and −1.0 (IQR −4.3 to 0) in Western Finland indicating earlier self-reported age at diagnosis. More reliable self-report was associated with non-allergic subjects and subjects who reported having asthma diagnosis more recently.
Conclusions
Agreement between self-reported and registered age at asthma diagnosis was good especially with adult-onset asthma patients. Poor agreement in early-onset asthma could be related to delay in registration due to reimbursement criteria.
Objective: To investigate the current prevalence of physician-diagnosed obstructive airway diseases by respiratory symptoms and by sex in Sweden and Finland.
Method: In 2016, a postal questionnaire was answered by 34,072 randomly selected adults in four study areas: Västra Götaland and Norrbotten in Sweden, and Seinäjoki-Vaasa and Helsinki in Finland.
Results: The prevalence of asthma symptoms was higher in Norrbotten (13.2%), Seinäjoki-Vaasa (14.8%) and Helsinki (14.4%) than in Västra Götaland (10.7%), and physician-diagnosed asthma was highest in Norrbotten (13.0%) and least in Västra Götaland (10.1%). Chronic productive cough was most common in the Finnish areas (7.7–8.2% versus 6.3–6.7%) while the prevalence of physician-diagnosed chronic bronchitis (CB) or chronic obstructive pulmonary disease (COPD) varied between 1.7 and 2.7% in the four areas. Among individuals with respiratory symptoms, the prevalence of asthma was most common in Norrbotten, while a diagnosis of COPD or CB was most common in Västra Götaland and Seinäjoki-Vaasa. More women than men with respiratory symptoms reported a diagnosis of asthma in Sweden and Seinäjoki-Vaasa but there were no sex differences in Helsinki. In Sweden, more women than men with symptoms of cough or phlegm reported a diagnosis of CB or COPD, while in Finland the opposite was found.
Conclusion: The prevalence of respiratory symptoms and corresponding diagnoses varied between and within the countries. The proportion reporting a diagnosis of obstructive airway disease among individuals with respiratory symptoms varied, indicating differences in diagnostic patterns both between areas and by sex.
For the last three decades, the guidelines for asthma management have supported a stepwise therapeutic approach, based on the administration of controller medications (especially inhaled corticosteroids) complemented by on-demand use of rescue medication. Classically, the rescue medication recommended comprised short-acting β agonists (SABA). Some years ago, the use of Symbicort Maintenance and Reliever Therapy (SMART) demonstrated the benefits of a combination of budesonide-formoterol, an inhaled corticosteroid, and a long-acting β agonist (ICS-LABA) as rescue medication in moderate and severe asthma. The results were enthusiastically received, and this therapeutic option was adopted in the guidelines for moderate to severe asthma patients. Recently, four trials (two randomised placebo control trials under the auspices of the SYGMA project and two real-life studies, Novel START, and the PRACTICAL trial) have explored the potential benefits of substituting SABA with budesonide-formoterol as rescue medication in mild asthma patients. The SYGMA 1 and 2 studies showed that the combination with formoterol-budesonide as rescue medication provides better asthma control than short-acting β-agonists alone in GINA step 2 patients, although the superiority was slight. Compared to budesonide maintenance therapy, the fixed combination of ICS-LABA on demand provides poorer asthma control. Regarding exacerbations, the fixed dose ICS-LABA combination on demand showed the same benefits for the prevention of exacerbations as chronic ICS treatment in mild asthma patients. The Novel START study, which assessed a population with milder symptoms, concluded that the fixed dose ICS-LABA combination used as needed was superior to SABA (albuterol) as needed for the prevention of asthma exacerbations. These results in fact show that, in undertreated GINA step 2 with only SABA as needed, ICS-LABA is more effective than SABA. The authors of PRACTICAL concluded that the study provided modest evidence that the ICS-LABA combination used as-needed for symptom relief reduces the rate of severe exacerbations compared with maintenance low-dose budesonide plus terbutaline as needed, although the study was not limited to mild asthma since according to the treatment consumed, it was evident that they had recruited some moderate asthma patients. Despite this poor evidence, and ignoring the clinical histological benefits of chronic inhaled corticosteroids (especially when administered promptly), GINA 2019 recently recommended daily low dose ICS or ICS-ICS as needed as a first option for step 2 patients. For step 1, symptom-driven or as-needed treatment with ICS-LABA is recommended rather than SABA alone (the preferred option until the last GINA update). Finally, the SIENA study showed that 73% of patients with mild asthma do not have an eosinophilic phenotype and that these patients have a similar clinical response to ICS (mometasone) and antimuscarinic drugs (tiotropium), results that challenge the indication of a drug combination that incorporates ICS as a first option. Overall, we believe there is insufficient evidence for the systematic recommendation of as-needed ICS-LABA instead of SABA on request for GINA step 1 or as a replacement for chronic ICS in GINA step 2.
Background:
Asthma is characterised by variable and reversible expiratory airflow limitations. Thus, it is logical to use the change in FEV1 in response to a bronchodilator (ΔFEV1BDR) as a diagnostic tool; increases of ≥12% and ≥200 mL from the baseline FEV1 are commonly used values.
Aim:
To evaluate the historical development of diagnostic cut-off levels for the ΔFEV1BDR for adults and the evidence behind these recommendations.
Methods:
We searched for studies from the reference lists of all the main statements, reports and guidelines concerning the interpretation of spirometry and diagnostics for asthma and conducted a literature search.
Results:
A limited amount of evidence regarding the ΔFEV1BDR in healthy populations was found, and even fewer patient studies were found. In healthy persons, the upper 95th percentile for the absolute ΔFEV1BDR ranges between 240 and 320 mL, for the relative ΔFEV1BDR calculated from the initial FEV1 ranges from 5.9-13.3%, and for the ΔFEV1BDR calculated from the predicted FEV1 ranges from 8.7-11.6%. However, the absolute and percentage ΔFEV1BDR values calculated from the initial FEV1 are dependent on age, sex, height and the degree of airway obstruction. Thus, the use of the ΔFEV1BDR calculated from the predicted FEV1 might be more appropriate.
Conclusions:
Not enough data exist to assess the sensitivity of any of the cut-off levels for the ΔFEV1BDR to differentiate asthma patients from healthy subjects. Further studies in newly diagnosed asthma patients are needed.
Background:
The diagnosis of asthma is not always straightforward and can be even more challenging in older adults. Asthma is ideally confirmed by demonstration of variable expiratory airflow limitation. However, many patients with asthma do not demonstrate airflow obstruction nor show bronchodilator reversibility. We aimed to investigate predictors for a positive bronchial challenge test with methacholine in older adults being evaluated for asthma.
Methods:
This is a diagnostic accuracy study with a cross-sectional design. Participants ≥60 years with suspected asthma and a negative postbronchodilator response on spirometry were included. All participants underwent a methacholine challenge test (MCT). We assessed the value of standard asthma screening questions and additional clinical questions to predict the MCT results. A multivariable logistic regression model was developed to assess the variables independently impacting the odds of a positive MCT result.
Results:
Our study included 71 participants. The majority were female (n = 52, 73.2%) and the average age was 67.0 years. Those with a positive MCT (n = 55, 77.5%) were more likely to have wheezing or coughing due to allergens (n = 51, 92.7% vs. n = 12, 75.0%; P = 0.004) and difficulty walking several blocks (n = 14, 25.5% vs. n = 1, 6.3%, P = 0.009). After adjustment, having wheezing or coughing due to allergens (OR = 4.2, 95% CI 1.7-7.8, P = 0.012) remained the only significant independent predictor of a positive MCT.
Conclusions:
In older adults with suspected asthma, questioning about wheezing or coughing due to allergens provides a modest independent value to predict a MCT result in those who previously had a negative postbronchodilator response on spirometry.
In a recent issue of the European Respiratory Journal, Sinet al. [1] presented recommendations on the definition of asthma–chronic obstructive pulmonary disease overlap syndrome (ACOS). The presented conclusions, based on a round table discussion, are very important and notable, especially considering the current lack of specific clinical criteria for ACOS. One of the key recommendations is that asthma or atopy should be diagnosed before age of 40 years (or patients should have very large airway reversibility) in order to fulfil the criteria of ACOS. However, the scientific basis of using the 40-year cut-off remains debatable. In addition, the proposal raises a major concern of underdiagnosing adult-onset asthma and ACOS if the suggested age limit is used.
The Finnish Medical Society Duodecim initiated and managed the update of the Finnish national guideline for Chronic Obstructive Pulmonary Disease (COPD). The Finnish COPD guideline was revised in order to acknowledge the progress in diagnosis and management of COPD. This Finnish COPD guideline in English language is a part of the original guideline and focuses on the diagnosis, assessment and pharmacotherapy of stable COPD. It is intended to be used mainly in primary health care but not forgetting respiratory specialists and other health care workers. The new recommendations and statements are based on the best evidence available from the medical literature, other published national guidelines and the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. This guideline introduces the diagnostic approach, differential diagnostics towards asthma, assessment and treatment strategy to control symptoms and to prevent exacerbations. The pharmacotherapy is based on the symptoms and a clinical phenotype of the individual patient. The guideline defines three clinically relevant phenotypes including the low and high exacerbation risk phenotypes and the neglected asthma-COPD overlap syndrome (ACOS). These clinical phenotypes can help clinicians to identify patients that respond to specific pharmacological interventions. For the low exacerbation risk phenotype, pharmacotherapy with short-acting β2-agonists (salbutamol, terbutaline) or anticholinergics (ipratropium) or their combination (fenoterol – ipratropium) is recommended in patients with less symptoms. If short-acting bronchodilators are not enough to control symptoms, a long-acting β2-agonist (formoterol, indacaterol, olodaterol or salmeterol) or a long-acting anticholinergic (muscarinic receptor antagonists; aclidinium, glycopyrronium, tiotropium, umeclidinium) or their combination is recommended. For the high exacerbation risk phenotype, pharmacotherapy with a long-acting anticholinergic or a fixed combination of an inhaled glucocorticoid and a long-acting β2-agonist (budesonide - formoterol, beclomethasone dipropionate - formoterol, fluticasone propionate -salmeterol or fluticasone furoate – vilanterol) is recommended as a first choice. Other treatment options for this phenotype include combination of long-acting bronchodilators given from separate inhalers or as a fixed combination (glycopyrronium – indacaterol or umeclidinium – vilanterol) or a triple combination of an inhaled glucocorticoid, a long-acting β2-agonist and a long-acting anticholinergic. If the patient has severe to very severe COPD (FEV1 < 50% predicted), chronic bronchitis and frequent exacerbations despite long-acting bronchodilators, the pharmacotherapy may include also roflumilast. ACOS is a phenotype of COPD in which there are features that comply with both asthma and COPD. Patients belonging to this phenotype have usually been excluded from studies evaluating the effects of drugs both in asthma and COPD. Thus, evidence-based recommendation of treatment cannot be given. The treatment should cover both diseases. Generally, the therapy should include at least inhaled glucocorticoids (beclomethasone dipropionate, budesonide, ciclesonide, fluticasone furoate, fluticasone propionate or mometasone) combined with a long-acting bronchodilator (β2-agonist or anticholinergic or both).This article is protected by copyright. All rights reserved.
Rationale:
Although asthma is usually considered to originate in childhood, adult-onset disease is being increasingly reported.
Objectives:
To contrast the proportion and natural history of adult-onset versus pediatric-onset asthma in a community-based cohort. We hypothesized that asthma in women is predominantly of adult onset rather than of pediatric onset.
Methods:
This study used data from the Coronary Artery Risk Development in Young Adults (CARDIA) cohort in the United States over a 25-year period. Adult- and pediatric-onset asthma phenotypes were studied, as defined by age at onset of 18 years or older. Subjects with asthma were categorized by sex, obesity, atopy, smoking, and race by mean age/examination year, using a three-way analysis of covariance model. Natural history of disease was examined using probabilities derived from a Markov chain model.
Measurements and main results:
Asthma of adult onset became the dominant (i.e., exceeded 50%) phenotype in women by age 40 years. The age by which adult-onset asthma became the dominant phenotype was further lowered for obese, nonatopic, ever-smoking, or white women. The prevalence trend with increasing time for adult-onset disease was greater among subjects with nonatopic than atopic asthma among both sexes. Furthermore, adult-onset asthma had remarkable sex-related differences in risk factors. In both sexes, the quiescent state for adult-onset asthma was less frequent and also "less stable" over time than for pediatric-onset asthma.
Conclusions:
Using a large national cohort, this study challenges the dictum that most asthma in adults originates in childhood. Studies of the differences between pediatric- and adult-onset asthma may provide greater insight into the phenotypic heterogeneity of asthma.
Asthma that starts in adulthood differs from childhood-onset asthma in that it is often non-atopic, more severe and associated with a faster decline in lung function.
Understanding of the underlying mechanism of adult-onset asthma and identification of specific phenotypes may further our understanding of pathophysiology and treatment response, leading to better targeting of both existing and new approaches for personalised management. Pivotal studies in past years have led to sustained progress in many areas, ranging from risk factors for development, identification of different phenotypes, and introduction of new therapies.
This review highlights and discusses literature on adult-onset asthma, with special focus on the differences from childhood-onset asthma, risk factors for development, phenotypes of adult-onset asthma and new approaches for personalised management.
Although asthma has been considered as a single disease for years, recent studies have increasingly focused on its heterogeneity. The characterization of this heterogeneity has promoted the concept that asthma consists of multiple phenotypes or consistent groupings of characteristics. Asthma phenotypes were initially focused on combinations of clinical characteristics, but they are now evolving to link biology to phenotype, often through a statistically based process. Ongoing studies of large-scale, molecularly and genetically focused and extensively clinically characterized cohorts of asthma should enhance our ability to molecularly understand these phenotypes and lead to more targeted and personalized approaches to asthma therapy.
Gender differences in respiratory health have, in recent years, been the focus of considerable scientific effort. This paper reviews recent literature on respiratory health in women in relation to age at menarche, menstrual cycle, irregular menstruation, polycystic ovarian syndrome, menopause and exogenous sex hormones. This literature provides substantial evidence that hormonal status plays an important role for respiratory health in women. Effects of hormonal status on the airways often appear to be heterogeneous and recent literature in particular suggests that the interplay between hormonal and metabolic factors is important. A view to developmental factors may also be relevant for the understanding of respiratory health according to hormonal status in women. Further knowledge of respiratory health in women holds interesting potential for intervention and personalized treatment.
Finland, like many other western countries, has experienced profound structural changes during the post-war period: urbanisation, increasing education, smaller family size, improved hygiene for food and household water, and prophylaxis and effective care of many potentially dangerous infectious diseases. Many of these factors have been associated with the increased risk for asthma and allergies1 which has also been found in Finland.2
In 1993 the Ministry of Social Affairs and Health in Finland recognised asthma as an important public health issue by appointing a working group to design a national programme for the prevention and alleviation of problems caused by asthma and for reduction of the relevant costs. The group decided to create an action programme emphasising guideline implementation and follow up, which are often neglected in consensus reports on asthma treatment. The 10 year programme was launched in 1994.3 The goals of prevention and treatment were stated as follows: (1) recovery of as many patients as possible with early asthma; (2) asthmatic patients should feel well and their ability for work and functional capacity should correspond with their age; (3) decline in the percentage of patients with severe and moderate asthma from the current 40% to 20%; (4) decrease in the number of bed days of asthmatic patients by 50% by the year 2000 (that is, to 50 000 a year); and (5) reduction in the annual treatment costs per patient by 50% as a result of more effective prevention and treatment of symptoms.
The measures towards achieving the goals were as follows: (1) early diagnosis and active treatment; (2) guided self-management as the primary form of treatment; (3) decrease in respiratory irritants such as smoking and tobacco smoke; (4) implementation of rehabilitation on an outpatient basis combined with normal treatment, planned individually and timed appropriately; (5) increase …
In recent years, several new studies have estimated the incidence of adult asthma. These studies vary in design and quality. The current paper summarises the findings of major population studies in the adult incidence of asthma. The pooled estimate of the adult incidence of asthma was 4.6 per 1000 person-years in women and 3.6 per 1000 person-years in men. The estimate among only general population cohort studies was higher, respectively 5.9 and 4.4 per 1000 person-years in women and men. The adult incidence of asthma was slightly higher in women than men. In the few studies that allowed the incidence of asthma to be estimated among those aged >50 years, there was a trend towards a higher incidence with age. It is thought likely that this is at least partly explained by misclassification with COPD. However, the current findings from these studies may imply that the incidence of asthma in the elderly has previously been under-estimated. Finally, the review shows that estimates of adult asthma incidence have tended to be higher in later studies, implying a rise in asthma incidence in adults within the timeframe of observation.
A National Asthma Programme was undertaken in Finland from 1994 to 2004 to improve asthma care and prevent an increase in costs. The main goal was to lessen the burden of asthma to individuals and society.
The action programme focused on implementation of new knowledge, especially for primary care. The main premise underpinning the campaign was that asthma is an inflammatory disease and requires anti-inflammatory treatment from the outset. The key for implementation was an effective network of asthma-responsible professionals and development of a post hoc evaluation strategy. In 1997 Finnish pharmacies were included in the Pharmacy Programme and in 2002 a Childhood Asthma mini-Programme was launched.
The incidence of asthma is still increasing, but the burden of asthma has decreased considerably. The number of hospital days has fallen by 54% from 110 000 in 1993 to 51 000 in 2003, 69% in relation to the number of asthmatics (n = 135 363 and 207 757, respectively), with the trend still downwards. In 1993, 7212 patients of working age (9% of 80 133 asthmatics) received a disability pension from the Social Insurance Institution compared with 1741 in 2003 (1.5% of 116 067 asthmatics). The absolute decrease was 76%, and 83% in relation to the number of asthmatics. The increase in the cost of asthma (compensation for disability, drugs, hospital care, and outpatient doctor visits) ended: in 1993 the costs were 218 million euro which had fallen to 213.5 million euro in 2003. Costs per patient per year have decreased 36% (from 1611 euro to 1031 euro).
It is possible to reduce the morbidity of asthma and its impact on individuals as well as on society. Improvements would have taken place without the programme, but not of this magnitude.
The Finnish Asthma Programme 1994-2004 focused on early intervention and disease control, thereby resulting in a significant reduction of asthma morbidity. During the follow-up period from 2000 to 2010, the number of hospital days continued to fall by 54%. Patients ≥65 years, especially women, accounted for 39% of the hospital days, and they need attention if the hospital burden is to be reduced further.
Segmentation of children with asthma and other wheezy disorders remains the main research challenge today, as it was when described 2 centuries ago. Early childhood wheezy disorders follow different temporal trajectories, probably representing different underlying mechanisms (endophenotypes). Prospective identification of endophenotypes allowing accurate prediction of the clinical course is currently not possible. The variability of the clinical course remains an enigma and difficult to predict. Three of 4 school-aged children with asthma have outgrown disease by midadulthood. The risk of persistence increases with severity, sensitization, smoking, and female sex. Genetic risk variants might help disentangle the heterogeneity of asthma and other wheezy disorders. At early school age, children with asthma have reduced lung function. It is an important and unresolved question whether the airflow limitation associated with asthma already existed at birth or developed along with symptoms. Likewise, the association between the infant's bronchial responsiveness and development of asthma and other wheezy disorders is unclear. Neither primary prevention through manipulation of environmental factors nor secondary prevention through the use of inhaled corticosteroids can effectively halt the long-term disease progression in childhood. In conclusion, the natural history of asthma and the associated airway changes is still poorly understood, and we have not managed to translate findings from long-term studies into a deeper understanding of the underlying endophenotypes or improved disease management. We propose the need for a translational research approach based on long-term clinical studies of birth cohorts with comprehensive and objective assessments of intermediate phenotypes and environmental exposures combined with interdisciplinary basic research and a systems biology approach.
Incidence of asthma increases during early adulthood. We aimed to estimate the contributions of sex and early life factors to asthma diagnosed in young adults.
1246 healthy newborn babies were enrolled in the Tucson Children's Respiratory Study. Parental characteristics, early-life wheezing phenotypes, airway function, and bronchial hyper-responsiveness to cold dry air and sensitisation to Alternaria alternata were determined before age 6 years. Physician-diagnosed asthma, both chronic and newly diagnosed, and airway function were recorded at age 22 years.
Of 1246 babies enrolled, 849 had follow-up data at 22 years. Average incidence of asthma at age 16-22 years was 12.6 per thousand person-years. 49 (27%) of all 181 cases of active asthma at 22 years were newly diagnosed, of which 35 (71%) were women. Asthma remittance by 22 years was higher in men than in women (multinomial odds ratio [M-OR] 2.0, 95% CI 1.2-3.2, p=0.008). Age at diagnosis was linearly associated with the ratio of forced expiratory volume at 1 s to forced vital capacity at age 22 years. Factors independently associated with chronic asthma at 22 years included onset at 6 years (7.4, 3.9-14.0) and persistent wheezing (14.0, 6.8-28.0) in early life, sensitisation to A alternata (3.6, 2.1-6.4), low airway function at age 6 years (2.1, 1.1-3.9), and bronchial hyper-responsiveness at 6 years (4.5, 1.9-10.0). Bronchial hyper-responsiveness (6.9, 2.3-21.0), low airway function at 6 years (2.8, 1.1-6.9), and late-onset (4.6, 1.7-12.0) and persistent wheezing (4.0, 1.2-14.0) predicted newly diagnosed asthma at age 22 years.
Asthma with onset in early adulthood has its origins in early childhood.