Long-term future risk of severe exacerbations: distinct 5-year trajectories of problematic asthma

• Main Authors: Yii, Anthony C. A., Tan, Jessica H. Y., Lapperre, Therese S., Chan, Adrian K.W., Low, Su Y., Ong, Thun H., Tan, Keng L., Chotirmall, Sanjay Haresh, Sterk, Peter J., Koh, Mariko S.
• Other Authors: Lee Kong Chian School of Medicine (LKCMedicine)
• Format: Article
• Language: English
• Published: 2017
• Online Access: https://hdl.handle.net/10356/80782; http://hdl.handle.net/10220/42235
• Institution: Nanyang Technological University

Background: Assessing future risk of exacerbations is an important component of asthma management. Existing studies have investigated short-, but not long-term risk. Problematic asthma patients with unfavorable long-term disease trajectory and persistently frequent severe exacerbations need to be identified early to guide treatment. Methods: Severe exacerbation rates over five years for 177 "problematic asthma" patients presenting to a specialist asthma clinic were tracked. Distinct trajectories of severe exacerbation rates were identified using group-based trajectory modeling. Baseline predictors of trajectory were identified and used to develop a clinical risk score for predicting the most unfavorable trajectory. Results: Three distinct trajectories were found: 58.5% had rare intermittent severe exacerbations ("infrequent"), 32.0% had frequent severe exacerbations at baseline but improved subsequently ("non-persistently frequent"), and 9.5% exhibited persistently frequent severe exacerbations, with the highest incidence of near-fatal asthma ("persistently frequent"). A clinical risk score composed of ≥2 severe exacerbations in the past year (+2 points), history of near-fatal asthma (+1 point), body mass index≥25kg/m2 (+1 point), obstructive sleep apnea (+1 point), gastroesophageal reflux (+1 point) and depression (+1 point) was predictive of the "persistently frequent" trajectory (area under the receiver operating characteristic curve: 0.84; sensitivity 72.2%, specificity 81.1% using cut-off ≥3 points). The trajectories and clinical risk score had excellent performance in an independent validation cohort. Conclusions: Patients with problematic asthma follow distinct illness trajectories over a period of five years. We have derived and validated a clinical risk score that accurately identifies patients who will have persistently frequent severe exacerbations in the future.