Papers by Tmirah Haselkorn
B92. ASTHMA PHENOTYPES: BETTER UNDERSTANDING OF ASTHMA AND RATIONALE FOR THERAPY, 2012
The journal of allergy and clinical immunology. In practice
Patients with severe or difficult-to-treat asthma on guideline-recommended Steps 4/5/6 therapy ha... more Patients with severe or difficult-to-treat asthma on guideline-recommended Steps 4/5/6 therapy have not previously been described. To characterize patients with severe or difficult-to-treat asthma on Steps 4/5/6 therapy and assess predictors of future asthma exacerbations. Patients ages ≥12 years with baseline and month 12 medication data were assigned to Steps 4/5/6 care levels from the 2007 National Heart, Lung, and Blood Institute guidelines. Demographic, atopic, and clinical characteristics at baseline and month 12 were assessed by using descriptive statistics. Asthma-related quality of life was assessed by using the Mini Asthma Quality of Life Questionnaire, and work and activity impairment was assessed by the Work Productivity and Activity Impairment Questionnaire-Asthma. Odds ratios (OR) and 95% CI for asthma exacerbation risk at month 12 were generated by using multivariable logistic regression. A total of 1186 patients were included. More than two-thirds of the patients (67...
The Journal of Allergy and Clinical Immunology: In Practice, 2014
Few data are available that evaluate the relationship among asthma exacerbations, asthma triggers... more Few data are available that evaluate the relationship among asthma exacerbations, asthma triggers, and asthma-related quality of life (QoL). To evaluate the impact of asthma exacerbations and asthma triggers on QoL. Patients with severe or difficult-to-treat asthma, ages ≥ 13 years (n = 2679) from the TENOR (The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens) 3-year observational study were included. Exacerbations were defined hierarchically in descending order of severity (hospitalization, emergency department [ED] visit, steroid burst, no exacerbation) by using data from months 6 and 12. The total number (frequency) of exacerbations was assessed. Asthma-related QoL was measured at month 12 by using the Mini-Asthma QoL Questionnaire (Mini-AQLQ); self-reported asthma triggers were collected at baseline and annually. We used 1-way ANOVA to test for differences in Mini-AQLQ domain scores across asthma exacerbation severity, the total number of asthma exacerbations, and the number of asthma triggers. A significant decrease (P < .001) in Mini-AQLQ domain scores was seen with increasing severity of asthma exacerbation (no exacerbation, steroid burst, ED visit, and hospitalization); symptom (5.5, 4.8, 4.3, and 4.2), activity (5.8, 5.2, 4.6, and 4.4), emotional (5.6, 5.0, 4.4, and 4.2), exposure (5.0, 4.5, 4.0, and 3.9); and overall (5.5, 4.9, 4.3, and 4.1). Increasing exacerbation frequency and the number of baseline asthma triggers also were associated with significant decreases in Mini-AQLQ domain scores. An increasing number of asthma triggers were associated with an increase in severity and frequency of exacerbations. Avoidance of asthma triggers may reduce exacerbation rates and improve asthma-related QoL in patients with severe or difficult-to-treat asthma. Interventional studies are warranted to further explore these outcomes.
Respiratory Medicine, 2009
Objective: To evaluate the effects of weight change on asthma control, asthma-related quality of ... more Objective: To evaluate the effects of weight change on asthma control, asthma-related quality of life, number of steroid bursts, and exacerbation of asthma symptoms in a population of adult patients with severe or difficult-to-treat asthma who participated in The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study. Methods: We categorized 2396 TENOR patients !18 years into three groups (!5 lb loss, stable, !5 lb gain), based on a AE5 lb (2.27 kg) difference between baseline and 12-month follow-up weight. We used proportional odds and logistic regression models to evaluate the effect of weight change on Asthma Therapy Assessment Questionnaire (ATAQ) and Asthma Quality of Life Questionnaire (AQLQ) scores, exacerbations, and steroid bursts at the 12-month follow-up. Results: Asthma patients who gained !5 lb (2.27 kg) during the 12-month interval between baseline and follow-up reported poorer asthma control (adjusted odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.01e1.49; p Z 0.04), worse quality of life (least square means: À0.18; 95% CI: À0.30 to À0.06; p Z 0.003), and a greater number of steroid bursts (OR: 1.31; CI: 1.04e1.66; p Z 0.02) than patients who maintained their baseline weight or lost !5 lb (2.27 kg). a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / r m e d Respiratory Medicine (2009) 103, 274e283
Pediatric Allergy and Immunology, 2010
Journal of Asthma, 2006
Skin tests are considered the gold standard for detecting allergen-specific immunoglobulin E (IgE... more Skin tests are considered the gold standard for detecting allergen-specific immunoglobulin E (IgE) in the clinical setting and are an important tool for diagnosing and managing allergic asthma. To assess the prevalence of skin testing in patients > or = 12 years enrolled in The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study. Patients were asked whether they had ever been skin tested and, if so, they were asked to provide the test results. Clinical characteristics were used to compare positive (ST+), negative (ST-), and skin test not done (STND) patients. Of 2,985 patients eligible, 85.8% recalled being skin tested. Of those tested, 93.5% were positive (allergist 95.7%, pulmonologist 87.3%). A high proportion of Whites (93.5%) and non-Whites (94.0%) were ST+; however, more non-Whites had never been skin tested (21.7% vs. 12.3%, respectively; p < 0.0001). Total serum IgE was 104.6 IU/mL for ST+ patients, 87.1 IU/mL for STND patients, and 32.4 IU/mL for ST- patients. Age at asthma onset, duration of asthma, and the prevalence of atopic disorders and asthma triggers differentiated the ST+ from the ST- group. Disease severity appeared similar between the two groups. In general, values for STND patients were closer to the ST+ group, suggesting that those not tested would have been ST+ if administered a test. The prevalence of ST+ patients was high in allergy and pulmonology practices, and in White and non-White patients. These data support the utility of a more complete allergic evaluation in severe asthmatics. Skin testing appears associated with disease pathophysiologies in asthma.
Journal of Asthma, 2006
Background. The TENOR study consists of a large cohort of subjects with severe or difficult-to-tr... more Background. The TENOR study consists of a large cohort of subjects with severe or difficult-to-treat asthma. The objective of this analysis was to evaluate demographic and clinical characteristics of subjects 12 years of age or older with immunoglobulin E (IgE)-mediated allergic asthma (skin test positive with an IgE level ≥30 to ≤700 IU/mL), and specifically, to assess gender differences in this cohort. Methods. A total of 4,756 subjects were enrolled by 283 US study sites between January and October 2001. Of those subjects 12 years or older at baseline with an IgE measure and who were skin tested (n = 2, 843), 1,783 (63%) were skin test positive and had an IgE level between ≥30 to ≤ 700 IU/mL. Results. Compared to males, females reported significantly greater healthcare utilization (steroid bursts in previous 3 months: 50% vs 42%, p < 0.001; unscheduled office visits in previous 3 months: 50% vs 36%, p < 0.0001; missed 1+ days of work/school in previous 2 weeks: 14% vs 10%, p < 0.01). Females also reported significantly more asthma control problems and lower asthma-related quality of life (4.6 ± 1.3 vs 5.2 ± 1.2; p < 0.0001); the difference was clinically meaningful. Asthma triggers and allergic comorbidities, such as allergic rhinitis and atopic dermatitis, were more common in female subjects. Despite their overall worse health outcomes, female subjects demonstrated better lung function, had similar treatment patterns, and showed no differences in physician-assessed asthma severity when compared with males. Conclusions. The reasons for these gender differences in subjects with IgE-mediated allergic asthma are complex, but results from this analysis suggest that detailed evaluations of asthma patients, including symptom-related questions and asthma-related healthcare utilization, are needed to accurately assess asthma severity and control.
Journal of Allergy and Clinical Immunology, 2009
RATIONALE: To evaluate the efficacy and tolerability of BUD/FM and FP/SM among asthma patients as... more RATIONALE: To evaluate the efficacy and tolerability of BUD/FM and FP/SM among asthma patients assigned to racial demographic groups of white (n 5 670; n 5 341, respectively), black (n 5 107; n 5 50), and other (n 5 39; n 5 15). METHODS: After a 10-14-day run-in, patients were randomized 2:1 to FD BUD/FM (160/4.5 mg 32 inhalations [320/9 mg] bid) or FD FP/SM (250/50 mg 31 inhalation bid) during an open-label study (J Allergy Clin Immunol. 2008;121:1407). After 1 month, FD FP/SM patients continued therapy; FD BUD/FM patients were randomized 1:1 to FD or AD BUD/FM for 6 months. Efficacy variables were analyzed as mean changes from baseline to the average over the randomized treatment period. RESULTS: Treatment with FD BUD/FM in patients categorized as white, black, and other, respectively, improved predose FEV 1 (0.15, 0.14, 0.15 L), morning PEF (31.38, 29.02, 35.63 L/min), nighttime symptoms (scale 0-3) (-0.36, -0.42, -0.32), and rescue use (-1.29, -1.60, -1.31 inhalations/day). Treatment with AD BUD/FM improved predose FEV 1 (0.13, 0.08, 0.18), morning PEF (35.60, 25.13, 36.95), nighttime symptoms (-0.41, -0.28, -0.43), and rescue use (-1.44, -1.30,-1.46), respectively. Treatment with FD FP/SM improved predose FEV 1 (0.16, 0.15 0.08), morning PEF (34.39, 20.30, 47.50), nighttime symptoms (-0.36, -0.40, -0.39), and rescue use (-1.35 -0.95,-1.20), respectively. The incidence of specific AEs varied among racial groups; headache was most common across groups (10.7%-13.0%). Serious AEs occurred in 20 (2.0%) white, 3 (1.9%) black and 2 (3.7%) other patients; no deaths occurred. CONCLUSIONS: Treatment with BUD/FM or FP/SM improved asthma outcomes and was well tolerated regardless of race.
Journal of Allergy and Clinical Immunology, 2008
Journal of Allergy and Clinical Immunology, 2012
Patients with severe or difficult-to-treat asthma are an understudied population but account for ... more Patients with severe or difficult-to-treat asthma are an understudied population but account for considerable asthma morbidity, mortality, and costs. The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study was a large, 3-year, multicenter, observational cohort study of 4756 patients (n=3489 adults ≥ 18 years of age, n=497 adolescents 13-17 years of age, and n=770 children 6-12 years of age) with severe or difficult-to-treat asthma. TENOR&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s primary objective was to characterize the natural history of disease in this cohort. Data assessed semiannually and annually included demographics, medical history, comorbidities, asthma control, asthma-related health care use, medication use, lung function, IgE levels, self-reported asthma triggers, and asthma-related quality of life. We highlight the key findings and clinical implications from more than 25 peer-reviewed TENOR publications. Regardless of age, patients with severe or difficult-to-treat asthma demonstrated high rates of health care use and substantial asthma burden despite receiving multiple long-term controller medications. Recent exacerbation history was the strongest predictor of future asthma exacerbations. Uncontrolled asthma, as defined by the 2007 National Heart, Lung, and Blood Institute guidelines&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; impairment domain, was highly prevalent and predictive of future asthma exacerbations; this assessment can be used to identify high-risk patients. IgE and allergen sensitization played a role in the majority of severe or difficult-to-treat asthmatic patients.
Journal of Allergy and Clinical Immunology, 2005
Patients with aspirin sensitivity experience hyperplastic sinusitis and nasal polyposis. We specu... more Patients with aspirin sensitivity experience hyperplastic sinusitis and nasal polyposis. We speculated that similar mechanisms could be acting in the lower airway and that these individuals would demonstrate more severe asthma and irreversible loss of lung function. We sought to investigate the role of aspirin-exacerbated respiratory disease (AERD) as a risk factor for the development of irreversible airway obstruction. The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study is a multicenter observational study of subjects with severe or difficult-to-treat asthma. Data were compared between subjects who reported asthma exacerbation after aspirin ingestion and those who did not. The primary measure of bronchodilator-resistant obstruction (possible remodeling) was the maximally achieved postbronchodilator spirometry averaged over the 3-year duration of the study. Adult subjects (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;/=18 years) with AERD (n = 459) were compared with subjects with non-aspirin-sensitive asthma (n = 2848). Subjects with AERD had significantly lower mean postbronchodilator percent predicted FEV(1) compared with subjects with non-aspirin-sensitive asthma (75.3% vs 79.9%, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Differences in spirometry between the 2 cohorts persisted after controlling for potential confounding variables. In addition, subjects with AERD were more likely to have severe asthma by means of physician assessment (66% vs 49%, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), to have been intubated (20% vs 11%, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), to have a steroid burst in the previous 3 months (56% vs 46%, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), and to have required high-dose inhaled corticosteroids (34% vs 26%, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). These data suggest that aspirin sensitivity is associated with increased asthma severity and possible remodeling of both the upper and lower airways.
Journal of Allergy and Clinical Immunology, 2009
for the TENOR Study Group* Background: Identification of patients at risk for asthma exacerbation... more for the TENOR Study Group* Background: Identification of patients at risk for asthma exacerbations can assist physicians in addressing disease management and improve asthma-related health outcomes. Objective: We sought to evaluate whether level of impairment, as defined by the 2007 asthma guidelines, predicts risk for future asthma exacerbations.
Journal of Allergy and Clinical Immunology, 2009
Background: Children with severe/difficult-to-treat asthma experience high morbidity including fr... more Background: Children with severe/difficult-to-treat asthma experience high morbidity including frequent severe exacerbations. More knowledge is required to identify predictors of these exacerbations to reduce their occurrence. Objective: To investigate the risk of future severe exacerbations (FSEs) in children with severe/difficult-to-treat asthma and recent severe exacerbations (RSEs). Methods: We analyzed the occurrence and association of RSE (defined as 1 or more corticosteroid bursts during the 3 months before each of 3 annual visits) and FSE (defined as 1 or more corticosteroid bursts 6 or 12 months later) in children age 6 to 11 years in The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens 3-year observational study. Repeated measures logistic regression analysis assessed the risk of FSE adjusted for demographics and clinical variables. Results: In a multivariable model, FSE at 6 months was most strongly predicted by RSE (odds ratio [OR], 3.08; 95% CI, 2.21-4.28) and having 3 to 4 allergic triggers (OR, 2.05; 95% CI, 1.31-3.20). Race (OR, 1.77; 95% CI, 1.25-2.51) and being very poorly controlled according to the impairment component of the National Heart, Lung, and Blood Institute guidelines (OR, 1.59; 95% CI, 1.14-2.23) also significantly predicted FSE. Conclusion: Recent severe asthma exacerbations are an important independent predictor of FSE in children with severe/ difficult-to-treat asthma and should be considered when establishing asthma management plans. (J Allergy Clin Immunol 2009;124:921-7.)
Journal of Allergy and Clinical Immunology, 2009
Journal of Allergy and Clinical Immunology, 2007
RATIONALE: To determine if a validated questionnaire can identify obstructive flow volume loop (F... more RATIONALE: To determine if a validated questionnaire can identify obstructive flow volume loop (FVL) in grade school children. METHODS: A group of 170 students, from an urban setting, completed with a parent the 15-item Kids Asthma Check Life Quality Test (KACLQT) prior to a school asthma screening in a mobile asthma unit. FVL and a limited examination were performed. Data were analyzed using a logistic regression model with either the total questionnaire score as a predictor or all individual questions as independent concurrent predictors. FVL results (normal vs. obstructive) was the outcome variable. RESULTS: 62 children presented with obstructive FVL, 108 with normal FVL. 50% of the children endorsed more than three questions. The obstructive FVL group scored significantly higher on the KACLQT (median score: 5, range: 0-15) than the normal group (median: 3, range: 0-12), p<0.01. Logistic regression analysis revealed a moderate (but statistically significant) increase in risk for obtaining obstructive FVL results associated with a one point increase in the questionnaire score (OR 5 1.18, 95% CI: 1.07-1.29, p<0.001). When all 15 KACLQT items were concurrently included as predictors of FVL results, endorsing the question ''colds make me cough or wheeze'' was the best predictor of obstructive results (OR 5 2.2, p 5 0.05). CONCLUSIONS: The questionnaire used in this study is a useful tool for predicting obstructive FVL in children 9-11 years of age. Higher KACLQT scores were associated with increased probability of obstructive results. Endorsing the item ''colds make me cough or wheeze'' appears to be the best predictor of an obstructive FVL. RATIONALE: Despite health initiatives for advancing management of asthma, evidence suggests that many asthmatics have uncontrolled disease. We assessed the prevalence of, and the risk factors for, uncontrolled asthma in a nationally representative population of moderate-to-severe asthmatics on standard asthma therapy. METHODS: A web-based survey was administered to a census-representative sample of adult (18 years) moderate-to-severe asthmatics diagnosed with asthma for at least one year and currently receiving multiple controller medications. The Asthma Control Test (ACT) was used to stratify respondents into controlled (score 20-25) and uncontrolled (score 5-19) cohorts. Multivariable analysis identified independent risk factors for uncontrolled asthma. RESULTS: A total of 1,812 patients were evaluated; 809 (45%) had controlled asthma and 1,003 (55%) had uncontrolled asthma. The majority of patients had healthcare coverage (88% of controlled, 86% of uncontrolled; P 5 NS) and received care from a general practitioner for their asthma; however, a large proportion of controlled (74%) and uncontrolled (65%) patients reported never receiving an asthma action plan. Inhaled corticosteroid plus long-acting beta-agonist was the most common medication regimen used in controlled (60%) and uncontrolled patients (48%). Uncontrolled patients reported significantly higher rates of healthcare utilization. Gastroesophageal reflux disease, chronic sinusitis, and high blood pressure were predictive of uncontrolled asthma. CONCLUSIONS: Uncontrolled asthma is highly prevalent (55%) in patients on standard asthma therapy. Our results support the need for a more global evaluation of asthma control, assessment of comorbid conditions, and alternative therapies for patients with difficult-to-control asthma despite guideline-based treatment.
Journal of Allergy and Clinical Immunology, 2007
RATIONALE: Historical aspirin (ASA) or nonsteroidal antiinflammatory drug (NSAID)-induced reactio... more RATIONALE: Historical aspirin (ASA) or nonsteroidal antiinflammatory drug (NSAID)-induced reactions might provide predictive information about the severity of reactions in patients with aspirin exacerbated respiratory disease (AERD) undergoing oral ASA challenges (OAC). METHODS: The provoking doses, treatments, and treatment settings of the historical ASA/NSAID-induced asthma attacks was obtained from 210 consecutive patients with suspected AERD referred for OAC and ASA desensitization. RESULTS: Of 210 subjects, 147 (70%) reported seeking acute medical care for their historical ASA/NSAID-induced asthma attacks. Of these 147, 101 (69%) were treated in ERs and released and 46 (31%) required hospitalization. During OAC in these 147 subjects, 37 (25%) had a >20% decline and 14 (10%) had a >30% decline in FEV1 values. Of the 46 patients previously hospitalized for ASA/NSAID-induced asthma attacks, 15 (33%) had a >20% decline and 6 (13%) had a >30% decline in FEV1 during OAC. By contrast, of the 63 patients who treated their prior ASA/NSAID-induced reactions at home, 10 (16%) had a >20% decline and 5 (8%) had a >30% decline in FEV1 during OAC (p value NS for both). The average provoking doses of ASA were 550 mg for the historical reaction and 62 mg during OAC. CONCLUSIONS: The severity of the historical ASA/NSAID-induced asthma attack was not helpful in predicting asthma severity during OAC. Even though 70% of patients sought acute medical care for asthma attacks provoked by therapeutic doses of ASA/NSAID, a minority had clinically significant asthma during low-dose OAC. These data provide further reassurance regarding the safety of outpatient ASA desensitization. Funding:
European Respiratory Journal, 2008
The aim of the present study was to assess the response of high-dose salmeterol/fluticasone combi... more The aim of the present study was to assess the response of high-dose salmeterol/fluticasone combination (SFC) and low-dose SFC compared with regimens without inhaled corticosteroid (ICS) plus long-acting beta-agonist (LABA) in a large cohort with severe or difficult-to-treat asthma. Subjects were administered low-dose SFC (100/50 or 250/50 microg) or high-dose SFC (500/50 microg), and a control group received medications that could include ICS or LABA but not both. The present authors calculated unadjusted and propensity score-adjusted differences in outcomes consistent with components of asthma control, comparing high-dose and low-dose SFC cohorts with controls. The low-dose SFC cohort had higher asthma-related quality of life and fewer asthma control problems compared with controls. The high-dose SFC cohort had higher forced expiratory volume in one second but higher odds of having severe asthma compared with controls. The present results support the evidence that some asthmatics achieve better outcomes while receiving a low-dose salmeterol/fluticasone combination, but also suggest that those on a high-dose salmeterol/fluticasone combination fail to achieve significant improvement in many control-related health outcomes as compared with similar patients not receiving salmeterol/fluticasone combination. These findings suggest a limited value of high-dose salmeterol/fluticasone combination compared with the alternatives. While additional studies are needed, the present findings call for alternative therapeutic approaches in severe/difficult-to-treat asthma for those unable to attain asthma control with or without salmeterol/fluticasone combination.
CHEST Journal, 2007
The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens study is among th... more The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens study is among the largest to assess persistent airflow limitation and the first to evaluate a wide range of potential risk factors in high-risk patients with severe or difficult-to-treat asthma. A better understanding is needed regarding factors associated with persistent airway obstruction; this study was performed to determine demographic and clinical characteristics associated with persistent airflow limitation. Data from adult patients (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or= 18 years old) with severe or difficult-to-treat asthma were evaluated. Patients with COPD, obesity with a restrictive respiratory pattern, or a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or= 30 pack-year history of smoking were excluded. Patients with persistent airflow limitation (postbronchodilator FEV1/FVC ratio &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or= 70% at two annual consecutive visits) and normal postbronchodilator FEV1/FVC ratio (75 to 85%) were compared. Multivariate analysis identified factors independently associated with persistent airflow limitation. Of 1,017 patients, 612 patients (60%) showed evidence of persistent airflow limitation. Risk factors were as follows: older age (odds ratio [OR] per 10 years, 1.4; 95% confidence interval [CI], 1.3 to 1.6); male gender (OR, 4.5; 95% CI, 2.3 to 8.5); black ethnicity (OR, 2.2; 95% CI, 1.3 to 3.8); current or past smoking (OR, 3.9; 95% CI, 1.8 to 8.6; and OR, 1.6; 95% CI, 1.2 to 2.3, respectively); aspirin sensitivity (OR, 1.5; 95% CI, 1.0 to 2.4); and longer asthma duration (OR per 10 years, 1.6; 95% CI, 1.4 to 1.8). Protective factors were Hispanic ethnicity, higher education, family history of atopic dermatitis, pet(s) in the home, and dust sensitivity. Persistent airflow limitation is prevalent in patients with severe or difficult-to-treat asthma and is associated with identifiable clinical and demographic characteristics.
Annals of Allergy, Asthma & Immunology, 2012
Accurate assessment of asthma control may help predict future asthma exacerbations. To evaluate a... more Accurate assessment of asthma control may help predict future asthma exacerbations. To evaluate asthma guidelines impairment domain components as predictors of exacerbations in severe/difficult-to-treat asthma. Children (aged 6-11 years; n = 289) and adolescents/adults (aged ≥ 12 years; n = 2,094) with complete baseline and 12-month data from The Epidemiology and Natural History of Asthma Outcomes and Treatment Regimens study were included. Asthma was categorized as very poorly controlled, not well-controlled, and well-controlled using impairment domain components. Effects of omitting each component on very poorly controlled and not well controlled groups were examined. Multivariable logistic regression determined the relationship of components in predicting asthma exacerbations. Omission of individual impairment domain components led to misclassification of asthma control in 11% to 39% of patients. A baseline exacerbation was the strongest independent predictor of exacerbation at month 12 in children (odds ratio = 2.94; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001) and adolescents/adults (odds ratio = 2.93; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). In children, very poorly controlled asthma-based short-acting β2-agonist use was associated with a 2-fold higher exacerbation risk (odds ratio = 2.03; P = .011). In adolescents/adults, not well controlled or very poorly controlled asthma based on short-acting β2-agonist use (odds ratio = 1.49), lung function (odds ratio = 1.66), and the Asthma Therapy Assessment Questionnaire (odds ratio = 1.94) were also independent predictors of exacerbations (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Although the combined use of individual components of the impairment domain increases the sensitivity of identifying patients at high risk for future asthma exacerbations, specific components may be more important than others in severe/difficult-to-treat asthma. Prior exacerbations, short-acting β2-agonist use, lung function, and (in adolescents/adults) the Asthma Therapy Assessment Questionnaire were independent predictors of exacerbations.
Annals of Allergy, Asthma & Immunology, 2008
Medicaid insurance has been associated with worse asthma outcomes, but the degree to which demogr... more Medicaid insurance has been associated with worse asthma outcomes, but the degree to which demographic factors contribute to this relationship has not been well explored. To evaluate whether insurance status is independently associated with health care utilization (HCU) and asthma control when demographic differences are taken into account. We used baseline data from adults with severe asthma in the Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens study. HCU was defined as hospitalization or emergency department visit for asthma in the past 3 months. Asthma control was evaluated using the Asthma Therapy Assessment Questionnaire. Multiple logistic regression was used to compare HCU and asthma control in patients with Medicaid vs those with private health insurance. Of 1315 patients analyzed, 130 (9.9%) had Medicaid insurance and 1,185 (90.1%) had private insurance. Medicaid insurance was associated with younger age, female sex, race other than white, obesity, active smoking, lower education level, and unemployment. In unadjusted analyses, Medicaid patients had significantly higher HCU (odds ratio [OR], 3.08; 95% confidence interval [CI], 2.11-4.50) and poorer asthma control (OR, 2.56; 95% CI, 1.84-3.57) compared with patients with private insurance. After adjusting for demographic differences, insurance status was no longer associated with HCU (OR, 1.43; 95% CI, 0.92-2.23), and the strength of its association with asthma control was reduced (OR, 1.67; 95% CI, 1.17-2.40). Medicaid insurance is not associated with increased HCU in patients with severe asthma once demographic factors have been taken into account but remains modestly associated with poorer asthma control.
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Papers by Tmirah Haselkorn