HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Strek, M. E. Search for Related Content PubMed PubMed Citation Articles by Strek, M. E.

Difficult Asthma

Section of Pulmonary and Critical Care Medicine, Department of Medicine, and Committee on Clinical Pharmacology and Pharmacogenetics, University of Chicago, Chicago, Illinois

Correspondence and requests for reprints should be addressed to Mary E. Strek, M.D., Department of Medicine, MC 6076, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637. E-mail: mstrek{at}medicine.bsd.uchicago.edu

ABSTRACT

The correct diagnosis of asthma is usually easily made and most patients with asthma respond to therapy. Approximately 5% of patients with asthma, however, have disease that is difficult to control despite taking maximal doses of inhaled medications. Patients with therapy-resistant or difficult-to-control asthma require a rigorous and systematic approach to their diagnosis and treatment. The first step is evaluation and testing directed at determining that asthma is the correct diagnosis. Many diseases mimic asthma and these alternate diagnoses should be considered. The second step is to identify and eliminate triggers that worsen asthma. Cigarette smoking, occupational exposures, and allergic rhinitis contribute to worsening disease. Most patients with "difficult asthma" require treatment with high-dose inhaled corticosteroids and long-acting inhaled ß₂-agonists. Despite maximal inhaled therapy, these patients will require either frequent bursts or chronic daily therapy with oral corticosteroids. These patients may have "resistant" inflammation with a persistent inflammatory state. Numerous studies also suggest that compliance with asthma therapy is poor. Combination therapy with inhaled corticosteroids and long-acting ß₂-agonist in a single inhaler may improve patient compliance. In selected patients, additional therapy with leukotriene modifiers or anti-IgE antibody can result in improved asthma control and may allow tapering of corticosteroids. Use of methotrexate is not justified based on current data. Emerging evidence suggests that different phenotypes of difficult or therapy-resistant asthma exist. Recognition of these subgroups allows tailored therapy and prevents overmedication in an attempt to normalize lung function in patients with irreversible airflow obstruction.

Key Words: asthma • diagnosis • difficult asthma • management

This article has been cited by other articles:

				R. L. Sorkness, E. R. Bleecker, W. W. Busse, W. J. Calhoun, M. Castro, K. F. Chung, D. Curran-Everett, S. C. Erzurum, B. M. Gaston, E. Israel, et al. Lung function in adults with stable but severe asthma: air trapping and incomplete reversal of obstruction with bronchodilation J Appl Physiol, February 1, 2008; 104(2): 394 - 403. [Abstract] [Full Text] [PDF]

				I. D. Pavord, G. Cox, N. C. Thomson, A. S. Rubin, P. A. Corris, R. M. Niven, K. F. Chung, M. Laviolette, and the RISA Trial Study Group Safety and Efficacy of Bronchial Thermoplasty in Symptomatic, Severe Asthma Am. J. Respir. Crit. Care Med., December 15, 2007; 176(12): 1185 - 1191. [Abstract] [Full Text] [PDF]