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Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) may exacerbate respiratory symptoms. A recent European Academy of Allergy and Clinical Immunology position paper recommended the use of an acronym, N-ERD (NSAID-exacerbated respiratory disease), for this hypersensitivity associated with asthma or chronic rhinosinusitis with or without nasal polyposis. Our aim was to estimate the prevalence of N-ERD and identify factors associated with N-ERD., Methods: In 2016, a cross-sectional questionnaire survey of a random adult population of 16 000 subjects aged 20-69 years was performed in Helsinki and Western Finland. The response rate was 51.5%., Results: The prevalence was 1.4% for N-ERD, and 0.7% for aspirin-exacerbated respiratory disease (AERD). The prevalence of N-ERD was 6.9% among subjects with asthma and 2.7% among subjects with rhinitis. The risk factors for N-ERD were older age, family history of asthma or allergic rhinitis, long-term smoking and exposure to environmental pollutants. Asthmatic subjects with N-ERD had a higher risk of respiratory symptoms, severe hypersensitivity reactions and hospitalisations than asthmatic subjects without N-ERD. The subphenotype of N-ERD with asthma was most symptomatic. Subjects with rhinitis associated with N-ERD, which would not be included in AERD, had the fewest symptoms., Conclusion: We conclude that the prevalence of N-ERD was 1.4% in a representative Finnish adult population sample. Older age, family history of asthma or allergic rhinitis, cumulative exposure to tobacco smoke, secondhand smoke, and occupational exposures increased odds of N-ERD. N-ERD was associated with significant morbidity., Competing Interests: Conflict of interest: H. Andersén, J. Honkamäki, E. Rönmark, A. Sovijärvi, L. Lehtimäki and P. Piirilä have nothing to disclose. P. Ilmarinen is an employee of GlaxoSmithKline, and reports personal fees from AstraZeneca, Mundipharma and Novartis outside the submitted work. L.E. Tuomisto reports personal fees and nonfinancial support from Boehringer Ingelheim, and personal fees from Astra Zeneca, outside the submitted work. H. Hisinger-Mölkänen is an employee of GlaxoSmithKline. H. Backman reports personal fees from AstraZeneca and Boehringer Ingelheim outside the submitted work. B. Lundbäck reports grants from AstraZeneca and ThermoFisher, and personal fees from Sanofi, outside the submitted work. T. Haahtela reports lecturing fees from GSK, Mundipharma, Orion Pharma and Sanofi, outside the submitted work. H. Kankaanranta reports personal fees and nonfinancial support from AstraZeneca, Boehringer Ingelheim and Orion Pharma, and personal fees from Chiesi, Novartis, Mundipharma, SanofiGenzyme and GlaxoSmithKline, outside the submitted work., (Copyright ©The authors 2022.)

Spirometry and testing for bronchodilator response have been recommended to detect asthma, and a bronchodilator response (BDR) of ≥12% and ≥200 mL has been suggested to confirm asthma. However, the clinical value of bronchodilation tests in newly diagnosed steroid-naïve adult patients with asthma remains unknown. We evaluated the sensitivity of BDR in forced expiratory volume in 1 s (FEV 1 ) as a diagnostic test for asthma in a real-life cohort of participants in the Seinäjoki Adult Asthma Study. In the diagnostic phase, 369 spirometry tests with bronchodilation were performed for 219 steroid-naïve patients. The fulfilment of each test threshold was assessed. According to the algorithm of the National Institute for Health and Care Excellence, we divided the patients into obstructive (FEV 1 /forced vital capacity (FVC) <0.70) and non-obstructive (FEV 1 /FVC ≥0.70) groups. Of the overall cohort, 35.6% fulfilled ΔFEV 1  ≥12% and ≥200 mL for the initial FEV 1 , 18.3% fulfilled ΔFEV 1  ≥15% and ≥400 mL for the initial FEV 1 , and 36.1% fulfilled ΔFEV 1  ≥9% of predicted FEV 1 at least once. One-third (31%) of these steroid-naïve patients was obstructive (pre-bronchodilator FEV 1 /FVC <0.7). Of the obstructive patients, 55.9%, 26.5% and 48.5%, respectively, met the same thresholds. In multivariate logistic regression analysis, different thresholds recognised different kinds of asthma patients. In steroid-naïve adult patients, the current BDR threshold (ΔFEV 1  ≥12% and ≥200 mL) has low diagnostic sensitivity (36%) for asthma. In obstructive patients, sensitivity is somewhat higher (56%) but far from optimal. If the first spirometry test with bronchodilation is not diagnostic but asthma is suspected, spirometry should be repeated, and other lung function tests should be used to confirm the diagnosis., Competing Interests: Conflict of interest: L.E. Tuomisto reports personal fees and nonfinancial support from Boehringer Ingelheim, and personal fees from AstraZeneca, outside the submitted work. Conflict of interest: P. Ilmarinen is an employee of GlaxoSmithKline, and reports personal fees from Mundipharma, AstraZeneca and Novartis, outside the submitted work. Conflict of interest: L. Lehtimäki reports personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Circassia, GSK, Novartis, Mundipharma, Orion Pharma, Sanofi and Teva outside the submitted work. Conflict of interest: O. Niemelä has nothing to disclose. Conflict of interest: M. Tommola reports personal fees from AstraZeneca, personal fees and nonfinancial support from Boehringer Ingelheim, personal fees from Pfizer, grants from the Orion Research Foundation, and personal fees from Chiesi and GSK, outside the submitted work. Conflict of interest: H. Kankaanranta reports grants, personal fees and nonfinancial support from AstraZeneca; personal fees from Chiesi Pharma AB; personal fees and nonfinancial support from Boehringer Ingelheim; personal fees from Novartis and Mundipharma; personal fees and nonfinancial support from Orion Pharma; personal fees from SanofiGenzyme and GlaxoSmithKline, outside the submitted work., (Copyright ©The authors 2021.)

Background: Obesity has been associated with poor outcomes of asthma in cross-sectional studies, but long-term effect of obesity on asthma remains unknown., Aims: To study the effects of obesity, found at the time of diagnosis of adult-onset asthma, on 12-year prognosis by focusing on oral corticosteroid (OCS) use and respiratory-related hospital admissions., Methods: Patients diagnosed with adult-onset asthma (n=203) were divided into three categories based on diagnostic body mass index (BMI) (<25 kg·m -2 , 25-29.9 kg·m -2 , ≥30 kg·m -2 ) and followed for 12 years as part of the Seinäjoki Adult Asthma Study. Self-reported and dispensed OCS were assessed for the 12-year period. Data on hospital admissions were analysed based on medical records., Results: 12 years after diagnosis, 86% of the patients who were obese (BMI ≥30 kg·m -2 ) at diagnosis remained obese. During the follow-up, no difference was found in weight gain between the BMI categories. During the 12-year follow-up, patients obese at diagnosis reported more frequent use of OCS courses (46.9% versus 23.1%, p=0.028), were dispensed OCS more often (81.6% versus 56.9%, p=0.014) and at higher doses (median 1350 (interquartile range 280-3180) mg versus 600 (0-1650) mg prednisolone, p=0.010) compared to normal-weight patients. Furthermore, patients who were obese had more often one or more respiratory-related hospitalisations compared to normal-weight patients (38.8% versus 16.9%, p=0.033). In multivariate logistic regression analyses, obesity predicted OCS use and hospital admissions., Conclusions: In adult-onset asthma, patients obese at diagnosis mostly remained obese at long-term and had more exacerbations and respiratory-related hospital admissions compared to normal-weight patients during 12-year follow-up. Weight loss should be a priority in their treatment to prevent this outcome., Competing Interests: Conflict of interest: P. Ilmarinen reports grants and personal fees for lectures from AstraZeneca, personal fees for lectures from Mundipharma, GlaxoSmithKline and Novartis, outside the submitted work. Conflict of interest: A. Pardo has nothing to disclose. Conflict of interest: L.E. Tuomisto reports personal fees for lectures and meeting attendance from Boehringer Ingelheim and AstraZeneca, outside the submitted work. Conflict of interest: I. Vähätalo has nothing to disclose. Conflict of interest: O. Niemelä has nothing to disclose. Conflict of interest: P. Nieminen has nothing to disclose. Conflict of interest: H. Kankaanranta reports grants, personal fees for lectures and consultancy, and non-financial support for meeting attendance from AstraZeneca, personal fees for lectures and consultancy from Chiesi Pharma AB, Novartis and GlaxoSmithKline, personal fees for lectures from Mundipharma, personal fees for lectures and consultancy, and non-financial support for meeting attendance from Boehringer Ingelheim and Orion Pharma, personal fees for consultancy from SanofiGenzyme, outside the submitted work., (Copyright ©ERS 2021.)

Background: In short-term studies, poor adherence to inhaled corticosteroids (ICS) has been associated with worse asthma control, but the association of long-term adherence and disease control remains unclear., Objective: To assess the relationship between 12-year adherence to ICS and asthma control in patients with adult-onset asthma., Methods: As part of the Seinäjoki Adult Asthma Study, 181 patients with clinically confirmed new-onset adult asthma and regular ICS medication were followed-up for 12 years. Adherence (%) to ICS was assessed individually ((µg dispensed/µg prescribed)×100) during the follow-up. Asthma control was evaluated after 12 years of treatment according to the Global Initiative for Asthma 2010 guideline., Results: Asthma was controlled in 31% and not controlled (partly controlled or uncontrolled) in 69% of the patients. Patients with not-controlled asthma were more often male, older, nonatopic and used higher doses of ICS than those with controlled disease. The mean±sd 12-year adherence to ICS was 63±38% in patients with controlled asthma and 76±40% in patients with not-controlled disease (p=0.042). Among patients with not-controlled asthma, those with lower 12-year adherence (<80%) had more rapid decline in forced expiratory volume in 1 s (-47 mL·year -1 ) compared to patients with better adherence (≥80%) (-40 mL·year -1 ) (p=0.024). In contrast, this relationship was not seen in patients with controlled asthma., Conclusions: In adult-onset asthma, patients with not-controlled disease showed better 12-year adherence to ICS treatment than those with controlled asthma. In not-controlled disease, adherence <80% was associated with more rapid lung function decline, underscoring the importance of early recognition of such patients in routine clinical practice., Competing Interests: Conflict of interest: I. Vähätalo has nothing to disclose. Conflict of interest: H. Kankaanranta reports fees for lectures and consulting, costs for attending an international congress, and research grant to his institution from AstraZeneca; fees for consulting from Chiesi Pharma AB; fees for lectures and consulting, and costs for attending an international congress from Boehringer Ingelheim; fees for lectures and consulting from Novartis; fees for lectures from Mundipharma; fees for lectures and consulting, and costs for attending international congress from Orion Pharma; fees for consulting from SanofiGenzyme; and fees for lectures and consulting from GlaxoSmithKline, all outside the submitted work. Conflict of interest: L.E. Tuomisto reports costs for attending an international congress and costs for lecture from Boehringer Ingelheim, and costs for a lecture from AstraZeneca, outside the submitted work. Conflict of interest: O. Niemelä has nothing to disclose. Conflict of interest: L. Lehtimäki reports personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Circassia, GSK, Novartis, Mundipharma, Orion Pharma, Sanofi and Teva, outside the submitted work. Conflict of interest: P. Ilmarinen reports a grant for analysis and write-up of a study, and a fee for a lecture from AstraZeneca; fees for lectures from Mundipharma and GlaxoSmithKline; and a fee for a lecture and for preparing presentation material from Novartis, all outside the submitted work., (Copyright ©ERS 2021.)

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., Competing Interests: Conflict of interest: I. Vähätalo reports personal fees for a lecture from AstraZeneca outside the submitted work. Conflict of interest: P. Ilmarinen reports a grant for analysis and write-up of a study and a fee for a lecture from AstraZeneca, and personal fees for lectures from Mundipharma, GlaxoSmithKline and Orion, outside the submitted work. Conflict of interest: L.E. Tuomisto reports reimbursement of costs for attending international congresses from Chiesi, Boehringer Ingelheim, Orion Pharma and TEVA; reimbursement of costs for a lecture from AstraZeneca; and attendance of an advisory board meeting for Novartis, outside the submitted work. Conflict of interest: M. Tommola reports personal fees for lectures from AstraZeneca, Pfizer and Chiesi; personal fees for lectures and consultation from Boehringer Ingelheim; and grants from the Orion Research Foundation, outside the submitted work. Conflict of interest: O. Niemelä has nothing to disclose. Conflict of interest: L Lehtimäki reports personal fees from ALK, AstraZeneca, Boehringer Ingelheim, Chiesi, GSK, Novartis, Mundipharma, OrionPharma, SanofiGenzyme and Teva, outside the submitted work. Conflict of interest: P. Nieminen has nothing to disclose. Conflict of interest: H. Kankaanranta reports fees for lectures and consulting, costs for attending an international congress, and a research grant to their institution from AstraZeneca; fees for consulting from Chiesi Pharma AB, SanofiGenzyme and GlaxoSmithKline; fees for lectures and consulting, and costs for attending international congresses from Boehringer Ingelheim and Orion Pharma; fees for lectures and consulting from Novartis; and fees for lectures from Mundipharma, outside the submitted work., (Copyright ©ERS 2020.)

Occupational exposure to vapours, gases, dusts or fumes (VGDF) increases the prevalence of asthma-COPD overlap (ACO) in adult-onset asthma. VGDF exposure is independently associated with ACO and an additive effect with smoking is proposed. http://bit.ly/2LiMiXW., Competing Interests: Conflict of interest: M. Tommola reports personal fees for lectures from AstraZeneca, Filha ry, GlaxoSmithKline, Pfizer and Chiesi, personal fees for lectures and consultation from Boehringer Ingelheim, and grants from the Orion Research Foundation, outside the submitted work. Conflict of interest: P. Ilmarinen reports grants from AstraZeneca, and payment for lectures from Mundipharma, Orion and AstraZeneca, outside the submitted work. Conflict of interest: L.E. Tuomisto reports compensation of costs for attending an international congress from Chiesi, Orion Pharma and Teva, for attending an international congress and costs for lectures from Boehringer Ingelheim, and for lectures from AstraZeneca, outside the submitted work. Conflict of interest: L. Lehtimäki reports personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GSK, Mundipharma, Novartis, Orion Pharma, Teva and ALK, outside the submitted work. Conflict of interest: H. Kankaanranta reports grants from AstraZeneca, during the conduct of the study; as well as personal fees and non-financial support from AstraZeneca and Boehringer Ingelheim, personal fees from Chiesi Pharma AB, GlaxoSmithKline, Leiras-Takeda, MSD, Novartis, Mundipharma, Roche, Sanofi Genzyme and Orion Pharma, and non-financial support from Intermune, all outside the submitted work., (Copyright ©ERS 2019.)