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Physicians still have great difficulty in diagnosing asthma. Over- and under diagnosis both occur for this lung disease from which around 300 million people suffer worldwide.1 For diagnosing asthma, after careful history taking, lung function testing is considered the most relevant investigation. However, other parameters could also assist in completing the asthma jigsaw. Since atopy is one of the predisposing factors for asthma, measurement of specific IgE (sIgE) could be of assistance. This statement only applies to sIgE and not to total IgE measurement, which cannot be used as crucial evidence for allergy diagnosis.2.

Marjan Kerkhof,1 Jaco Voorham,1 Paul Dorinsky,2 Claudia Cabrera,3,4 Patrick Darken,5 Janwillem WH Kocks,1,6 Mohsen Sadatsafavi,7,8 Don D Sin,7,8 Victoria Carter,1 David B Price1,9 1Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore; 2AstraZeneca, Durham, NC, USA; 3AstraZeneca, Mölndal, Sweden; 4Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden; 5AstraZeneca, Morristown, NJ, USA; 6General Practitioners Research Institute, Groningen, The Netherlands; 7Respiratory Evaluation Sciences Program, Collaboration for Outcomes Research and Evaluation, University of British Columbia, Vancouver, BC, Canada; 8Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, BC, Canada; 9Academic Primary Care, University of Aberdeen, Aberdeen, UKCorrespondence: David B Price Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UKTel +65 6962 3627Email dprice@opri.sgIntroduction: Early identification of preventable risk factors of COPD progression is important. Whether exacerbations have a negative impact on disease progression is largely unknown. We investigated whether the long-term occurrence of exacerbations is associated with lung function decline at early stages of COPD.Methods: Patients diagnosed with mild/moderate COPD (obstruction and FEV1% predicted 50– 90%), aged ≥ 35 years, and a smoking history, who had ≥ 6 years of UK electronic medical records after initiation of maintenance therapy were studied. Multilevel mixed-effect linear regression was performed to determine the association between the count of any year in which the patient had ≥ 1 exacerbation over a 6-year period and FEV1 decline, adjusted for sex, age, anthropometrics and smoking habits. Exacerbations were defined as any prescription for an acute oral corticosteroid course and/or lower respiratory-related antibiotics and/or any COPD-related emergency or inpatient hospitalization.Results: Of 11,337 patients included (mean age 65 years; 49% female) 31.6%, 23.3%, 16.6%, 11.6%, 8.1%, 5.3% and 3.4% had 0, 1, 2, 3, 4, 5 and 6 years with ≥ 1 exacerbation. The mean annual FEV1 decline accelerated by 1.50 mL/year (95% Confidence Interval 1.02; 1.98) with every additional year with ≥ 1 exacerbation from 31.0 mL/year in subjects without any exacerbation to 40.0 mL/year in patients experiencing ≥ 1 exacerbation every year. Patients with more years with ≥ 1 exacerbation had a lower mean FEV1 at first diagnosis: 14.7 mL (11.7; 17.8) lower with every additional year with exacerbations. When counting years with ≥ 2 exacerbations, greater effects were observed (2.19 [1.50; 2.88] mL/year excess decline per year with ≥ 2 exacerbations; 16.5 mL [12.1; 20.8] lower FEV1 at diagnosis).Conclusion: Patients who experienced a greater exacerbation burden after initiation of maintenance therapy had worse lung function at diagnosis and a more rapid lung function decline thereafter, which emphasizes the need for better treatment strategies.Keywords: COPD, exacerbations, spirometry, inhalation therapy, observational study

Konstantinos Kostikas,1 Chin Kook Rhee,2 John R Hurst,3 Piergiuseppe Agostoni,4,5 Hui Cao,6 Robert Fogel,6 Rupert Jones,7 Janwillem WH Kocks,8– 10 Karen Mezzi,1 Simon Wan Yau Ming,8 Ronan Ryan,8 David B Price8,11 1Novartis Pharma AG, Basel, Switzerland; 2Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea; 3UCL Respiratory, University College London, London, UK; 4Centro Cardiologico Monzino, IRCCS, Milan, Italy; 5Department of Clinical Science and Community Health, University of Milan, Milan, Italy; 6Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA; 7Plymouth University, Faculty of Medicine and Dentistry, Plymouth, UK; 8Observational and Pragmatic Research Institute, Singapore, Singapore; 9General Practitioners Research Institute, Groningen, the Netherlands; 10Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, Groningen, the Netherlands; 11Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UKCorrespondence: David B PriceCentre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UKTel +65 6802 9724Email dprice@opri.sgPurpose: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) often occur concomitantly, presenting diagnostic and therapeutic challenges for clinicians. We examined the characteristics of patients prescribed adequate versus inadequate therapy within 3 months after newly diagnosed comorbid COPD or HF.Patients and Methods: Eligible patients in longitudinal UK electronic medical record databases had pre-existing HF and newly diagnosed COPD (2017 GOLD groups B/C/D) or pre-existing COPD and newly diagnosed HF. Adequate COPD therapy was defined as long-acting bronchodilator(s) with/without inhaled corticosteroid; adequate HF therapy was defined as beta-blocker plus angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker.Results: Of 2439 patients with HF and newly diagnosed COPD (mean 75 years, 61% men), adequate COPD therapy was prescribed for 726 (30%) and inadequate for 1031 (42%); 682 (28%) remained untreated for COPD. Adequate (vs inadequate) COPD therapy was less likely for women (35%) than men (45%), smokers (36%) than ex-/non-smokers (45%), and non-obese (41%) than obese (47%); spirometry was recorded for 57% prescribed adequate versus 35% inadequate COPD therapy. Of 12,587 patients with COPD and newly diagnosed HF (mean 75 years, 60% men), adequate HF therapy was prescribed for 2251 (18%) and inadequate for 5332 (42%); 5004 (40%) remained untreated for HF. Adequate (vs inadequate) HF therapy was less likely for smokers (27%) than ex-/non-smokers (32%) and non-obese (30%) than obese (35%); spirometry was recorded for 65% prescribed adequate versus 39% inadequate HF therapy.Conclusion: Many patients with comorbid COPD/HF receive inadequate therapy after new diagnosis. Improved equity of access to integrated care is needed for all patient subgroups.Keywords: beta-blocker, long-acting bronchodilator, integrated care, multimorbidity

BACKGROUND: Medication non-adherence management of patients with asthma/COPD remains challenging. Given the multitude of underlying causes, a personalized approach is required. The Test of Adherence to Inhalers (TAI) can identify reasons for non-adherence, but does not provide guidance on how to effectively act on results. OBJECTIVE: To develop a practical, evidence-based decision support toolkit for healthcare professionals managing adult patients with asthma and/or COPD, by matching TAI-identified adherence barriers to proven effective adherence enhancing interventions. METHODS: A literature review in PubMed and Embase was performed identifying interventions that enhanced medication adherence in adult patients with asthma and/or COPD. Randomised controlled trials (RCTs) published in English with full-texts available were included. Effective interventions were assessed by the Cochrane risk of bias tool, categorized, matched with specific TAI responses and developed into a practical TAI Toolkit. The Toolkit was assessed on content and usability (System Usability Scale, SUS) by a multidisciplinary group of healthcare professionals. RESULTS: Forty RCTs were included in the review. In total, seven effective interventions catergories were identified, informing the TAI Toolkit: reminders, educational interventions, motivational strategies, feedback on medication use, shared decision making, simplifying medication regimen and multiple component interventions. Healthcare professionals rated the TAI Toolkit with a mean SUS score of 71.4 (range: 57.5-80.0). CONCLUSION: Adherence can be improved using different interventions that the TAI Toolkit helps selecting. The TAI Toolkit was well received by healthcare professionals. Further research is required to test its validity, practicality and effectiveness in practice.