When to “Undiagnose” Asthma

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Asthma may not be a permanent diagnosis in adults. A study finds that up to one-third of adults with clinician-diagnosed asthma no longer have it after 5 years.



Practice Changer

Two years ago, a now 45-year-old woman was diagnosed with asthma based on her history and physical exam findings; she was prescribed an inhaled corticosteroid and a bronchodilator rescue inhaler. She has had no exacerbations since. Should you consider weaning her off the inhalers?

Asthma is a prevalent problem; 8% of adults ages 18 to 64 have the chronic lung disease.2 Diagnosis can be challenging, partially because it requires measurement of transient airway resistance, and treatment entails significant costs and possible adverse effects. Without pulmonary function measurement or trials off medication, there is no clinical way to differentiate patients with well-controlled asthma from those who are being treated unnecessarily. Not surprisingly, studies have shown that ruling out active asthma and reducing medication use are cost effective.3,4 This study followed a cohort of patients to see how many could be weaned off their asthma medications.


About one-third of adults with asthma are “undiagnosed” within 5 years

The researchers recruited participants from the general population of the 10 largest cities and surrounding areas in Canada by randomly dialing cellular and landline phone numbers and asking about adult household members with asthma.1 The researchers focused on those with a recent (<5 years) asthma diagnosis to represent contemporary diagnostic practice and make it easier to collect medical records. Participants lived within 90 minutes of 10 medical centers. Patients were excluded if they were using long-term oral steroids, were pregnant or breastfeeding, were unable to tolerate spirometry or methacholine challenges, or had a smoking history of >10 pack-years.

Of the 701 patients enrolled, 613 (87.4%) completed all study assessments. Patients progressed through a series of spirometry tests and were then tapered off their asthma-controlling medications.

The initial spirometry test confirmed asthma if bronchodilators caused a significant improvement in forced expiratory volume in one second (FEV1). Patients who showed no improvement took a methacholine challenge 1 week later; if they did well, their maintenance medications were reduced by half. About 1 month later, another methacholine challenge was given; if the patient did well, maintenance medications were stopped and the patient underwent a third methacholine challenge 3 weeks later.

Asthma was confirmed at any methacholine challenge if there was a 20% decrease in FEV1 from baseline at a methacholine concentration of ≤8 mg/mL; these patients were restarted on appropriate medications. If current asthma was ruled out, follow-up bronchial challenges were repeated at 6 and 12 months.

Results. Among the patients with clinician-diagnosed asthma, 33.1% no longer met criteria for an asthma diagnosis. Of those who no longer had asthma, 44% had previously undergone objective testing of airflow limitation. Another 12 patients (2%) had other serious cardiorespiratory conditions instead of asthma (eg, ischemic heart disease, subglottic stenosis, and bronchiectasis).

Continue to: During the 1-year follow-up period...

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