Elsevier

The Lancet

Volume 391, Issue 10118, 27 January–2 February 2018, Pages 350-400
The Lancet

The Lancet Commissions
After asthma: redefining airways diseases

https://doi.org/10.1016/S0140-6736(17)30879-6Get rights and content

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Executive summary

Asthma is responsible for considerable global morbidity and health-care costs. Substantial progress was made against key outcomes such as hospital admissions with asthma and mortality in the 1990s and early 2000s, but little improvement has been observed in the past 10 years, despite escalating treatment costs. New assessment techniques are not being adopted and new drug discovery has progressed more slowly than in other specialties.

In this Commission, we aim to provide our view of where we are

Changes in the concept of asthma over the years

Asthma has been recognised since antiquity. The word asthma is derived from the Greek ασθμα, meaning a short-drawn breath, hard breathing, or death rattle (figure 2) and thus was, at the outset, a term used to describe a complex of symptoms rather than a specific disease entity. Early pathogenic models suggested that airflow to the body was impeded by phlegm from the brain lodging in the lungs. These models also indicated an association between the condition and environmental factors, including

The rise and fall of guidelines

The framework for the management of asthma, recommended by numerous national and international guidelines, is a one-size-fits-all stepwise approach based on the level of asthma control (figure 6). This basic construct has not changed much since the first guidelines were published 27 years ago.14, 15, 16, 17 Current treatment is initiated with an inhaled short-acting β2 agonists as required in intermittent asthma, with the addition of maintenance low-dose inhaled corticosteroids in mild

Where are we now?

The evolution of airway function in patients between the first and tenth decade has been illustrated by curves produced from almost 100 000 cross-sectional observations (panel 6). These curves and other data highlight three key stages of life in which abnormal lung development can affect long-term risk of airways disease: birth, childhood, and after age 25 years. First, normal lung function should be confirmed at birth because abnormal lung function at birth or in patients younger than 5 years

Where are we now?

The greatest unmet need in asthma is generally considered to be the requirement for more effective therapeutics for patients with chronic asthma who are refractory to currently available treatments. Although this requirement understandably resonates with treating physicians and their patients, the blanket acceptance of this need as the number one priority across a substantial proportion of the asthma research community, and among drug developers, health-care providers, and regulatory

Where are we now?

Clear terminology is important. Definitions vary and some events, such as episodes of increased symptoms or increased airflow limitation, have been identified as mild exacerbations in some studies.89, 268 These episodes tend to be responsive to short-acting β2 agonists prescribed for relief and are prevented by long-acting β2 agonists, whereas events leading to the prescription of oral corticosteroids or hospital admission are less responsive,89, 188 suggesting important differences in

Where are we now?

The UK national report on asthma deaths86 stated that 60% of asthma deaths were in patients with mild or moderate asthma. These findings suggest that our definitions of severe asthma must be wrong, because it is difficult to think of a worse outcome than death. The conventional definition of severe asthma is of symptoms and poor lung function or exacerbations (used interchangeably) despite the prescription of high-dose anti-inflammatory and bronchodilator therapy.286 This subset of patients

Clinical trials

Since the 1990s, clinical research has been characterised by randomised controlled trials of moderate and severe asthma, in populations poorly generalisable to asthma patients in clinical practice,179 without characterisation of phenotypic subgroups, and inadequate consideration of other treatable traits associated with overlapping disorders, comorbidities, and lifestyle or environmental factors. Progress could have also been delayed by the pharmaceutical industry setting the agenda primarily

Overall conclusions and recommendations

The Commissioners collectively identified seven key recommendations, along with ideas for operationalising them and assessing their effect. We specify goals over the next 25 years.

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