Risk of future exacerbations in patients with severe uncontrolled asthma in primary care

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Background: Longitudinal data on patients with severe uncontrolled asthma (SUA) in primary care is limited. Our study examines characteristics, treatment escalations and associations with future exacerbations in patients with SUA, in Swedish primary care. Methods: The study included 29,760 adult asthma patients from primary care, all with a documented visit in the Swedish National Airway Register between July 2017-February 2019 (index date). National register data provided information on lung function, medication use and exacerbations 12 months pre- and post-index. SUA was defined as GINA step 4-5 treatment, with a medication possession ratio ≥80% and a score on Asthma Control Test ≤19. Treatment escalation was defined as an increase in inhalation treatment or starting biologics. Comorbidities were identified by pharmacy claims up to 24 months pre-index. Results: SUA was identified in 4.2% of primary care patients (n = 1261), and only 5% (n = 66) had their treatment escalated post-index. Post-index exacerbations were associated with cardiovascular disease (OR 1.38 95%CI 1.06-1.08) and rhinitis (1.46, 1.14-1.88), high SABA use (1.79, 1.38-2.34) and treatment escalation (1.83, 1.08-3.11). SUA patients who escalated treatment had lower FEV1%pred (67.8 vs 80.9 vs 79.4,) and more regular OCS use (34.8% vs 17.0% vs 21.9%) compared to those who maintained or reduced their treatment step (all p<0.001). Conclusions: Only a minority of SUA patients escalated treatment in primary care. These patients had lower lung function, more OCS use and a higher risk for future exacerbation, indicating the need for earlier referral to secondary care.

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