Disease trajectory and treatment escalation in asthma: A retrospective analysis of data from the optimum patient care research database (OPCRD)

Background: Approximately 5% of patients with asthma have severe disease. Treatment escalation may occur despite symptoms not being due to asthma, leading to comorbidities occurring. Objective: To explore factors associated with treatment escalation to Global Initiative for Asthma (GINA): step 4/5 in patients with asthma. Methods: A nested case-control study of patients with asthma from the Optimum Patient Care Research Database. Study 1: patients who transitioned from GINA: steps 2/3 to steps 4/5 were compared with matched controls (GINA: step 2/3). Study 2: patients who transitioned from step 4 to step 5 were compared with matched controls (step 4). Results: Study 1: Step 4/5 cases (n = 12,780) were older, obese, predominantly female, more comorbid (≥2) with increased exacerbations versus step 2/3 controls (n = 31,974) (P < .001). Exacerbations increased nearing treatment escalation in cases but not controls. Study 2: There was no difference in age, sex, or obesity levels in step 5 cases (n = 12,780) versus step 4 controls (n = 31,974). Cases were more comorbid (≥2) (54.0% vs 44.3%, P = .001), with increased mood disorder levels (depression/anxiety) (21.0% vs 13.7%, P = .002) and more exacerbations (81.4% vs 34.3%, P < .001), versus controls. Exacerbations and mood disorder were associated with treatment escalation (P < .001). Mood disorder and exacerbations were more common in cases than in controls, before study entry, but increased in cases alone nearing treatment escalation. Conclusions: Treatment escalation is associated with mood disorder and asthma exacerbations. Obesity is highly prevalent in patients with asthma before treatment escalation. A symptom-based treatment approach potentially exposes patients to inappropriate treatment escalation.