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Management of co-morbidities in asthma

Module summary

This module will highlight the importance of the early recognition of comorbidities in patients with asthma.

Learning objectives

After completing the module, you should be able to:

  • Describe the major comorbidities associated with asthma
  • List the more common tests required to identify and assess comorbidities
  • Discuss how some comorbidities can contribute to the pathogenesis and poor control of asthma
  • Communicate the benefits of diagnosing and treating comorbidities in the overall management of asthma
  • Set out the key principles in the treatment of difficult asthma, including when to make a specialist referral


Patients with asthma often present with various comorbidities which can lead to poorer outcomes of their condition, through factors such as a misdiagnosis or misinterpretation of symptoms, and this can complicate management.1-3

For example, symptoms such as increased breathlessness may be misattributed to a patient’s asthma when they are, in fact, caused by a coexistent condition such as chronic obstructive pulmonary disease (COPD). Some comorbid conditions can alter the phenotype, or the way in which asthma presents, making it harder to diagnose. For example, the coexistence of nasal polyps in asthmatics has been linked with aspirin intolerance and a more severe asthma phenotype.1 A misdiagnosis may also occur if a patient has a coexistent condition, e.g. a psychological morbidity which causes them to incorrectly perceive their asthmatic symptoms. Clearly, the failure to correctly diagnose comorbidities can result in the inappropriate management of a patient’s asthma.1,3-5

The prevalence of comorbidities may be higher in difficult asthma, a subgroup of patients defined by the BTS/SIGN 2016 asthma guideline as having persistent symptoms and/or frequent asthma attacks despite treatment with high-dose therapies or continuous or frequent use of oral steroids.6

Difficult asthma can greatly affect a patient’s quality of life. Patients experience frequent exacerbations that can result in many days of absence from work or school. Difficult asthma increases the likelihood of hospital admission by 20 times and accounts for 50% of asthma-related expenditure in the United Kingdom.5,7

Recognising the role of comorbidities in difficult asthma, the BTS/SIGN 2016 asthma guideline recommends checking for such conditions as part of the evaluation process in a patient with difficult asthma.6

List of abbreviations
 ACOS  Asthma–COPD overlap  syndrome  ICS  Inhaled corticosteroid
 BMI  Body mass index  LAMA  Long-acting muscarinic  antagonist
 BTS/SIGN  British Thoracic Society/  Scottish Intercollegiate  Guidelines Network  OSA  Obstructive sleep apnoea
 COPD  Chronic obstructive pulmonary  disease  PEF  Peak expiratory flow
 CT  Computed topography  PPI  Proton pump inhibitor
 ECG  Electrocardiogram  RCPH  Royal College of Paediatrics  and  Child Health
 FEV1  Forced expiratory volume in 1  second  SABA  Short-acting beta agonist
 GINA  Global Initiative for Asthma  TLCO  Transfer factor for carbon  monoxide
 GORD  Gastro-oesophageal reflux  disease

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