Optimal Asthma Control: Time for a New Target

The stepwise approach to pharmacological treatment in adult asthma mandates that asthma treatment is progressively stepped up to achieve symptom control and reduce the risk of exacerbations and stepped down after a period of prolonged control. This review proposes that in adults without good asthma control, well-controlled asthma can only be achieved in approximately 70% of patients across the strata of severity, and only if there is a progressive increase in inhaled corticosteroid/long-acting β agonist therapy to a maintenance inhaled corticosteroid dose that causes the same magnitude of systemic side effects as oral prednisone at a 5-mg daily dose. Another consideration is that in a person with asthma, there are numerous overlapping disorders that can present with symptoms indistinguishable from asthma, comorbidities that contribute to poor control and lifestyle/environmental factors that require treatment in their own right and that if specifically managed might lead to better outcomes. The disparity between patients' perceptions and guideline assessment of control may be due to partially controlled asthma being associated with near-maximal levels of quality of life, with minimal impairment. Finally, it is widely assumed that asthma symptom control equates to elimination of risk of asthma attacks, an assumption that may not apply to many patients, particularly those with more severe asthma. We propose that further research be undertaken to determine the optimal levels of asthma control and the potential value of different treatment targets, such as control of type-2 airway inflammation, that can be achieved with currently available treatment, based on efficacy, side effects, and cost.