Main text
The paper by Tomisa et al. [1] describes the prevalence of several common comorbidities of asthma in relation to patient characteristics (age, gender and body mass index [BMI]) and their association with asthma control in a large, specialist-managed patient population.
Although just cryptically mentioned in this paper and presumably hidden under the name of seasonal rhinitis/perennial rhinitis (according to ARIA intermittent or persistent), CRS is a common and prevalent disease imposing a significant health problem that is known to affect up to 10.9% of the global population, while severe CRSwNP is present in approximately 1–2% of the European population [2]. The prevalence of asthma in CRSsNP patients is 21.2%, and 44.9% for CRSwNP patients [3]. Both lead to a significant burden on society in terms of healthcare consumption and productivity loss [4‐6].
Anzeige
CRSwNP is an invalidating disease characterized by type 2 inflammation with a major impact on quality of life of those severely affected and often associated with comorbidities such as asthma, allergies, sleep-disordered breathing and non-steroidal anti-inflammatory drugs exacerbated respiratory disease (N-ERD) [7, 8].
Despite a substantial burden and affect of quality of life in individuals (extensively confirmed with validated questionnaires including the general health EQ-5D [9, 10] and SF36 [11, 12]), their relatives, as well as society and health economics, CRS often remains un-diagnosed, and thus under-estimated, and consequently under- or mistreated [13].
The work by Tomisa et al. does not give a prominent role to rhinitis or CRS to influence the control or severity of asthma. However, given the anatomic, epidemiologic and pathophysiologic connections between the upper and lower airways [14‐16], the concept of united airway disease (one airway – one disease, as exposed in EPOS and GINA) has gained more interest in the past years, leading to better diagnosis and therapeutic approaches in patients with such problems [17‐19]. Lower airway inflammation often co-exists in CRS, with up to two-thirds of those patients affected by comorbid asthma, COPD or bronchiectasis [20‐23].
Several immune mechanisms have been reported to be involved in the naso-bronchial interaction in patients with global airway disease. Type 2 inflammation, present in the majority of adult asthma patients, has also been demonstrated in their sinonasal secretions [24, 25]. In addition, challenging either compartment of the airways has been shown to induce inflammation in the counterpart [26].
Anzeige
More recently, targeted treatment options with biologics provided further insight into the underlying mechanisms and relationship between upper and lower airways in patients with asthma and CRSwNP. Therefore, it is not surprising that biological treatments targeting inflammatory pathways and molecules such as IL-4, IL-13, IL-5 and IgE in both upper and lower airway T2-high inflammation are effective in both asthma and CRSwNP [27‐31].
Further evidence for associations between upper and lower airway compartments has shown that co-existent CRS increases the patient´s risk of exacerbations even if they have few asthma symptoms, and it is associated with a more severe asthma course, especially in patients with nasal polyps [32, 33].
Like other comorbidities such as obesity, sleep apnoea, and anxiety, the presence of AR or CRS are among the criteria for difficult-to-treat asthma [34].
In fact, the HELIUS study showed CRS to be associated with adult-onset asthma [35] and the Asthma Clinical Research Network demonstrated that CRS is associated with increased risk of asthma exacerbations [36].
Chen et al. [37] identified patients newly diagnosed with asthma in Taiwan and analyzed the incidence of CRS in that population. After adjustment for gender, age and medical comorbidities, they showed that asthma is an independent predictor of CRS, with or without nasal polyps (OR: 2.58 for CRSsNP).
In addition, endoscopic sinus surgery in asthma has been reported to improve multiple clinical asthma parameters [38]. The frequency of severe asthma exacerbations decreased in 84.8% (95% CI, 76.6–93.0%) of patients and the number of hospitalizations decreased in 64.4% (95% CI, 53.3–75.6%). Decreased use of oral corticosteroids was seen in 72.8% (95% CI, 67.5–78.1%) of patients; inhaled corticosteroid use decreased in 28.5% (95% CI, 22.6–34.5%) and bronchodilator use decreased in 36.3% (95% CI, 28.9–43.7%) of patients [39].
Unable to access the questionnaire applied, we can only speculate why CRS is not explicitly mentioned in this paper. Possibly, the sample consisted of patients with allergic asthma, which is associated with AR more than CRS and not with late-onset non-allergic asthma.
However, we found it very interesting that this work is based on a previous one (Tomisa G et al. Prevalence and impact of risk factors for poor asthma outcomes in a large, specialist-managed patient cohort: a real-life study. J Asthma Allergy. 2019; 12:297–307. https://doi.org/10.2147/JAA.S211246), in which the same sample was used, and AR and CRS are named as the first comorbidity found and also remarked as one of the main risk factors for uncontrolled disease.
Anzeige
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
Diego Conti is the academic manager at EUFOREA. He has no competing interest to declare. Peter Hellings is consultant and recipient of lecture fees and/or research grants from Sanofi, Regeneron, Novartis, GSK, ALK, and Viatris. Zuzana Diamant received in the past three years speaker fees or honoraria or serving on advisory boards or as a consultant from Antabio, Boehringer Ingelheim, Foresee Pharmaceuticals, GlaxoSmithKline, QPS-Netherlands, Sanofi-Genzyme-Regeneron, all outside the submitted work. Leif Bjermer has no competing interest to declare in relation to this work. Milos Jesenak reports receiving consultancy/speaker honoraria from CSL Behring, SOBI, Novartis, GSK, Sanofi, Viatris, and Takeda Pharmaceutical Co. Ltd.; and serving as a principal investigator for clinical trials sponsored by Takeda, Mundipharma, Octapharma, BioCryst Pharmaceuticals, Inc. and Pharming Group NV. Vibeke Backer has no competing interest to declare in relation to this work. Wytske Fokkens has no competing interest to declare in relation to this work. Susanne Lau has received honoraria for lectures and AD Boards from Sanofi-Aventis, DBV, Allergopharma, ALK, Leti, GSK, and Leo Pharma in the last three years. Elizabeth Van Staeyen is the Scientific Communications & Advocacy Manager at EUFOREA. She has no competing interest to declare. Glenis Scadding is a Board member of EUFOREA. She has received remuneration from Sanofi Regeneron and has undertaken trials for GSK.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.