We are grateful to F. Madsen, and A. Bush and colleagues for their positive comments on the work of the American Thoracic Society/European Respiratory Society Task Force on Asthma Control, Severity and Exacerbations, only part of which is contained in the recently published article 1. We await the publication of the full statement, which contains specific recommendations about the assessment of asthma control.
We agree with F. Madsen that social and cultural perspectives on the part of the patient as well as the clinician will determine the relationship between optimum asthma control and the minimum treatment required to achieve it. In the paper we state that “the patient's perspective of what constitutes “ideal” control may reflect a personal balance of priorities between clinical benefits and real or perceived risks (including side-effects and the cost of treatment)”. This is consistent with F. Madsen’s operational definition.
However, for reasons outlined in the article 1, it remains important that the relationship between treatment requirements and asthma severity should be considered separately. Asthma severity is defined as “the intensity of treatment required to control the patient's asthma”. This is focused more on objective rather than subjective measurements, and is affected by the asthma phenotype. The distinction may seem subtle, but it is an important one which needs to be grasped so that the relationship between clinical trial evidence and individual patient treatment requirements can be more clearly understood.
We believe that A. Bush and colleagues' model for “problematic severe asthma” does not differ substantially from that outlined in our paper (see fig. 1 in our previously published study 1). Identifying therapy-resistant asthma as a particular phenotype separate from other causes of difficult-to-treat asthma is an important clinical goal that we would support. However, the model of A. Bush and colleagues does not take into account patients in whom good control is achieved using high doses of therapy, in which case it is severe but not necessarily clinically problematic.
Statement of interest
None declared.
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