医生诊断的哮喘和/或慢性阻塞性肺病之间的内在异质性：NOVELTY队列
2021/03/22
摘要
背景：通常将对哮喘和慢性阻塞性肺疾病（COPD）的研究重点分别放在这些诊断上，从而限制了对疾病机制和治疗选择的理解。NOVELTY是一项根据现实世界临床实践，对哮喘和/或COPD患者进行的为期3年的全球性的前瞻性观察性研究。在该队列中，我们通过诊断和严重程度调查了其异质性和重叠。
方法：纳入医生确诊的哮喘、COPD或两者兼有的患者（哮喘合并COPD），并根据诊断和严重程度进行分层。基线特征按医师指定的诊断和/或严重程度进行描述性报告。采用序贯logistic回归分析进行评估与医师评估的严重程度相关的因素。
结果：在11243名患者中，其中有5940名（52.8％）患有医师确诊的哮喘，1396名（12.4％）患有哮喘合并COPD，3907名（34.8％）患有COPD，以上几乎一半患者来自初级保健。症状、与健康相关的生活质量和肺活量测定法显示哮喘、哮喘合并COPD和COPD之间存在明显的异质性和重叠，分别有23％、62％和64％的患者使用支气管扩张剂后FEV 1/ FVC <正常值下限。症状及其加重随医师评估的严重程度增加而增加，哮喘合并COPD的症状及其加重程度更高，但24.3%的轻度哮喘患者和20.4%的轻度慢性阻塞性肺病患者在过去12个月内出现≥1次加重。药物记录表明，治疗不足和治疗过度与疾病的严重程度相关。在诊断/严重度组中，血液嗜酸性粒细胞计数变化不大，但在所有诊断中，血液中性粒细胞计数随严重程度而增加。
结论：这项分析表明，在哮喘和/或COPD患者中，医师指定的诊断和严重程度组之间存在明显的内在异质性和相互重叠。目前临床实践中的诊断和严重程度分类很难区分可能具有特定风险和治疗意义的临床表型。
Heterogeneity within and between physician-diagnosed asthma and/or COPD: NOVELTY cohort
Helen K Reddel, Jørgen Vestbo, Alvar Agustí, Gary P Anderson, Aruna T Bansal, Richard Beasley, Elisabeth H Bel, Christer Janson, Barry Make, Ian D Pavord, David Price, Eleni Rapsomaniki, Niklas Karlsson, Donna K Finch, Javier Nuevo, Alex de Giorgio-Miller, Marianna Alacqua, Rod Hughes, Hana Müllerová, Maria Gerhardsson de Verdier, NOVELTY study investigators
Abstract
BACKGROUND:Studies of asthma and chronic obstructive pulmonary disease (COPD) typically focus on these diagnoses separately, limiting understanding of disease mechanisms and treatment options. NOVELTY is a global, 3-year, prospective observational study of patients with asthma and/or COPD from real-world clinical practice. We investigated heterogeneity and overlap by diagnosis and severity in this cohort.
METHODS:Patients with physician-assigned asthma, COPD or both (asthma+COPD) were enrolled, stratified by diagnosis and severity. Baseline characteristics were reported descriptively by physician-assigned diagnosis and/or severity. Factors associated with physician-assessed severity were evaluated using ordinal logistic regression analysis.
RESULTS: Of 11 243 patients, 5940 (52.8%) had physician-assigned asthma, 1396 (12.4%) had asthma+COPD and 3907 (34.8%) had COPD; almost half were from primary care. Symptoms, health-related quality of life and spirometry showed substantial heterogeneity and overlap between asthma, asthma+COPD and COPD, with 23%, 62% and 64% of patients, respectively, having post-bronchodilator FEV1/FVC <lower limit of normal.Symptoms and exacerbations increased with greater physician-assessed severity, and were higher in asthma+COPD, but 24.3% with mild asthma and 20.4% with mild COPD had experienced ≥1 exacerbation in the past 12 months. Medication records suggested both under-treatment and over-treatment relative to severity. Blood eosinophil counts varied little across diagnosis/severity groups, but blood neutrophil counts increased with severity across all diagnoses.
CONCLUSION:This analysis demonstrates marked heterogeneity within, and overlap between, physician-assigned diagnosis and severity groups in patients with asthma and/or COPD. Current diagnostic and severity classifications in clinical practice poorly differentiate between clinical phenotypes that may have specific risks and treatment implications.
背景：通常将对哮喘和慢性阻塞性肺疾病（COPD）的研究重点分别放在这些诊断上，从而限制了对疾病机制和治疗选择的理解。NOVELTY是一项根据现实世界临床实践，对哮喘和/或COPD患者进行的为期3年的全球性的前瞻性观察性研究。在该队列中，我们通过诊断和严重程度调查了其异质性和重叠。
方法：纳入医生确诊的哮喘、COPD或两者兼有的患者（哮喘合并COPD），并根据诊断和严重程度进行分层。基线特征按医师指定的诊断和/或严重程度进行描述性报告。采用序贯logistic回归分析进行评估与医师评估的严重程度相关的因素。
结果：在11243名患者中，其中有5940名（52.8％）患有医师确诊的哮喘，1396名（12.4％）患有哮喘合并COPD，3907名（34.8％）患有COPD，以上几乎一半患者来自初级保健。症状、与健康相关的生活质量和肺活量测定法显示哮喘、哮喘合并COPD和COPD之间存在明显的异质性和重叠，分别有23％、62％和64％的患者使用支气管扩张剂后FEV 1/ FVC <正常值下限。症状及其加重随医师评估的严重程度增加而增加，哮喘合并COPD的症状及其加重程度更高，但24.3%的轻度哮喘患者和20.4%的轻度慢性阻塞性肺病患者在过去12个月内出现≥1次加重。药物记录表明，治疗不足和治疗过度与疾病的严重程度相关。在诊断/严重度组中，血液嗜酸性粒细胞计数变化不大，但在所有诊断中，血液中性粒细胞计数随严重程度而增加。
结论：这项分析表明，在哮喘和/或COPD患者中，医师指定的诊断和严重程度组之间存在明显的内在异质性和相互重叠。目前临床实践中的诊断和严重程度分类很难区分可能具有特定风险和治疗意义的临床表型。
(中日友好医院呼吸与危重症医学科 王静茹 摘译 林江涛 审校)
(Eur Respir J. 2021 Feb 25;2003927. doi: 10.1183/13993003.03927-2020.)
(Eur Respir J. 2021 Feb 25;2003927. doi: 10.1183/13993003.03927-2020.)
Heterogeneity within and between physician-diagnosed asthma and/or COPD: NOVELTY cohort
Helen K Reddel, Jørgen Vestbo, Alvar Agustí, Gary P Anderson, Aruna T Bansal, Richard Beasley, Elisabeth H Bel, Christer Janson, Barry Make, Ian D Pavord, David Price, Eleni Rapsomaniki, Niklas Karlsson, Donna K Finch, Javier Nuevo, Alex de Giorgio-Miller, Marianna Alacqua, Rod Hughes, Hana Müllerová, Maria Gerhardsson de Verdier, NOVELTY study investigators
Abstract
BACKGROUND:Studies of asthma and chronic obstructive pulmonary disease (COPD) typically focus on these diagnoses separately, limiting understanding of disease mechanisms and treatment options. NOVELTY is a global, 3-year, prospective observational study of patients with asthma and/or COPD from real-world clinical practice. We investigated heterogeneity and overlap by diagnosis and severity in this cohort.
METHODS:Patients with physician-assigned asthma, COPD or both (asthma+COPD) were enrolled, stratified by diagnosis and severity. Baseline characteristics were reported descriptively by physician-assigned diagnosis and/or severity. Factors associated with physician-assessed severity were evaluated using ordinal logistic regression analysis.
RESULTS: Of 11 243 patients, 5940 (52.8%) had physician-assigned asthma, 1396 (12.4%) had asthma+COPD and 3907 (34.8%) had COPD; almost half were from primary care. Symptoms, health-related quality of life and spirometry showed substantial heterogeneity and overlap between asthma, asthma+COPD and COPD, with 23%, 62% and 64% of patients, respectively, having post-bronchodilator FEV1/FVC <lower limit of normal.Symptoms and exacerbations increased with greater physician-assessed severity, and were higher in asthma+COPD, but 24.3% with mild asthma and 20.4% with mild COPD had experienced ≥1 exacerbation in the past 12 months. Medication records suggested both under-treatment and over-treatment relative to severity. Blood eosinophil counts varied little across diagnosis/severity groups, but blood neutrophil counts increased with severity across all diagnoses.
CONCLUSION:This analysis demonstrates marked heterogeneity within, and overlap between, physician-assigned diagnosis and severity groups in patients with asthma and/or COPD. Current diagnostic and severity classifications in clinical practice poorly differentiate between clinical phenotypes that may have specific risks and treatment implications.
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