Treatable Traits in Asthma: The Importance of Extrapulmonary Traits-GERD, CRSwNP, Atopic Dermatitis, and Depression/Anxiety.

Treatable traits is a personalized medicine approach to the management of airway disease. Assessing traits within the 3 domains of pulmonary, extrapulmonary, and behavioral/lifestyle/risk factor traits, and applying targeted treatments to effectively manage these traits, enables a holistic and personalized approach to care. Asthma is a heterogeneous and complex airway disease that is frequently complicated by several extrapulmonary traits that impact asthma outcomes and predict future outcomes. We propose that the identification of extrapulmonary and behavioral risk factor traits and the implementation of targeted therapy will lead to improved management of people with asthma. Furthermore, many extrapulmonary traits present as "connected comorbidities"; that is, they coexist with asthma, have an impact on asthma, and effective treatment improves both asthma and the comorbidity or the comorbidities may share a similar mechanism. In this review, we explore this concept and look at atopic dermatitis, chronic rhinosinusitis with nasal polyps, gastroesophageal reflux disease, anxiety, and depression as treatable traits of asthma and how these can be managed using this approach.

Treatable traits and challenges in the clinical management of non-tuberculous mycobacteria lung disease in people with cystic fibrosis.

INTRODUCTION: Over the last ten years an increasing prevalence and incidence of non-tuberculous mycobacteria (NTM) has been reported among patients with cystic fibrosis (CF) Viviani (J Cyst Fibros, 15(5):619-623, 2016). NTM pulmonary disease has been associated with negative clinical outcomes and often requires pharmacological treatment. Although specific guidelines help clinicians in the process of diagnosis and clinical management, the focus on the multidimensional assessment of concomitant problems is still scarce. MAIN BODY: This review aims to identify the treatable traits of NTM pulmonary disease in people with CF and discuss the importance of a multidisciplinary approach in order to detect and manage all the clinical and behavioral aspects of the disease. The multidisciplinary complexity of NTM pulmonary disease in CF requires careful management of respiratory and extra-respiratory, including control of comorbidities, drug interactions and behavioral factors as adherence to therapies. CONCLUSIONS: The treatable trait strategy can help to optimize clinical management through systematic assessment of all the aspects of the disease, providing a holistic treatment for such a multi-systemic and complex condition.

Multimorbidity in Difficult Asthma: The Need for Personalised and Non-Pharmacological Approaches to Address a Difficult Breathing Syndrome.

Three to ten percent of people living with asthma have difficult-to-treat asthma that remains poorly controlled despite maximum levels of guideline-based pharmacotherapy. This may result from a combination of multiple adverse health issues including aggravating comorbidities, inadequate treatment, suboptimal inhaler technique and/or poor adherence that may individually or collectively contribute to poor asthma control. Many of these are potentially "treatable traits" that can be pulmonary, extrapulmonary, behavioural or environmental factors. Whilst evidence-based guidelines lead clinicians in pharmacological treatment of pulmonary and many extrapulmonary traits, multiple comorbidities increase the burden of polypharmacy for the patient with asthma. Many of the treatable traits can be addressed with non-pharmacological approaches. In the current healthcare model, these are delivered by separate and often disjointed specialist services. This leaves the patients feeling lost in a fragmented healthcare system where clinical outcomes remain suboptimal even with the best current practice applied in each discipline. Our review aims to address this challenge calling for a paradigm change to conceptualise difficult-to-treat asthma as a multimorbid condition of a "Difficult Breathing Syndrome" that consequently needs a holistic personalised care attitude by combining pharmacotherapy with the non-pharmacological approaches. Therefore, we propose a roadmap for an evidence-based multi-disciplinary stepped care model to deliver this.

Prevalence of suspected poor bone health in people with chronic obstructive pulmonary disease - a cross-sectional exploratory study.

BACKGROUND: Compared to the general population, adults with chronic obstructive pulmonary disease (COPD) have an increased prevalence of osteoporosis. Despite the known risk factors and potential complications of compromised bone health in COPD, little is known about whether poor bone health is routinely suspected. We measured, in people with COPD, the prevalence of those who had one or more indicators suggestive of suspected poor bone health, and compared the characteristics of those with versus without these indicators. METHODS: Data were collected from adults with COPD presenting to three tertiary hospitals. Indicators of suspected poor bone health were defined as any of the following criteria: (i) self-reported problems with bone health, (ii) previous imaging for bone health, (iii) history of fragility fracture or, (iv) advised to use medication/supplements to optimise bone health. Characteristics compared between those with versus without indicators of suspected poor bone health comprised age, sex, body mass index (BMI), FEV1% predicted and recruitment setting. RESULTS: 361 participants were included (age 70 ± 10, BMI 27.9 ± 7.8 kg/m2, FEV1% predicted 49 ± 20; 161 [45%] female). Indicators suggestive of suspected poor bone health were present in 53% (95% confidence interval [CI] 47-58) of the participants. The odds of this outcome increased with advancing age (odds ratio; OR [95% CI] 1.05 [1.03 to 1.08]) and being female (OR [95% CI] 3.4 [2.2 to 5.7]) . CONCLUSION: In people with COPD, the odds of having indicators suggestive of suspected poor bone health increase with advancing age and in females. Further work is required to promote the importance of bone health in this population.