Letters Difficult to treat severe asthma

Improving quality of life relies on valid outcome measures as well as drugs

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4623 (Published 12 October 2017) Cite this as: BMJ 2017;359:j4623
  1. Rupert C Jones, senior clinical research fellow1,
  2. Matthew Masoli, consultant physician2,
  3. Joseph W Lanario, associate research fellow1,
  4. Michael E Hyland, professor of health psychology3
  1. 1Community and Primary Care, Peninsula School of Medicine and Dentistry, University of Plymouth, Plymouth PL4 8BX, UK
  2. 2Plymouth Hospital’s NHS Trust, Plymouth, UK
  3. 3School of Psychology, University of Plymouth of Plymouth, Plymouth, UK
  1. rupert.jones{at}plymouth.ac.uk

The review from the Drug and Therapeutics Bulletin on managing difficult to treat asthma1 states that studies of novel biological agents have shown marked improvements in the frequency of exacerbations and healthcare consumption and reductions in oral steroid dosage but that limited evidence shows benefits in quality of life. Failure to detect quality of life improvement among so many other improvements might be the fault of the quality of life instruments, not the drug.

Current asthma quality of life scales were designed for patients with mild to moderate asthma, not to assess the burden of disease and treatment in patients with the most severe asthma.2 In severe asthma, oral corticosteroids impose a high level of adverse effects as perceived by patients. These adverse effects can be ameliorated by reducing oral corticosteroids, which can be achieved when patients start biological treatment.

The National Institute for Health and Care Excellence has confirmed that important factors related to oral steroid burden were not captured when calculating the quality of life adjusted life years.3 The severe asthma questionnaire (www.saq.org.uk) was developed specifically using the input of patients with severe asthma to meet current US Food and Drug Administration standards on the design of questionnaires for health related quality of life.4 The severe asthma questionnaire is currently undergoing validation but represents a more valid outcome measure for patients with severe asthma.

Interventions that improve health related quality of life can only be evaluated accurately if appropriate measures are used to assess the specific health deficits experienced by people with severe asthma.


  • Competing interests: RCJ reports personal fees from Astra Zeneca, Boehringher Ingelheim, Chiesi, Cipla, GSK, and Novartis and grants from Astra Zeneca.


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