Cláudia Chaves Loureiro

Background and Objective: Severe asthma (SA) is commonly complicated by multiple comorbidities, which significantly worsen clinical outcomes. However, the recognition of asthma comorbidities in clinical practice remains unclear. We aimed to assess gaps in comorbidity documentation in SA registries, evaluate comorbidity prevalence and variation across Europe, and explore physician perspectives on multimorbidity management, with a focus on real-world recognition and documentation of comorbidities. Methods: We analysed data from 13,245 SA patients across 22 European registries. Thirty-two clinically relevant comorbidities were grouped into five categories (type 2 (T2)-related, pulmonary, extrapulmonary, psychophysiological, and steroid–related) to assess registry capture and national prevalence. A pan-European online survey of 239 SA specialists explored clinical approaches and resources for multimorbidity management. Results: Across the registries, T2-related and pulmonary comorbidities were captured more consistently than extrapulmonary, psychophysiological, and steroid-related conditions, with substantial variation between countries. The most prevalent recorded comorbidities included chronic sinusitis (40%), nasal polyps (35%), obesity (30%), allergic rhinitis (30%), and gastroesophageal reflux disease (29%) but their prevalence varied widely across countries. Forty-one percent of surveyed physicians lacked multidisciplinary team (MDT) access, with lack of time (36%) and funding (26%) reported as the main barriers. Eighty-five percent of respondents acknowledged the impact of multimorbidity on asthma outcomes and expressed a need for improved training and patient education to improve its management. Conclusion: Comorbidities are highly prevalent in European SA populations but remain inconsistently documented across registries, especially steroid–related conditions. However, these findings should be interpreted in the context of heterogeneity in registry structure, diagnostic pathways, and data capture practices across countries. Limited resources further constrain optimal multimorbidity management. These findings highlight the need for standardized registry protocols, improved MDT access, and targeted education. This study provides the first pan-European evaluation of comorbidity capture in SA registries alongside physician perspectives on multimorbidity.

Purpose: Time to biologic initiation for the treatment of severe asthma (SA) is affected by many factors, including ease of access to biologics, which is often subject to approval by regulatory authorities and reimbursement criteria by relevant agencies. We investigated the association between ease of biologic access (using the biologic accessibility score [BACS] as a proxy) and post-biologic asthma outcomes, including remission. Methods: This ecological study, using data from CHRONICLE (a US severe asthma registry), the International Severe Asthma Registry (ISAR), and the Optimum Patient Care Research Database (OPCRD), included patients with SA from 21 countries. Associations at the country level, between BACS, a composite score of prescription criteria for biologics in SA, and the proportion of patients with a favorable asthma outcome 1-year post-biologic in each setting (ie ISAR country or in the CHRONICLE or OPCRD datasets) were tested. Several definitions of favorable outcome were used, including proportion of patients who achieved clinical remission (defined using 2, 3 and 4 domains), experienced no exacerbations, had well- or partly controlled asthma, a percent predicted forced expiratory volume in 1 second (ppFEV₁) or percent predicted peak expiratory flow rate (ppPEFR) ≥ 80%, and no long-term oral corticosteroid (LTOCS) use. Results: A total of 9,183 patients were included. A higher BACS (as a proxy of easier access to biologics) was associated with a higher likelihood of achieving clinical remission (p≤ 0.001), no exacerbations (p< 0.001), well- or partly controlled asthma (p=0.047), a ppFEV₁ or ppPEFR ≥ 80% (p=0.004), and no need for LTOCS (p=0.045) 1 year post-biologic initiation. Conclusion: Easier access to biologics for patients with SA, a prerequisite for shorter time-to-initiation, was associated with a greater probability of achieving clinical remission and other favorable asthma outcomes. Initiating biologics earlier in the asthma disease course may help unlock greater therapeutic potential in SA. These findings warrant confirmation in additional studies to further establish the causal relationship between biologic accessibility, timing of initiation, and clinical outcomes in SA.

1. Asthma poses a major public health challenge, impacting over 300 million individuals worldwide.1In Portugal, prevalence ranges from 3.3 to 15%, with only half of patients achieving optimal disea...

Background: Multimorbidity refers to the presence of multiple co-existing conditions, but is often underappreciated in the context of severe asthma (SA) management. We sought to identify differences in approaches to multimorbidity management in SA, variability in access to multidisciplinary team (MDT) resources, and whether physician perspectives on multimorbidity differ between SA specialists and general respiratory physicians. Methods: The Severe Heterogeneous Asthma Registry, Patient-centred (SHARP) Clinical Research Collaboration circulated an online physician survey via European national respiratory societies to assess a) available resources to address multimorbidity and b) physician perspectives on multimorbidity in SA. Results: 495 responses from 25 European countries included 48% SA specialists and 52% general respiratory physicians. SA specialists had more experience with SA patients (20% seeing>60 patients/month) compared to general respiratory physicians. SA specialists had greater access to multidisciplinary care – including better access to MDT, allied health professionals and referrals to external specialists and therefore more routinely assessed comorbidities and considered them greater influences on their practice. They also considered multimorbidity to a greater degree, and rated its impact on their patients’ asthma outcomes (and general health outcomes) as more substantial. Conclusions: Alongside more experience of treating SA, SA specialists have increased awareness of multimorbidity and better resources to manage it. However, access to MDTs remains a significant gap for both SA specialists and general respiratory physicians. Furthermore, both groups identified a high need for further education and training about multimorbidity. These findings highlight key areas for improvement in clinical practice, resources and training.

Rationale: Although clinical trials have documented the oral corticosteroid (OCS)-sparing effect of biologics in patients with severe asthma, little is known about whether this translates to a reduction of new-onset OCS-related adverse outcomes. Objectives: To compare the risk of developing new-onset OCS-related adverse outcomes between biologic initiators and noninitiators. Methods: This was a longitudinal cohort study using pooled data from the International Severe Asthma Registry (ISAR; 16 countries) and the Optimum Patient Care Research database (OPCRD; United Kingdom). For biologic initiators, the index date was the date of biologic initiation. For noninitiators, it was the date of enrollment (for ISAR) or a random medical appointment date (for OPCRD). Inverse probability of treatment weighting was used to improve comparability between groups, and weighted Cox proportional hazard models were used to estimate the hazard ratios (HRs) of developing OCS-related adverse outcomes for up to 5 years from the index date. Measurements and Main Results: A total of 42,908 patients were included. Overall, 27.3% and 4.7% of biologic initiators and noninitiators were long-term OCS users (daily intake ⩾90 consecutive days in year before the index date), with a mean prednisolone-equivalent daily dose of 10.2 mg and 6.2 mg, respectively. Compared with noninitiators, biologic initiators had decreased rate of developing any OCS-related adverse outcome (HR [95% confidence interval (CI)]: 0.82 [0.72–0.93]; P = 0.002), primarily driven by reduced rate of developing diabetes (0.62 [0.45–0.87]; P = 0.006), major cardiovascular events (0.65 [0.44–0.97]; P = 0.034), and anxiety and/or depression (0.68 [0.55–0.85]; P = 0.001). There were no significant differences in the rates of new-onset cataract (HR, 0.77 [95% CI, 0.47–1.25]), sleep apnea (HR, 0.82 [95% CI, 0.78–1.41]), or other OCS-related adverse outcomes assessed (e.g., osteoporosis). The results were consistent across both datasets. Conclusions: Our findings highlight the role for biologics in preventing new-onset OCS-related adverse outcomes in patients with severe asthma.

ObjectivesAtopic/allergic diseases impose a growing burden on public health, affecting millions of patients worldwide. The main objective of this study was to develop a national expert consensus on relevant clinical questions related to type 2 inflammation.MethodsWe conducted: a comprehensive literature review with a qualitative analysis to identify the most repeated themes on the overlap of conditions; a modified 3-round Web-Delphi (or e-Delphi); and a final online decision conference.ResultsWe included 51 studies. Following three Web-Delphi rounds, we ended up with 30 statements with a 76% overall full agreement rate, 16% agreement, 2% disagreement, and 0% full disagreement. The decision conference enabled adjustments, and the expert panel agreed unanimously on the final set of statements. The consensus used evidence synthesis, Web-Delphi, and decision conference to produce 30 statements on type 2 inflammation as a driver for multimorbidity in asthma, certain rhinitis phenotypes, atopic dermatitis, chronic rhinosinusitis with nasal polyps, and eosinophilic esophagitis grouped under five domains in underlying pathophysiology, multimorbidity, diagnosis and management, multidisciplinary management, and impact on mental health.ConclusionWe expect the first Portuguese expert consensus INFLAT2-PT to promote understanding of type 2 inflammation diseases, multidisciplinary care, integrated care pathways, future research, and inform health authorities.

Adherence to controller medication is a major problem in asthma management, being difficult to assess and tackle. mHealth apps can be used to assess adherence. We aimed to assess the adherence to inhaled corticosteroids+long-acting β2-agonists (ICS+LABA) in users of the MASK-air® app, comparing the adherence to ICS+formoterol (ICS+F) with that to ICS+other LABA. We analysed complete weeks of MASK-air® data (2015-2022; 27 countries) from patients with self-reported asthma and ICS+LABA use. We compared patients reporting ICS+F versus ICS+other LABA on adherence levels, symptoms and symptom-medication scores. We built regression models to assess whether adherence to ICS+LABA was associated with asthma control or short-acting beta-agonist (SABA) use. Sensitivity analyses were performed considering the weeks with no more than one missing day. In 2598 ICS+LABA users, 621 (23.9%) reported 4824 complete weeks and 866 (33.3%) reported weeks with at most one missing day. Higher adherence (use of medication ≥80% of weekly days) was observed for ICS+other LABA (75.1%) when compared to ICS+F (59.3%), despite both groups displaying similar asthma control and work productivity. The ICS+other LABA group was associated with more days of SABA use than the ICS+F group (median=71.4% versus 57.1% days). Each additional weekly day of ICS+F use was associated with a 4.1% less risk in weekly SABA use (95%CI=-6.5;-1.6%;p=0.001). For ICS+other LABA, the percentage was 8.2 (95%CI=-11.6;-5.0%;p<0.001). In asthma patients adherent to the MASK-air app, adherence to ICS+LABA was high. ICS+F users reported lower adherence but also a lower SABA use and a similar level of control.

Este trabalho investiga as facetas envolvidas na crença generalizada de que espaço e sociedade interagem, positiva ou negativamente, e que, portanto, o desenho do espaço seja, em parte, responsável por...