Table 1 Prime treatable traits and their treatment outcomes.
Treatable trait | How to identify the trait in primary care | Impact on disease burden | Treatment | Evidence | |
|---|---|---|---|---|---|
Asthma | COPD | ||||
Airflow obstruction/limitation | Spirometry test to confirm FEV1/FVC is below the lower limit of normal (usually >0.75–0.80 in adults, >90 in children)1,2 | Airflow obstruction is associated with increased lung function decline, and limited exercise capacity1,39,40 | Airflow obstruction can be treated with bronchodilators, such as LAMA and/or LABA, in COPD, and LAMA and/or LABA in combination with ICS, in asthma1,2 | Treatment with ICS-formoterol has demonstrated a reduced risk of exacerbations compared with ICS, while still maintaining symptom and FEV1 control, and is recommended for the initial treatment of mild asthma1 | LABA and LAMA can significantly improve FEV1 and lung volumes, as well as dyspnoea and exacerbation rate2,41 |
Eosinophilic inflammation | Eosinophilic inflammation is directly linked to an increased risk of exacerbations and uncontrolled asthma36 | ICS can be used to treat eosinophilic inflammation, and blood eosinophil levels are effective in predicting response to ICS in COPD and asthma, as well as biologic therapy in asthma4,34,35,55 | Treatment of mild asthma with ICS-formoterol reliever therapy has been shown to reduce the rate of exacerbations by 60% when compared with SABAs54 | Pooled analysis of 7,495 patients across 7 studies demonstrated that treatment with ICS-LABA reduced the frequency of exacerbations compared with placebo in patients with mild to very severe COPD (RR 0.73; 95% CI, 0.69–0.78)58 | |
Adherence | Open discussion between HCPs and patients, checking prescription refill rate, and use of ‘smart’ chipped inhaler technology1,4 | Various strategies have been established to improve adherence: shared decision-making for medication dosage, inhaler reminders and home visits1 | A systematic literature review found that greater adherence is associated with a higher FEV1, a reduced risk of hospitalisation, a lower percentage of sputum eosinophils and reduced OCS dependency47 | Improved adherence is associated with a reduced risk of admission to hospital and mortality due to a COPD exacerbation59 | |
Inhaler technique | Observation of inhaler technique and use of training devices4 | Worsening of symptoms and an increased risk of exacerbations1 | HCP-led training and development of smart inhalers to provide immediate feedback to patients49,60 | Patient errors when using inhalers could cause suboptimal drug delivery49 and, in turn, result in higher risks of hospitalisation (OR 1.47), ER visits (OR 1.62) and OCS use (OR 1.54)61. After training, the percentage of asthma patients with optimal inhaler technique has been shown to rise from 24% to 79% (p < 0.001)60. Furthermore, correct inhaler technique has the combined benefit of improving asthma control and treatment response to ICS1 | |
Smoking | Open discussion between HCPs and patients. Exposure can be measured by cotinine or exhaled concentration of carbon monoxide4 | Smoking is the main risk factor for COPD2. It is also associated with an increased rate of lung function decline and reduced responsiveness to ICS and OCS in asthma1,29, as well as worse outcomes in both conditions1,2 | Education and smoking cessation support, a quit plan with social support and clinician counselling1,2 | A study found patients to have significantly increased lung function 6 weeks after smoking cessation50 | Lung function decline is slowed in patients following smoking cessation51. Smoking cessation by the age of 40 years significantly reduces the risk of mortality in patients with COPD62 |
Low BMI/obesity | Documentation of BMI for all patients, as well as assessment of diet and exercise1 | Obesity can contribute to worse symptom control in patients with asthma1. A low BMI in patients with COPD is associated with worse outcomes2 | Exercise and a healthy diet1 | After just a 5–10% body weight loss among overweight and obese patients, evident improvement to asthma control has been reported63 | Malnutrition and weight loss in patients with COPD was found to be significantly associated with disease severity (p = 0.039). An extra one meal a day was observed to improve QoL, with a 3.61 decrease in SGRQ score64 |
Anxiety and depression | Questionnaires and an assessment with a psychiatrist or liaison psychiatrist1,4 | Anxiety and depression are associated with worse symptom control, poor adherence and increased exacerbations in patients with asthma1. Anxiety and depression contribute to fatigue, poorer exercise tolerance and higher frequency of acute exacerbations in patients with COPD65 | CBT, pharmacotherapy, mind-body interventions and other psychotherapies are among management options for anxiety and depression1,2 | Patients with asthma and comorbid anxiety who received 4–6 1-h weekly sessions of CBT had a statistically significant reduction in asthma-specific fear when compared with routine treatment; this was maintained at a 6-month follow-up. In addition, significant improvements in asthma-specific QoL and depression were observed in CBT groups, with a 5% reduction in the number of patients with possible clinical depression at the end of treatment52 | Mind-body interventions have been shown to improve lung function and exercise capacity in patients with psychological comorbidities2 |
