Distinguishing characteristics of difficult-to-control asthma in inner-city children and adolescents

Jacqueline A. Pongracic, Rebecca Z. Krouse, Denise C. Babineau, Edward M. Zoratti, Robyn T. Cohen, Robert A. Wood, Gurjit K. Khurana Hershey, Carolyn M. Kercsmar, Rebecca S. Gruchalla, Meyer Kattan, Stephen J. Teach, Christine C. Johnson, Leonard B. Bacharier, James E. Gern, Steven M. Sigelman, Peter J. Gergen, Alkis Togias, Cynthia M. Visness, William W. Busse, Andrew H. Liu

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Background Treatment levels required to control asthma vary greatly across a population with asthma. The factors that contribute to variability in treatment requirements of inner-city children have not been fully elucidated. Objective We sought to identify the clinical characteristics that distinguish difficult-to-control asthma from easy-to-control asthma. Methods Asthmatic children aged 6 to 17 years underwent baseline assessment and bimonthly guideline-based management visits over 1 year. Difficult-to-control and easy-to-control asthma were defined as daily therapy with 500 μg of fluticasone or greater with or without a long-acting β-agonist versus 100 μg or less assigned on at least 4 visits. Forty-four baseline variables were used to compare the 2 groups by using univariate analyses and to identify the most relevant features of difficult-to-control asthma by using a variable selection algorithm. Nonlinear seasonal variation in longitudinal measures (symptoms, pulmonary physiology, and exacerbations) was examined by using generalized additive mixed-effects models. Results Among 619 recruited participants, 40.9% had difficult-to-control asthma, 37.5% had easy-to-control asthma, and 21.6% fell into neither group. At baseline, FEV1 bronchodilator responsiveness was the most important characteristic distinguishing difficult-to-control asthma from easy-to-control asthma. Markers of rhinitis severity and atopy were among the other major discriminating features. Over time, difficult-to-control asthma was characterized by high exacerbation rates, particularly in spring and fall; greater daytime and nighttime symptoms, especially in fall and winter; and compromised pulmonary physiology despite ongoing high-dose controller therapy. Conclusions Despite good adherence, difficult-to-control asthma showed little improvement in symptoms, exacerbations, or pulmonary physiology over the year. In addition to pulmonary physiology measures, rhinitis severity and atopy were associated with high-dose asthma controller therapy requirement.

Original languageEnglish
Pages (from-to)1030-1041
Number of pages12
JournalJournal of Allergy and Clinical Immunology
Issue number4
StatePublished - Oct 1 2016


  • Child
  • IgE
  • allergen sensitization
  • asthma
  • asthma exacerbations
  • asthma morbidity
  • asthma phenotype
  • asthma severity
  • inner-city asthma
  • pulmonary function
  • rhinitis


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