Risk for exacerbations exists among patients with asthma regardless of control level, treatment adherence, or disease severity, according to study findings presented at the American College of Allergy, Asthma & Immunology (ACAAI) 2022 Annual Scientific Meeting, held from November 10 to 14, in Louisville, Kentucky.

The MANDALA study (ClinicalTrials.gov Identifier: NCT03769090) showed that those with moderate to severe uncontrolled asthma who used as-needed combined short-acting beta2-agonists (SABA)-inhaled corticosteroid fixed combination therapy had fewer exacerbations. To explore the broader implications of the MANDALA findings, investigators for the current study assessed the effects of asthma control, maintenance adherence, and/or disease severity on the occurrence of severe exacerbations in patients using as-needed SABA.

The researchers analyzed 351,870 US patients at least 12 years of age from the IBM MarketScan databases who received SABA for asthma from 2010 to 2017. Patients were indexed based on a random SABA prescription fill for which they 12 months pre- and post-index continuous eligibility and at least 1 post-index maintenance claim. Investigators stratified patients by asthma control, with “well controlled” defined as having the index SABA fill only; “not well-controlled” defined as 2-3 SABA prescription fills; and “very poorly controlled” defined as 4 or more SABA prescription fills. Investigators determined adherence by the patient’s maintenance medication possession ratio (MPR), which was stratified into 3 levels (at least 80%; 50% to 79%; and less than 50%). Disease severity was defined according to the patient’s maintenance group.

With respect to asthma control, the researchers found that 31% or participants were well-controlled; 35% were not well controlled; and 34% were very poorly controlled. The researchers found 13% adherence in the highest (≥80%) MPR group; 23% adherence in the middle (50% to 79%) MPR group; and 64% adherence in the lowest (<50%) MPR group.

Investigators found adherence was unrelated to exacerbations for those with well controlled asthma (P =.11) or not well controlled (P =.46); however, a lower proportion of patients with very poorly controlled asthma who were at least 80% adherent experienced exacerbations vs those who were less than 80% adherent (P <.0001). Notably, the analysis also found that greater adherence combined with better control was associated with reduced exacerbations. Across maintenance levels, however, 36% to 54% of patients with well-controlled asthma who were at least 80% adherent had exacerbations.

Investigators concluded that “Many asthmatics are at risk for exacerbations irrespective of control, adherence, or disease severity. As-needed SABA-inhaled corticosteroid should be considered broadly to mitigate variability in airway inflammation that could lead to asthma exacerbations.”


Lanz M, Pollack M, Gilbert I, Gandhi H, Tkacz J, Lugogo N. Asthmatic patients are at risk for exacerbations irrespective of control, maintenance adherence, or disease severityAnn Allergy Asthma Immunol. 2022;125(5):S47. doi:10.1016/j.anai.2022.08.633

This article originally appeared on Pulmonology Advisor.