Interprofessional Team
Difficult-to-control asthma, defined as: uncontrolled asthma despite use of maximum dose inhaled corticosteroids or chronic oral corticosteroids with daily asthma symptoms, frequent exacerbations, and/or hospitalization results in a substantial medical and financial burden with a resultant decrease in quality-of-life. Extrapulmonary co-morbidities, such as obesity, nicotine use, GERD, allergic rhinitis, chronic rhinosinusitis, sleep apnea, anxiety/depression, females of older age, vocal cord dysfunction (VCD), and type 2 diabetes mellitus (T2DM) have been shown to increase exacerbation frequency, missed days of school/work, and lessened quality-of life. Of these comorbidities, that latter has garnered recent attention as a focal point for asthma management.
Dr. David W. Unkle
As many as one in six asthmatics has T2DM, and the obvious impact of oral/systemic corticosteroids runs counter to the treatment armamentarium for difficult-to-control asthma. Furthermore, patients with concomitant T2DM and asthma have poor glycemic control, higher risk of pneumococcal pneumonia, and poor quality-adjusted life expectancy (Black MH et al. Pediatrics. 2014;128:e839-47) Of growing interest is the use of metformin in the treatment of Type 2 diabetes mellitus in patients with asthma. Metformin attenuates eosinophilic airway inflammation and theoretically inhibits airway remodeling through AMP-activated protein kinase (Li, et al. Respirology. 2016;21:1210).
The management of this heterogeneous group of patients with difficult-to-control asthma and the aforementioned comorbidities underscores the need for interdisciplinary collaboration as well as orchestration with specialty providers (family/internal medicine, GI, ENT, endocrine, psych/mental health, et al). Further studies are needed to evaluate the anti-inflammatory properties of metformin and its role in asthma management and improvement in outcome.
David W. Unkle, MSN, APRN, FCCP
Steering Committee Chair