One size does not fit all
There is no doubt that these old strategies had a huge impact, the ‘magic bullet’ served us well when the main threat to health was from infectious disease (millions of lives have been saved by an antibiotic targeting a suspectable pathogen). Then with the exponential rise in non-communicable diseases such as diabetes, vascular disease and of course, COPD heralded a drive to define and measure disease severity and then to escalate treatment in a stepwise way accordingly, perhaps the most recognisable example being the BTS/SIGN Asthma guidelines.
This has prompted criticism of the current ‘stepwise approach’ which fails to account for this complexity and also does not incorporate recent discoveries in underlying biological mechanisms (often referred to as endotypes), for example TH2 driven airway inflammation characterised by raised exhaled nitric oxide and eosinophilia.
What are Treatable Traits?
- Airways (e.g fixed or reversible airflow obstruction, airway inflammation)
- Extrapulmonary or co-morbidities
- Treatable behaviours and lifestyle risk factors.
There will be many of you reading this who are perhaps not unreasonably thinking that this all sounds wonderful, but in the real world, how are we expected to adopt this approach without more time, resources and an extended multidisciplinary team?
The reality is that such a comprehensive, multi-dimensional assessment may be restricted to centralised specialist centres such as those commissioned by NHS England for Severe Asthma, but this perhaps ignores an uncomfortable truth that all of our patients with airways disease are likely to benefit from (and deserve) such a comprehensive management strategy. But is this affordable? Treatable traits enthusiasts may argue, can we afford not to?
Certainly, there is great appeal to us as healthcare professionals who by adopting a multidimensional assessment, are able to respond to the needs of the whole person and provide targeted holistic care.
What's the evidence?
So, whether you are a ‘Treatable Traits’ enthusiast or sceptic, what is clear is that there are many challenges to overcome in order to improve the lives of our patients living with a significant burden of COPD and Asthma, but there is also reason to be optimistic.
It’s an exciting time to be involved in airways disease as we look to new ways of delivering precision medicine, recognising the complexities of the whole patient and have access to new and transformative medications which target underlying abnormal lung biology.
- The Kings Fund. (2019) Long-term conditions and multi-morbidity. https://www.kingsfund.org.uk/projects/time-think-differently/trends-disease-and-disability-long-term-conditions-multi-morbidity. [Accessed 10/09/2019].
- Cavaillès, A. et al (2013). Comorbidities of COPD. European Respiratory Review, 22(130), 454-475.https://err.ersjournals.com/content/22/130/454
- Serra-Batlles, J. et al (1998). Costs of asthma according to the degree of severity. European Respiratory Journal, 12(6), 1322-1326. https://erj.ersjournals.com/content/erj/12/6/1322.full.pdf
- British Lung Foundation. (2019) Chronic obstructive pulmonary disease (COPD) statistics https://statistics.blf.org.uk/copd#worldview. [Accessed 10/09/2019]
- Severe Asthma Toolkit (201. Systematic & Multidimensional Asthma Assessment Resources. https://toolkit.severeasthma.org.au/resources/systematic-multidimensional-assessment-resources/. [Accessed 10/09/2019]
- British Lung Foundation. (2019) Cystic Fibrosis statistics. https://statistics.blf.org.uk/cystic-fibrosis. [Accessed 10/09/2019]
- Clark, V. et al (2017). Multidimensional assessment of severe asthma: a systematic review and meta‐analysis. Respirology, 22(7), 1262-1275.
- Vanessa M. McDonald et al (2019). Treatable Traits: a new paradigm for 21st century management of crhonic airway diseases. European Respiratory Journal 2019