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Background: Patients with uncontrolled asthma should be evaluated for medication adherence. This study aimed to identify characteristics associated with poor adherence to inhaled corticosteroids (ICS) and to explore adherence prior to treatment escalation.

Methods: This nationwide longitudinal cohort study included adult asthma patients (n = 30880) with a healthcare visit including Asthma Control Test (ACT) and registered in the Swedish National Airway Register between 1 July 2017 and 28 February 2019 (index date). Patient data was crosslinked to other national registers. Treatment steps two years pre- and one year post-index, were identified by prescribed drugs. Poor adherence was defined as Medication Possession Ratio <80 %.

Results: Poor adherence was identified in 73 % of patients in treatment steps 2–5, where of 35 % had uncontrolled asthma (ACT≤19). In adjusted models, poor adherence was associated with better disease control; ACT≤19 (OR 0.78, 95 % CI 0.71–0.84), short-acting β2-agonist (SABA) overuse (0.69, 0.61–0.79) and exacerbations (0.79, 0.70–0.89) in steps 2–3. Among patients with uncontrolled asthma, poor adherence was associated with SABA overuse (1.71, 1.50–1.95), exacerbations (1.29, 1.15–1.46), current smoking (1.38, 1.21–1.57) and inversely associated with asthma management education (0.85, 0.78–0.93. Similar results were observed in steps 4–5. When investigating post-index treatment, 53 % remained stationary, 30 % stepped down and 17 % escalated treatment. Prior to escalation, 49 % had poor adherence.

Conclusions: Poor ICS adherence was associated with better asthma control. Among uncontrolled patients, poor adherence was associated with SABA overuse and exacerbations. Our result highlights the importance of asthma management education to improve adherence in uncontrolled patients.

Background: Chronic airway obstruction (CAO) and restrictive spirometry pattern (RSP) are associated with mortality, but sex-specific patterns of all-cause and specific causes of death have hardly been evaluated.

Objectives: To study the possible sex-dependent differences of all-cause mortality and patterns of cause-specific mortality among men and women with CAO and RSP, respectively, to that of normal lung function (NLF).

Design: Population-based prospective cohort study.

Methods: Individuals with CAO [FEV1/vital capacity (VC) < 0.70], RSP [FEV₁/VC ⩾ 0.70 and forced vital capacity (FVC) < 80% predicted] and NLF (FEV₁/VC ⩾ 0.70 and FVC ⩾ 80% predicted) were identified within the Obstructive Lung Disease in Northern Sweden (OLIN) studies in 2002–2004. Mortality data were collected through April 2016, totally covering 19,000 patient-years. Cox regression and Fine–Gray regression accounting for competing risks were utilized to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, body mass index, sex, smoking habits and pack-years.

Results: The adjusted hazard for all-cause mortality was higher in CAO and RSP than in NLF (HR, 95% CI; 1.69, 1.31–2.02 and 1.24, 1.06–1.71), and the higher hazards were driven by males. CAO had a higher hazard of respiratory and cardiovascular death than NLF (2.68, 1.05–6.82 and 1.40, 1.04–1.90). The hazard of respiratory death was significant in women (3.41, 1.05–11.07) while the hazard of cardiovascular death was significant in men (1.49, 1.01–2.22). In RSP, the higher hazard for respiratory death remained after adjustment (2.68, 1.05–6.82) but not for cardiovascular death (1.11, 0.74–1.66), with a similar pattern in both sexes.

Conclusion: The higher hazard for all-cause mortality in CAO and RSP than in NLF was male driven. CAO was associated with respiratory death in women and cardiovascular death in men, while RSP is associated with respiratory death, similarly in both sexes.

INTRODUCTION: How e-cigarette use relates to changes in smoking status and respiratory symptoms in the population remains controversial. The aim was to study the association between e-cigarette use and, changes in smoking status and changes in respiratory symptoms.

METHODS: A prospective, population-based study of random samples of the population (age 16–69 years) was performed within The Obstructive Lung Disease in Northern Sweden (OLIN) study and West Sweden Asthma Study (WSAS). A validated postal questionnaire containing identical questions was used in OLIN and WSAS at baseline in 2006–2008 and at follow-up in 2016. In total, 17325 participated on both occasions. Questions about respiratory symptoms and tobacco smoking were included in both surveys, while e-cigarette use was added in 2016.

RESULTS: In 2016, 1.6% used e-cigarettes, and it was significantly more common in persistent tobacco smokers (10.6%), than in those who quit smoking (2.1%), started smoking (7.8%), or had relapsed into tobacco smoking at follow-up (6.4%) (p<0.001). Among current smokers at baseline, tobacco smoking cessation was less common in e-cigarette users than e-cigarette non-users (14.2% vs 47.6%, p<0.001) and there was no association with a reduction in the number of tobacco cigarettes smoked per day. Those who were persistent smokers reported increasing respiratory symptoms. In contrast, the symptoms decreased among those who quit tobacco smoking, but there was no significant difference in respiratory symptoms between quitters with and without e-cigarette use.

CONCLUSIONS: E-cigarette use was associated with persistent tobacco smoking and reporting respiratory symptoms. We found no association between e-cigarette use and tobacco smoking cessation, reduction of number of tobacco cigarettes smoked per day or reduction of respiratory symptoms.

Background: Acute exacerbations (AEs) of COPD are increasingly recognized as episodes of heightened risk of cardiovascular events. It is not known whether exacerbation history is differentially associated with future myocardial infarction (MI) or pulmonary embolism (PE).

Research Question: Is the number and severity of AEs of COPD associated with increased risk of MI or PE in a real-life cohort of patients with COPD?

Study Design and Methods: We identified a cohort of 66,422 patients (≥ 30 years of age) with a primary diagnosis of COPD in the Swedish National Airway Register from January 2014 to June 2022, with complete data on lung function. Patients were classified by moderate (prescription of oral corticosteroids) and severe (hospitalization) exacerbations the year before index date and were followed until December 2022 for hospitalization or death from MI or PE, corresponding to > 265,000 patient-years, with a maximum follow-up time of 9 years. Competing risk regression, according to the Fine-Gray model, was used to calculate subdistribution hazard ratios with 95% CIs.

Results: Compared with no AEs of COPD in the baseline period, AE of COPD number and severity were associated with increased long-term risk of both MI and PE in a gradual fashion, ranging from a subdistribution hazard ratio of 1.10 (95% CI, 0.97-1.24) and 1.33 (95% CI, 1.11-1.60), respectively, for one moderate exacerbation, to 1.82 (95% CI, 1.36-2.44) and 2.62 (95% CI, 1.77-3.89), respectively, for two or more severe exacerbations. In a time-restricted follow-up sensitivity analysis, the associations were stronger during the first year of follow-up and diminished over time.

Interpretation: The risk of MI and PE increased with the frequency and severity of AEs of COPD in this large, real-life cohort of patients with COPD.

Purpose: Patient education in chronic obstructive pulmonary disease (COPD) is recommended in treatment strategy documents, since it can improve the ability to cope with the disease. Our aim was to identify the extent of and factors associated with patient education in patients with COPD in a primary health care setting.

Patients and Methods: In this nationwide study, we identified 29,692 COPD patients with a registration in the Swedish National Airway Register (SNAR) in 2019. Data on patient education and other clinical variables of interest were collected from SNAR. The database was linked to additional national registers to obtain data about pharmacological treatment, exacerbations and educational level.

Results: Patient education had been received by 44% of COPD patients, 72% of whom had received education on pharmacological treatment including inhalation technique. A higher proportion of patients who had received education were offered smoking cessation support, had performed spirometry and answered the COPD Assessment Test (CAT), compared with patients without patient education. In the adjusted analysis, GOLD grade 2 (OR 1.29, 95% CI 1.18–1.42), grade 3 (OR 1.41, 95% CI 1.27–1.57) and grade 4 (OR 1.79, 95% CI 1.48–2.15), as well as GOLD group E (OR 1.17, 95% CI 1.06–1.29), ex-smoking (OR 1.70, 95% CI 1.56–1.84) and current smoking (OR 1.45, 95% CI 1.33–1.58) were positively associated with having received patient education, while cardiovascular disease (OR 0.92, 95% CI 0.87–0.98) and diabetes (OR 0.93, 95% CI 0.87–1.00) were negatively associated with receipt of patient education.

Conclusion: Fewer than half of the patients had received patient education, and the education had mostly been given to those with more severe COPD, ex-and current smokers and patients with fewer comorbidities. Our study highlights the need to enhance patient education at an earlier stage of the disease.

Introduction: Assessing COVID-19 risk in asthma patients is challenging due to disease heterogeneity and complexity. We hypothesized that potential risk factors for COVID-19 may differ among asthma age groups, hindering important insights when studied together.

Methods: We included a population-based cohort of asthma patients from the Swedish National Airway Register (SNAR) and linked to data from several national health registers. COVID-19 outcomes included infection, hospitalization, and death from Jan 2020 until Feb 2021. Asthma patients were grouped by ages 12–17, 18–39, 40–64, and ≥65 years. Characteristics of asthma patients with different COVID-19 outcomes were compared with those in their age-corresponding respective source population.

Results: Among 201,140 asthma patients studied, 11.2% were aged 12–17 years, 26.4% 18–39, 37.6% 40–64, and 24.9% ≥65 years. We observed 18,048 (9.0%) COVID-19 infections, 2172 (1.1%) hospitalizations, and 336 (0.2%) COVID-19 deaths. Deaths occurred only among patients aged ≥40. When comparing COVID-19 cases to source asthma populations by age, large differences in potential risk factors emerged, mostly for COVID-19 hospitalizations and deaths. For ages 12–17, these included education, employment, autoimmune, psychiatric, and depressive conditions, and use of short-acting β-agonists (SABA) and inhaled corticosteroids (ICS). In the 18–39 age group, largest differences were for age, marital status, respiratory failure, anxiety, and body mass index. Ages 40–64 displayed notable differences for sex, birth region, cancer, oral corticosteroids, antihistamines, and smoking. For those aged ≥65, largest differences were observed for cardiovascular comorbidities, type 1 diabetes, chronic obstructive pulmonary disease, allergic conditions, and specific asthma treatments (ICS-SABA, ICS-long-acting bronchodilators (LABA)). Asthma control and lung function were important across all age groups.

Conclusion: We identify distinct differences in COVID-19-related risk factors among asthma patients of different ages. This information is essential for assessing COVID-19 risk in asthma patients and for tailoring patient care and public health strategies accordingly.

Highlights:

• Severe obesity strongly associates to blood neutrophils in adult-onset asthma.
• B-neutrophils may partly mediate associations between obesity and asthma control.
• Clinical evaluation of adult-onset asthma should include assessing B-neutrophils.

Background and Objective: Uncontrolled asthma in patients treated for mild/moderate disease could be caused by non-pulmonary treatable traits (TTs) that affect asthma control negatively. We aimed to identify demographic characteristics, behavioural (smoking) and extrapulmonary (obesity, comorbidities) TTs and the risk for future exacerbations among patients with uncontrolled asthma prescribed step 1–3 treatment according to the Global Initiative for Asthma (GINA).

Methods: Twenty-eight thousand five hundred eighty-four asthma patients (≥18 y) with a registration in the Swedish National Airway Register between 2017 and 2019 were included (index-date). The database was linked to other national registers to obtain information on prescribed drugs 2-years pre-index and exacerbations 1-year post-index. Asthma treatment was classified into step 1–3 or 4–5, and uncontrolled asthma was defined based on symptom control, exacerbations and lung function.

Results: GINA step 1–3 included 17,318 patients, of which 9586 (55%) were uncontrolled (UCA 1–3). In adjusted analyses, UCA 1–3 was associated with female sex (OR 1.34, 95% CI 1.27–1.41), older age (1.00, 1.00–1.00), primary education (1.30, 1.20–1.40) and secondary education (1.19, 1.12–1.26), and TTs such as smoking (1.25, 1.15–1.36), obesity (1.23, 1.15–1.32), cardiovascular disease (1.12, 1.06–1.20) and depression/anxiety (1.13, 1.06–1.21). Furthermore, UCA 1–3 was associated with future exacerbations; oral corticosteroids (1.90, 1.74–2.09) and asthma hospitalization (2.55, 2.17–3.00), respectively, also when adjusted for treatment step 4–5.

Conclusion: Over 50% of patients treated for mild/moderate asthma had an uncontrolled disease. Assessing and managing of TTs such as smoking, obesity and comorbidities should be conducted in a holistic manner, as these patients have an increased risk for future exacerbations.