Redefining asthma treatment success: bridging remission goals with patient-centred outcomes

Extract

I read with great interest the recent review discussing the challenges of defining and achieving remission in asthma [1]. While the authors aptly highlight the limitations of current remission criteria, including symptom variability, biomarker fluctuations and comorbidity impacts, I propose that this debate presents an opportunity to explore patient-centred, multidimensional assessment approaches, with tools like the CompOsite iNdex For Response in asthMa (CONFIRM) offering one potential framework [2].

Shareable abstract

CONFIRM provides a patient-centred approach to asthma remission, combining clinical metrics and quality-of-life outcomes for more accurate, real-world assessment. https://bit.ly/43TSUnu

To the Editor:

I read with great interest the recent review discussing the challenges of defining and achieving remission in asthma [1]. While the authors aptly highlight the limitations of current remission criteria, including symptom variability, biomarker fluctuations and comorbidity impacts, I propose that this debate presents an opportunity to explore patient-centred, multidimensional assessment approaches, with tools like the CompOsite iNdex For Response in asthMa (CONFIRM) offering one potential framework [2].

As noted in the review, existing remission frameworks (e.g. 12 months without exacerbations, Asthma Control Test score >20 and stable lung function [1, 3]) face two critical limitations:

• 1) Low achievability: Post hoc analyses of clinical trials demonstrate that only 20–30% of biologic-treated patients meet these criteria across multiple studies [4, 5], with placebo groups often achieving similar rates in controlled trials.

• 2) Neglect of patient priorities: Strict clinical benchmarks may overlook meaningful improvements in quality of life (QoL) or functional capacity that matter most to patients [6].

This challenge aligns with the heterogeneity of severe asthma and the inadequacy of one-size-fits-all definitions for “response”. For example, a patient in “clinical remission” per the current criteria might still report poor QoL due to unmet needs (e.g. persistent fatigue or comorbidities like gastro-oesophageal reflux disease), a gap that multidimensional assessment tools are designed to address [2, 6].

CONFIRM offers a standardised yet flexible framework to evaluate treatment response by integrating: clinical metrics (exacerbations, forced expiratory volume in 1 s, corticosteroid use); patient-reported outcomes (e.g. Severe Asthma Questionnaire for adults, Paediatric Asthma Quality of Life Questionnaire for paediatric patients); and weighted scoring (0–100) to capture partial or domain-specific improvements [2, 6].

Potential advantages of CONFIRM include:

• 1) Nuanced assessment: CONFIRM's continuous scoring identifies “sufficient responders” (e.g. scores of 50–69) who may not meet remission thresholds but still achieve clinically meaningful gains. This accommodates patients with comorbidities (e.g. obesity, anxiety) whose symptoms may not fully resolve but whose QoL improves significantly.

• 2) Holistic evaluation: Unlike remission criteria focused on extreme responders, CONFIRM's multicriteria decision analysis weights outcomes by patient and clinician priorities [2, 6].

However, important limitations must be acknowledged:

• 1) Lack of real-world validation: CONFIRM has not yet been extensively validated in routine clinical practice settings outside of research contexts.

• 2) Absence of an established minimal clinically important difference (MCID): a MCID has not been established for CONFIRM scores, limiting interpretation of meaningful change.

• 3) Implementation challenges: the tool requires comprehensive data collection that may be resource-intensive in clinical practice.

• 4) Limited longitudinal data: long-term outcomes and the tool's responsiveness to treatment changes over time require further study.

While the referenced review highlights the “cons” of achieving remission, CONFIRM could potentially address both challenges and opportunities. CONFIRM could extend the “pros” by:

• 1) Providing objective evidence of multi-domain improvement for patients who show meaningful gains despite not meeting strict remission criteria.

• 2) Supporting personalised treatment goals that align with individual patient priorities.

• 3) Offering standardised metrics for clinical trials and real-world effectiveness studies.

CONFIRM could address the “cons” by:

• 1) Reducing the binary nature of remission assessment through continuous scoring.

• 2) Capturing patient-centred outcomes often missed by traditional clinical measures.

• 3) Potentially identifying patients suitable for treatment optimisation rather than treatment failure.

To advance the field responsibly, future work should:

• 1) Validate CONFIRM in diverse clinical settings: conduct real-world studies to establish feasibility, reliability and clinical utility across different healthcare systems.

• 2) Establish MCID thresholds: Determine clinically meaningful change scores for different patient populations and treatment contexts.

• 3) Comparative effectiveness research: Direct comparisons between CONFIRM-guided management and traditional approaches to assess patient outcomes and healthcare use.

• 4) Integration studies: Explore how CONFIRM complements rather than replaces current remission definitions, potentially serving as an intermediate assessment tool.

While remission remains an important aspirational goal, patient-centred tools like CONFIRM may provide a practical complement to current definitions. By acknowledging both the potential benefits and current limitations of such approaches, we can work towards a more nuanced, individualised assessment of treatment success that serves the diverse needs of asthma patients. Further research is essential to establish the real-world utility and clinical impact of these tools before widespread implementation.