Number of Patient-Reported Asthma Triggers Predicts Uncontrolled Disease Burden

In patients with severe asthma, each additional asthma trigger increased annualized exacerbations by 7% and asthma hospitalization rates by 17%.

Among patients with severe asthma, the number of patient-reported triggers is a strong independent predictor of uncontrolled disease burden, according to a study in the Annals of Allergy, Asthma, & Immunology.

Investigators assessed the prevalence of asthma triggers and their associations with asthma disease burden in subspecialist-treated patients with severe asthma.

The study involved 2793 patients enrolled in the CHRONICLE study ( Identifier: NCT03373045) from February 2018 to February 2021. CHRONICLE, an ongoing, observational trial, includes adults (aged ≥18 years) with severe asthma who receive biologics or maintenance systemic corticosteroids (mSCS) or whose disease is persistently uncontrolled on high-dosage inhaled corticosteroids with additional controllers. All participants receive treatment from a subspecialist at a participating site.

For the current study, researchers summarized the prevalence of reported triggers based on responses from 51% of study participants (mean age, 54; 70% female, 80% White) who completed a questionnaire regarding asthma triggers. Asthma control was evaluated at enrollment with use of investigator-reported responses to the Global Initiative for Asthma (GINA) control questions and patient responses to the Asthma Control Test (ACT).

The median number of triggers was 8 (interquartile range, 5 to 10) among participants with available trigger information, and all participants reported at least 1 trigger. The most frequently reported triggers were air/weather changes (77%), viral infections (70%), year-round allergies (67%), and seasonal allergies (66%).

A better understanding of asthma triggers and their relationship to disease burden and health-related quality of life may help clinicians develop better asthma management plans with their patients.

About half (51%) of patients had at least 1 asthma exacerbation in the 12 months before enrollment, and those reporting asthma medication changes as a trigger had the highest proportion (61%), with at least 1 asthma exacerbation. According to the investigator-reported GINA categorization of asthma control, 41% were uncontrolled. The highest proportions of uncontrolled asthma occurred in those who reported triggers of nonasthma medication (53%), specific foods (52%), and cleaning/housework (52%). Among participants with available ACT scores (n=1178), 27% had asthma that was not well controlled and 43% had very poorly controlled asthma. ACT scores in patients with individual triggers ranged from 13 to 16.

An overall 61% of patients reported at least 7 trigger categories. Women, younger adult patients, Black patients, those with comorbid chronic obstructive pulmonary disease, and those who received mSCS were more likely to have an increased number of triggers.

Participants who had a higher number of triggers had more poorly controlled disease, a worse quality of life, and reduced work productivity overall. In the year preceding enrollment, 61% of participants reporting 14 to 17 triggers (n=81) had at least 1 asthma exacerbation vs 43% of those reporting 1 to 3 triggers (n=228).

Age, body mass index (BMI), and the number of triggers were significant independent predictors of asthma exacerbation in the final analysis models (n=1296), with only BMI and the number of triggers significant independent predictors of hospitalization rates. The exacerbation rate increased 7% for each additional trigger (rate ratio [RR] 1.07; 95% CI, 1.03-1.11; P =.0009), with an annual exacerbation rate of 0.4 per patient-year. The asthma hospitalization rate increased 17% for each additional trigger, with an annual hospitalization rate of 0.06 per patient-year (RR 1.17; 95% CI, 1.08-1.27; P =.0002).

Among several limitations, some patients did not complete the triggers questionnaire and/or other surveys and were excluded. Additionally, specific triggers were based on patient reports only, and the analysis was limited to US subspecialist-treated adults with severe asthma.

“A higher number of asthma triggers was positively and significantly associated with a greater uncontrolled disease burden across multiple measures, including exacerbation frequency, hospitalization frequency, asthma control, quality of life, and work productivity,” stated the researchers. “A better understanding of asthma triggers and their relationship to disease burden and health-related quality of life may help clinicians develop better asthma management plans with their patients.”

Disclosure: This analysis and the CHRONICLE study are supported and funded by AstraZeneca. Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Chipps BE, Soong W, Panettieri RA, et al. Number of patient-reported asthma triggers predicts uncontrolled disease among specialist-treated patients with severe asthma. Ann Allergy Asthma Immunol. Published online March 9, 2023. doi:10.1016/j.anai.2023.03.001