GERD A randomized, placebo-controlled trial revealed no role of proton-pump inhibitors in severe asthmatics without any symptoms of reflux disease [86]. Besides, the meta-analysis of all randomized controlled trials with proton-pump inhibitors and asthma confirmed statistically significant improvement in the morning peak flow but such low magnitude improvement in peak-flow is unlikely to have any clinical significance [87]. Hence, proton-pump inhibitors cannot be recommended for empirical use in asthmatics.
Obesity and OSA Reduced response to typical asthma medications, including inhaled cortico-steroid and bronchodilators, in obesity might cause severe asthma[88]. Causes of this reduced response are not known. Weight loss does lead to improve asthma symptoms and peak flow [89]. Obstructive sleep apnea may be associated with asthma and obesity. The association between asthma and obesity is not completely obvious yet. However, OSA is associated with upper and systemic airway inflammation and thus, could confound asthma management[90].
Psychological disturbances Psychological factors such as anxiety, depression and panic disorders are more common in severe asthmatics and thus need to be attended quickly [85] [91]. Furthermore, psychological factors such as anxiety and depression are associated with poor compliance to inhaled asthma treatment and
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Allergy testing can be done to know triggers and possibly arrange for immunotherapy. A Cochrane review performed by Abramson and colleagues showed immunotherapy reduces asthma symptoms, need for asthma medication. Developing local and systemic adverse events may exist , including anaphylaxis, when undergoing this therapy[97]. In order to improve the treatment of patients with severe asthma and to control the disease, comorbidities must be taken into consideration, and it is important to treat these conditions