Treating asthma has changed dramatically over the past few decades. The widespread adoption of inhaled corticosteroids (ICS) in the 1990s allowed symptom control and the prevention of exacerbations to become central goals of asthma management. The introduction of biologic medications for patients with severe asthma has created yet another paradigm shift, allowing patients and physicians to gain better control, minimize exacerbations, reduce oral steroid exposure, and slow lung function decline. Medication management has traditionally emphasized a pharmacotherapeutic ladder, or stepwise, approach. When a patient has ongoing symptoms or experiences an exacerbation, they move up the medication ladder by increasing the dose or adding medications. This is essentially a one-size-fits-all approach to patient management and is successful in controlling most patients’ asthma. Unfortunately, this approach does not address patients who do not respond as expected or who may have other factors, such as comorbidities, contributing to the symptoms being treated. The treatable traits approach addresses the patient in a systematic, holistic manner, considering pulmonary, extrapulmonary, and behavioral treatable traits.

Pulmonary treatable traits are related to the lungs, while extrapulmonary traits extend beyond the lungs. Pulmonary treatable traits include conditions such as breathing pattern disorders, comorbid COPD, eosinophilia, high exhaled nitric oxide (FeNO), and poor inhaler technique. Extrapulmonary treatable traits include allergic rhinitis, obesity, depression, anxiety, GERD, vocal cord dysfunction (VCD), nasal polyps, and cardiovascular disease. Behavioral treatable traits include nonadherence to medication, poor inhaler technique, smoking, and inactivity. A strategic treatable traits approach allows for personalized care of heterogeneous diseases such as asthma. Implementing a multidimensional evaluation for patients with asthma is essential, given that asthma manifests differently from patient to patient and within the same patient over time. Although often associated with severe asthma management, the treatable traits approach was not intended to be applied only in that setting.

There are several benefits to implementing a treatable traits approach. When evaluating pulmonary treatable traits, a patient with high eosinophils or high FeNO will likely respond well to ICS or to an increased ICS dose. Laboratory testing is widely available, making it possible to evaluate eosinophils and guide medication decisions. Likewise, evaluating FeNO can aid in medication management decisions, including whether to start or titrate ICS to address inflammation. Assessing the behavioral treatable trait of poor inhaler technique may help resolve persistent symptoms or frequent exacerbations. Reevaluating and reteaching proper inhaler technique, along with when, how, and why to use medications correctly, may help avoid unnecessary medication escalation. Extra-pulmonary treatable traits such as obesity, VCD, and GERD are also often present and untreated in patients with asthma. Each can cause symptoms similar to asthma but requires different treatment. Unidentified conditions that mimic asthma likely contribute to many patients overusing their inhalers for symptoms not caused by asthma. Inappropriate inhaler use increases symptom burden, exposes patients to the side effects of unnecessary medications, and can affect quality of life. Additionally, comorbidities can worsen the impact of true asthma symptoms. Identifying and treating extrapulmonary treatable traits may improve asthma symptom control.

Given that there are dozens of relevant treatable traits to identify and manage, a multidisciplinary team-based approach to asthma care would be ideal. Traits need to be measurable, clinically relevant, and responsive to treatment. A treatable traits approach in asthma care can be implemented in both primary and specialty care. It is clear that asthma needs to be identified and treated early, and that untreated comorbid conditions contribute to more rapid lung function decline, increased symptoms, decreased quality of life, and other adverse outcomes. Although this approach has shown significant benefits in severe asthma care, there is no consensus on how to implement treatable trait management in everyday asthma care. Further research and discussion are needed.

Author:

Heather Murgatroyd, BA, RRT, CPFT, AE-C 

Senior Clinical Specialist 

Methapharm Respiratory 

 References:

1. P.E. Pfeffer, H. Rupani, A. De Simoni. Bringing the treatable traits approach to primary care asthma management. Front Allergy. 2023 Sep 20;4:1240375.
2. I. Farinha, P.G. Gibson, V.M. McDonald, L.G. Heaney. Treatable traits as a pathway to remission in asthma. J Allergy Clin Immunol Pract. 2025 Jul;13(7):1542-1552.