Background
Patients with difficult-to-treat asthma have multiple targetable traits that should be assessed and addressed systematically.

Aim
To determine longitudinal outcomes and predictors to response after systematic assessment and protocolised care at a difficult asthma clinic.

Methods
Patients seen in our difficult asthma clinic were systematically assessed and treated for pulmonary (airflow limitation and eosinophilic airway inflammation), comorbid (allergic rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obstructive sleep apnoea, obesity, vocal cord dysfunction, dysfunctional breathing, anxiety and depression) and behavioural (adherence, inhaler technique and smoking) traits. Asthma outcomes at one year were compared with baseline values.

Results
99 patients seen in clinic from 2017-2021 with 1 year follow-up data were included for analysis. Mean asthma control test (ACT) improved by 3 (p<0.001), exacerbation rate decreased by 0.73 per year (RR 0.48, 95% CI 0.33-0.69, p<0.001), and mean forced expiratory volume in 1 second (FEV1) increased by 6.98% (p=0.005) with no change in proportion of patients on maintenance oral corticosteroids or other add-on therapies apart from biologics. 66.7% of patients with baseline ACT<20 and 54.3% with baseline FEV1<80% achieved the minimally clinically important difference (MCID) improvement in ACT (?3 points) and FEV1 (?15%), respectively. (Bonini M, et al. Eur Respir Rev. 2020 Jun 3;29(156):190137.) No specific traits predicted response for ACT but patients with a lower baseline FEV1 were more likely to have improvement in FEV1.

Conclusion
Protocolised care improved symptom, exacerbation and lung function outcomes in difficult asthma.