How are asthma and type 2 diabetes connected. What mechanisms contribute to their association. How does this relationship affect asthma control and overall health. What are the implications for patient care and management.

The Prevalence of Asthma and Type 2 Diabetes: A Global Health Concern

Asthma and type 2 diabetes mellitus (T2DM) are two chronic conditions that affect millions of people worldwide. According to the Global Asthma Network, approximately 339 million people suffer from asthma globally. Meanwhile, the International Diabetes Federation reports that 463 million adults are living with diabetes, with type 2 diabetes accounting for about 90% of all cases. These staggering numbers underscore the importance of understanding the relationship between these two conditions.

In recent years, researchers have observed an intriguing association between asthma and T2DM. But what exactly is the nature of this relationship? Let’s delve deeper into the mechanisms that link these two seemingly unrelated conditions.

Unraveling the Connection: Mechanisms Linking Asthma and Type 2 Diabetes

The association between asthma and T2DM is complex and multifaceted. Several mechanisms have been proposed to explain this connection:

• Chronic inflammation
• Obesity as a common risk factor
• Metabolic dysregulation
• Shared genetic factors
• Environmental influences

Chronic Inflammation: The Common Thread

Both asthma and T2DM are characterized by chronic low-grade inflammation. In asthma, this inflammation primarily affects the airways, while in T2DM, it impacts insulin-sensitive tissues. The persistent inflammatory state in both conditions may contribute to their mutual exacerbation.

How does chronic inflammation link asthma and T2DM? In asthma, inflammatory mediators such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) are elevated. These same mediators are also implicated in insulin resistance, a hallmark of T2DM. This shared inflammatory profile suggests a potential bidirectional relationship between the two conditions.

Obesity: A Common Risk Factor

Obesity is a well-established risk factor for both asthma and T2DM. Excess adipose tissue secretes various proinflammatory cytokines, contributing to systemic inflammation. This chronic inflammatory state can worsen both asthma symptoms and insulin resistance.

Moreover, obesity can lead to mechanical changes in lung function, such as reduced lung volumes and increased airway hyperresponsiveness. These alterations may predispose individuals to asthma or exacerbate existing asthma symptoms.

Metabolic Dysregulation: A Vicious Cycle

The metabolic disturbances associated with T2DM may directly impact lung function and asthma control. Hyperglycemia, a characteristic feature of T2DM, can lead to glycation of proteins in the lungs, altering their structure and function. This process may contribute to airway remodeling and increased bronchial hyperresponsiveness in asthmatic patients with diabetes.

Conversely, asthma medications, particularly corticosteroids, can affect glucose metabolism. Long-term use of systemic corticosteroids may increase the risk of developing insulin resistance and T2DM. This creates a potential feedback loop where the treatment for one condition may exacerbate the other.

The Impact of Diabetes on Asthma Control: Challenges and Considerations

The presence of T2DM can significantly impact asthma control and management. Several studies have shown that individuals with both asthma and T2DM tend to have:

1. More frequent asthma exacerbations
2. Increased healthcare utilization
3. Higher rates of hospitalization
4. Poorer overall asthma control

Why does diabetes complicate asthma management? The reasons are multifaceted:

• Metabolic changes affecting lung function
• Increased susceptibility to respiratory infections
• Potential drug interactions between asthma and diabetes medications
• Comorbid conditions such as obesity and sleep apnea

Healthcare providers must be aware of these challenges when treating patients with both conditions. A comprehensive, personalized approach to management is essential for optimal outcomes.

Diagnostic Considerations: Identifying Comorbid Asthma and Diabetes

Given the significant overlap between asthma and T2DM, early detection of both conditions is crucial. Healthcare providers should consider screening for T2DM in patients with asthma, particularly those with risk factors such as obesity, family history, or prolonged corticosteroid use.

What diagnostic tools are available for identifying comorbid asthma and diabetes? Some key assessments include:

• Spirometry and lung function tests for asthma diagnosis
• Glycated hemoglobin (HbA1c) testing for diabetes screening
• Fasting plasma glucose and oral glucose tolerance tests
• Assessment of body mass index (BMI) and waist circumference
• Evaluation of inflammatory markers such as C-reactive protein (CRP)

Early identification of both conditions allows for timely intervention and more effective management strategies.

Treatment Strategies: Navigating the Complexities of Dual Management

Managing patients with both asthma and T2DM requires a thoughtful, integrated approach. Treatment strategies should address both conditions while minimizing potential adverse interactions.

Asthma Management in Diabetic Patients

When treating asthma in patients with T2DM, healthcare providers should consider the following:

• Optimizing inhaled corticosteroid doses to minimize systemic effects
• Regular monitoring of blood glucose levels, especially when using systemic corticosteroids
• Considering alternative or add-on therapies such as long-acting beta-agonists or leukotriene receptor antagonists
• Emphasizing the importance of proper inhaler technique and adherence

Diabetes Management in Asthmatic Patients

For diabetic patients with asthma, treatment considerations include:

• Selecting diabetes medications with minimal impact on lung function
• Monitoring for potential interactions between diabetes and asthma medications
• Emphasizing the importance of glycemic control in maintaining overall health and asthma stability
• Considering the use of newer diabetes medications with potential anti-inflammatory effects

A collaborative approach involving pulmonologists, endocrinologists, and primary care physicians is often necessary to provide comprehensive care for these complex patients.

Lifestyle Interventions: A Cornerstone of Management

Lifestyle modifications play a crucial role in managing both asthma and T2DM. Key interventions include:

1. Weight management: Achieving and maintaining a healthy weight can improve both asthma control and insulin sensitivity.
2. Regular physical activity: Exercise can enhance lung function, improve glycemic control, and reduce inflammation.
3. Smoking cessation: Quitting smoking is essential for improving lung health and reducing cardiovascular risk.
4. Dietary modifications: A balanced diet rich in fruits, vegetables, and whole grains can help manage both conditions.
5. Stress reduction: Techniques such as mindfulness and relaxation exercises may help manage stress-related exacerbations.

How effective are lifestyle interventions in managing comorbid asthma and diabetes? Studies have shown that comprehensive lifestyle programs can lead to significant improvements in both asthma control and glycemic parameters. For example, weight loss interventions have been associated with reduced asthma symptoms, improved lung function, and better diabetes control.

Future Directions: Research and Therapeutic Opportunities

The growing recognition of the relationship between asthma and T2DM opens up new avenues for research and therapeutic development. Some promising areas of investigation include:

• Exploring common inflammatory pathways as potential therapeutic targets
• Investigating the role of the gut microbiome in both conditions
• Developing dual-action medications that address both asthma and diabetes
• Studying the long-term outcomes of patients with comorbid asthma and T2DM
• Evaluating the impact of early intervention strategies on disease progression

What potential breakthroughs might we see in the coming years? Researchers are exploring several exciting possibilities:

1. Novel anti-inflammatory agents that target shared pathways in asthma and T2DM
2. Personalized medicine approaches using genetic and biomarker profiles
3. Advanced drug delivery systems for more effective and targeted therapies
4. Digital health solutions for improved disease monitoring and management

As our understanding of the asthma-diabetes connection deepens, we can expect to see more tailored and effective treatment strategies emerge.

Public Health Implications: Addressing the Dual Epidemic

The rising prevalence of both asthma and T2DM presents significant challenges for healthcare systems worldwide. Addressing this dual epidemic requires a multifaceted approach:

• Increased public awareness about the link between asthma and T2DM
• Enhanced screening programs to identify at-risk individuals
• Implementation of preventive strategies targeting shared risk factors
• Development of integrated care models for managing comorbid conditions
• Allocation of resources for research and treatment of complex patients

How can healthcare systems adapt to address this growing challenge? Some potential strategies include:

1. Establishing specialized clinics for patients with multiple chronic conditions
2. Developing clinical guidelines for the management of comorbid asthma and T2DM
3. Training healthcare providers in the complexities of managing dual diagnoses
4. Implementing telemedicine solutions for improved monitoring and follow-up
5. Fostering collaborations between different medical specialties to provide comprehensive care

By addressing the asthma-diabetes connection at a public health level, we can work towards reducing the burden of these chronic conditions on individuals and society as a whole.

Association between Asthma and Type 2 Diabetes Mellitus: Mechanisms and Impact on Asthma Control—A Literature Review

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Asthma in adults with diabetes: treat their diabetes with metformin, improve their asthma?

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Respirology. Author manuscript; available in PMC 2017 Oct 1.

Published in final edited form as:

Respirology. 2016 Oct; 21(7): 1144–1145.

Published online 2016 Aug 17. doi: 10.1111/resp.12869

PMCID: PMC5021626

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PMID: 27533627

, M.D., M.P.H.

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After decades of increasing prevalence in numerous countries, asthma affects over 300 million people worldwide. Similarly, the prevalence of obesity has doubled since the 1980s, and according to the World Health Organization it now affects over 600 million people around the world (with an additional 1.3 billion being overweight)¹. Obesity is a major risk factor for diabetes, and it is also associated with higher risk of asthma. Obese people with asthma tend to have more symptoms, more frequent exacerbations, lower quality of life, and decreased response to asthma medications^2–4. The pathways linking obesity to asthma have not yet been fully elucidated, but are likely multifactorial and include a mechanical effect on the lungs and the airways, genetic predisposition, epigenetic modification, dietary changes, a pro-inflammatory state, and others.

The metabolic complications of obesity –insulin resistance, the metabolic syndrome, and diabetes– likely play an important role in the pathophysiology of “obese asthma”^5,6. The association between obesity and asthma is greater in the presence of insulin resistance⁷. Independent of obesity, subjects with diabetes may be at higher risk of asthma⁸. Similarly, insulin resistance and the metabolic syndrome have been associated to lower lung function among obese adolescents, with a more pronounced decreased among obese adolescents with asthma⁹. In light of these and other similar studies, it is crucial to determine whether preventing or adequately treating and controlling these complications of obesity may reduce asthma morbidity.

In this issue of Respirology, Li et al. use data from the Taiwan National Health Insurance Research Database (NHIRD) to evaluate whether the use of metformin among subjects with asthma and diabetes is associated with the risk of asthma exacerbations, emergency room visits, or hospitalizations¹⁰. Using a retrospective cohort approach, the authors analyzed insurance claims and medication data from 1,332 patients with concomitant asthma and diabetes: 444 taking metformin for their diabetes, and 888 age- and sex-matched subjects who were not using metformin. For each subject, they looked at data over a period of three years after the first prescription of metformin. After adjusting for several clinical covariates, they found that metformin use was associated with significantly reduced risk of asthma exacerbations (OR=0.39, 95% confidence interval [CI]=0.19–0.79%) or hospitalizations (OR=0.21, 95% CI=0.07–0.63%).

Metformin is one of the most commonly prescribed oral anti-diabetic drugs; its mechanism of action is not completely understood, but proposed pathways include the activation of AMP-activated protein kinase (AMPK), an enzyme that plays an important role in the regulation of insulin signaling and glucose metabolism¹¹. It also increases insulin sensitivity and may antagonize glucagon, thereby reducing blood glucose levels¹². Metformin has been shown to attenuate allergic eosinophilic airway inflammation in obese mice, normalizing levels of eotaxin and tumor necrosis factor alpha (TNF-α) in bronchoalveolar lavage, and restoring levels of AMPK in lung tissue¹³. It may also inhibit airway smooth muscle cell proliferation through AMPK-dependent pathways¹⁴. Interestingly, AMPK induction by metformin ameliorates sodium and water transport in cystic fibrosis airway epithelial cell cultures¹⁵. Thus, there is evidence that metformin may have a potential role in the treatment of asthma. The study by Li and colleagues expands our current knowledge in two key aspects: First, it adds another important step to establish causality in the association between insulin resistance (or hyperglycemia) and asthma morbidity in humans. Second, and more importantly, it demonstrates an important clinical benefit among adults with asthma and diabetes taking metformin.

The present study has several strengths, including the use of matched data from a large, population-based cohort; the longitudinal nature of the analysis; the use of both diagnostic code and medication records to ensure accuracy; and the adjustment for multiple covariates and potential confounders such as short- and long-acting beta-agonists (SABA and LABA), inhaled corticosteroids (ICS), and oral steroids. At the same time, the study has limitations that are inherent to claims and coding database analysis. For instance, several covariates were not available in the NHIRD database that could be important confounders, including information on body mass index, tobacco smoking, race and ethnicity, socioeconomic status, allergen or pollution exposures, etc. Importantly, the database provides no information on medication compliance (for either asthma or diabetes), asthma severity, or blood glucose levels. Thus, we cannot ascertain whether the results are directly related to the use of metformin, to better diabetes control with improved glycaemia, or to other potential confounders.

In a world with 1.9 billion overweight/obese people, 400 million people with diabetes, and over 300 million people with asthma, the results reported in this issue of Respirology are novel and important, and certainly merit further investigation. Future studies should build on these findings, and improve on the current limitations by conducting prospective studies in cohorts specifically designed to address the effect of metformin on asthma outcomes. It is premature to recommend clinicians to modify their management of these patients, but if the results were replicated in independent cohorts, they would likely constitute sufficient grounds to consider randomized clinical trials. Future research will also have to address whether the effects of metformin on asthma are limited to patients with diabetes, or whether it may also be beneficial in subjects with obesity, insulin resistance, or the metabolic syndrome.

Funding from the National Heart, Lung, and Blood Institute at the US National Institutes of Health (HL125666) is acknowledged.

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The combination of bronchial asthma and diabetes: synergism or antagonism? | Ivanov

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Bronchial asthma and diabetes mellitus

Bronchial asthma and diabetes mellitus occur against the background of impaired functioning of the immune system. Diabetes mellitus develops as an autoimmune disease with the production of antibodies against the pancreas’ own cells. In bronchial asthma, plant pollen, food, animal hair, bacteria, etc. act as an antigen. The risk of developing asthma in diabetics is higher than in people without autoimmune diseases.

There is also a risk of impaired carbohydrate metabolism for asthmatics using glucocorticosteroids for treatment. With this combination, the development of diabetes as a complication of steroid therapy is less common than osteoporosis or other side effects, but all steroids and a number of other drugs used to treat bronchial asthma worsen the course of existing diabetes, as they increase blood sugar levels.

Patients with asthma who are diagnosed with steroid diabetes usually have severe asthma, which is the reason for the prescription of systemic steroids. Their use in high doses or for a long time leads to obesity. Obesity, in turn, worsens the course of diabetes.

Bronchial asthma in diabetes mellitus occurs more often in the first, insulin-dependent type. There was no association between type 2 diabetes and the incidence of asthma.

For patients with bronchial asthma, a complete cessation of smoking is necessary, since this factor leads to frequent attacks of suffocation and causes circulatory disorders, vasospasm. In diabetes mellitus, in conditions of angiopathy, smoking increases the risk of developing diabetic neuropathy, heart disease, destruction of the glomeruli of the kidneys and kidney failure.

In order to prevent complications of diabetes in the treatment of bronchial asthma, patients are recommended to:

1. Constant monitoring of blood sugar levels and dose adjustment while prescribing glucocorticoids.