CHEST Curriculum Pathway for Asthma: Treatment Highlights-A Practical Approach to Severe Asthma Therapies

Video Transcription

Even when asthma is controlled with appropriate treatment, many patients often continue to experience symptoms or exacerbations. That's why today we'll be taking a look  at practical therapeutic approaches for severe asthma and other key considerations through the lens of three patient cases. This is CME on ReachMD, and I'm Dr. Sandra Adams.  Here with me today is Dr. Anju Peters, Professor of Medicine and the Director of Clinical Research in the Division of Allergy Immunology  at Northwestern University Feinberg School of Medicine. Dr. Peters, welcome to the program. Thank you, Sandra, it's my pleasure. So I'd like to begin our discussion, Anju,  by setting up the framework of a severe asthma program. What's your typical approach when considering treatment options for a patient with severe asthma?  So Sandra, that's actually something very important because we know severe asthma leads to significant morbidity,  significant cost to our healthcare system. And when I think of severe asthma, I think of it as part of a group of patients who are difficult to control.  And they may have severe asthma due to their biology or comorbidities, and it's very heterogeneous. And the main thing that I think of when I think of a severe asthma patient  is that there should be a systematic approach, a multidisciplinary approach. So it doesn't have to be a severe asthma clinic per se, where in one space, all the different folks  who are involved in treatment of severe asthma are there. But more importantly, that there's a multidisciplinary approach where a patient could see all the different folks  that are involved in severe asthma care. And these could be healthcare professionals, such as allergists like me, a pulmonologist like you,  ENT, gastroenterologists, sleep specialists, and in addition, allied health groups, such as asthma educators, our nurses, our respiratory therapists, et cetera,  to make sure we treat the patient, looking at all different aspects of their treatment. That's really good information, the multidisciplinary approach.  I'm interested in knowing, you mentioned the asthma specialist. I'm interested in knowing when you think people should really be referred to an asthma specialist  and what groups could be taken care of in a general practice. Sure, so Sandra, that I think is very important. And in my point, a patient should be recommended  to an asthma specialist or a multidisciplinary clinic when a patient's asthma is difficult to control. And this could be for many reasons.  It could be that they don't have a proper diagnosis and it's something else other than asthma, but also for other reasons, such as, you know, if a patient,  to find out if they have comorbidities. In fact, there are eight different ones that have been studied. And a study showed that a median of three comorbidities  are present in patients with severe asthma. So it may be important to send a patient to a specialist or a multidisciplinary severe asthma clinic  if these comorbidities need to be addressed. However, I think if it is, you know, if a patient's asthma is difficult to control, no matter what reason,  if they're having frequent or severe exacerbations, if they have poor lung function, so the biology suggests it's severe asthma. Well, that makes a lot of sense.  I wanna dig into this subject a little deeper and discuss a few real world cases. Let's talk about a first case of a 24 year old man  with allergic rhinitis and asthma with worsening symptoms. For the past couple of years, he's needed three courses of oral corticosteroids for asthma exacerbations.  He's currently using albuterol almost daily and has nocturnal awakenings about three to four times a week for shortness of breath and coughing.  He has a beloved cat who's in his bedroom and sleeps with him at night. He denies water damage in his home and his skin testing is positive for cat dander, dust mites, and molds.  His serum IgE is 220, absolute eosinophil count is 200. His FEV1 is 78% of predicted and his asthma control test score is 14. He's currently on an ICS laba.  So how, Anju, would you approach treating and managing this patient? So Sandra, this is quite often the type of patient I'll get. So when I would see a patient like this,  who's 24 years old, who has allergic rhinitis, so makes me think he is allergic, his asthma is getting worse, his asthma control test score is 14.  So we know his asthma is not controlled.  And he is currently on ICS laba. So he says he's on inhaled steroids and long-acting beta agonists. So when I think of someone like this, one of the first things I think of,  you know, I would have skin tested him like he was. He is allergic to cat dust mites and molds. So he has what I would say perennial allergens, year-round allergens for the patient.  And he has a cat. We know patients who are pet allergic and have a pet have increased likelihood of having more severe asthma with more ER exacerbations and urgent care utilization.  So one of the first things I would do in a patient like this, and this is where the interdisciplinary approach is important, in that I would make sure  that an asthma nurse or an asthma educator makes sure and goes over proper inhaler technique, make sure there is adherence to his medications. And after that, in an allergic patient  with known exposure to allergen, it's important that we talk about allergen avoidance with this patient. So if he goes through allergen avoidance techniques,  is using the meds correctly, is compliant with them, and he continues to have symptoms and exacerbations, this is when I would consider a biologic on this patient.  As he's had three courses of steroids in the past year, past couple of years. And in his case, omelazumab, which blocks the allergic antibody IgE or anti-IgE,  would be probably the best choice. It's been around for a long time. Omelazumab has shown to decrease exacerbations in an allergic asthmatic, and is FDA approved for treatment  of moderate to severe asthma. So that's how I would consider this patient. He would be an ideal patient for a pulmonologist or a general physician to send to an allergist.  For those just joining us, this is CME on ReachMD. And I'm Dr. Sandra Adams. Today, I'm reviewing three patient cases with Dr. Anju Peters,  to learn more about developing practical approaches when caring for patients with severe asthma. So Anju, let's continue with our next case.  The patient that we're gonna talk about now is a 56-year-old woman with a history of reflux, GERD, and obstructive sleep apnea, who comes in with complaints of worsening cough,  trouble breathing, and wheezing. She's required one hospitalization, and has been to the emergency department once an additional time for shortness of breath  associated with viral infections in this last year. She's taking ICS-LABA and LAMA inhalers. She's also on a PPI, and her BMI is 32. Skin testing is negative for the aro allergens.  Serum IgE is 28, with an absolute eosinophil count of 600. Her chest X-ray is normal, and her FEV1 is 67% of predicted. So given all these details,  what are your initial thoughts and approach  to really optimally evaluate and manage this person? So Sandra, if I were to see this patient, this is where I would think she is someone who probably has eosinophilic asthma,  which is not controlled.  And I think she is ideal for a severe asthma interdisciplinary evaluation. If I were seeing her as an allergist, I would make sure there is no other medical condition  going on that could be mimicking her symptoms. I may have my pulmonary colleagues see her.  And if that evaluation is negative, then in someone who has eosinophilic asthma that is not controlled, she tells us she has GERD or reflux. Her BMI is 32, so she is obese.  We know she's not allergic.  I would recommend that she see a sleep physician for regular CPAP use, because we know sleep apnea is associated and is one of the comorbidities of severe asthma.  In addition, I would consider a GI evaluation because we also know that GERD potentially can trigger pulmonary symptoms as well.  So in this patient who undergoes a multidisciplinary severe asthma evaluation, we make sure she's taking her meds correctly. She is adherent to them. She's seen a sleep physician  using her CPAP machine regularly.  Has a full GI evaluation, is doing reflux precautions. If she is still not controlled, then I think a biologic could be considered, and the best biologic in her  could be an anti-IL-5 agent, such as mepolizumab, razizumab, or benralizumab, those that are approved for eosinophilic severe asthma.  We know they improve asthma-specific quality of life and decrease exacerbations. And given her history of two exacerbations  needing a hospitalization and another one needing ER visit, I think a biologic, specifically an anti-IL-5 agent, would be appropriate. Okay, that's excellent information.  Thanks for that review. Let's turn to our final case, which focuses on a 46-year-old man with asthma, chronic rhinosinusitis with the nasal polyps, and allergic rhinitis,  who reports worsening asthma symptoms despite high-dose ICS-LAVA and Montelukast. He also reports increased sinus infections with worsening congestion and the inability to smell.  Sinus infections tend to cause worsening cough in him, worsening shortness of breath, and wheezing. He's had three courses of oral corticosteroids  in the past year and two courses of antibiotics for rhinosinusitis and asthma exacerbations. His skin testing is positive for dust mites. CRM IgE is 200,  absolute eosinophil count is 350, and his FEV1 is 67% of predicted. So with all this information in mind, what would you consider next, Anju? So, Sandra, this is, again,  a patient that's ideal for a severe asthma, interdisciplinary approach is, one of the first things I would think of, yes, he's got asthma, he's got nasal polyps,  he is allergic, he's had multiple courses of antibiotics and oral steroids. So one of the things I would consider is get him an allergy evaluation like he did.  I would do allergen avoidance, make sure he's taking his meds correctly. This is where the respiratory therapists, the nurses are important. Make sure he has an asthma action plan.  And after that, I would consider an ENT evaluation to be seen for possible surgical options. As we know, sinusitis is associated with more frequent asthma exacerbations  in those with severe asthma. And treating their sinus disease may improve their asthma.  If this patient decides surgery, he could proceed that way. But another option to consider is dupilumab, which is a biologic, which is a proof  for moderate to severe asthma, as well, type 2 asthma,  as well as for nasal polyps. So in this patient with rhinosinusitis with nasal polyps and asthma that's difficult to control, you could consider dupilumab,  which blocks anti-IL-4 receptor alpha, which is shown to improve asthma, decrease exacerbations, improve asthma control, but also shown to decrease nasal polyps  and improve symptoms associated with rhinosinusitis with nasal polyps, including improving congestion and improving smell and improving quality of life in these patients.  So that's a lot of really good information. You've certainly given us a lot to think about. Just to bring our discussion to a close,  what are the key takeaway points that we can learn from these three cases, specifically, how long do you try to get them controlled before you would consider stepping up therapy?  And is there anything, final word, that you'd like to pass along to our listeners? So Sandra, I think it's important to remember  that patients with severe asthma often have comorbidities.  These patients may have poor symptom control and exacerbations despite appropriate treatment. And it's really up to the referring physician  or healthcare worker to consider sending these patients to the multidisciplinary asthma evaluation if a patient has poor symptom control or exacerbations  so that we don't use repeated use of medications such as oral corticosteroids in these patients. These patients should be assessed for contributing factors  and to optimize their treatment, and I've mentioned all along, requires an interdisciplinary evaluation. So any patient who is difficult to control  frequent or severe exacerbations with comorbidities  should be considered for evaluation  in a severe asthma program. Well, with those key learning points in mind, I want to thank my guest, Dr. Anju Peters, for sharing insights on practical treatment approaches  for patients with severe asthma. Dr. Peters, it was great having you on the program. Sandra, thank you so much for having me on the program, and I just want to end by saying  that a multidisciplinary severe asthma management program has shown to improve asthma outcomes, decrease exacerbations, and improve symptoms. So thank you again. Thank you.

Video Summary

In this video, Dr. Anju Peters discusses practical therapeutic approaches for severe asthma through the lens of three patient cases. Dr. Peters emphasizes the importance of a multidisciplinary approach in treating severe asthma patients, involving various healthcare professionals such as allergists, pulmonologists, ENTs, gastroenterologists, sleep specialists, and allied health groups. The first patient case is a 24-year-old man with allergic rhinitis and asthma, with worsening symptoms and frequent exacerbations. Dr. Peters suggests a systematic approach, including proper inhaler technique, allergen avoidance, and considering a biologic medication. The second case involves a 56-year-old woman with reflux, GERD, and obstructive sleep apnea, experiencing worsening symptoms and frequent hospitalizations. Dr. Peters suggests evaluating comorbidities and considering a biologic for eosinophilic asthma. The third case focuses on a 46-year-old man with asthma, chronic rhinosinusitis, nasal polyps, and allergic rhinitis. Dr. Peters suggests allergen avoidance, ENT evaluation for possible surgical options, and considering the biologic dupilumab. The key takeaway points include the need for a multidisciplinary evaluation for severe asthma patients and the importance of optimizing treatment and managing comorbidities.

Asset Subtitle

Selection among therapies for severe asthma can be challenging, but there are treatable traits clinicians can use to better predict which patients will have a favorable response. Personalized management strategies for patients with severe asthma should consider patient history, lifestyle, triggers, comorbidities, symptoms, and patient technique, compliance, and education, as the three patient cases in this ReachMD podcast detail.

Last Reviewed: September 2022

Keywords

severe asthma

therapeutic approaches

multidisciplinary approach

patient cases

biologic medication