Precision Medicine in the Treatment of Severe Asthma - Episode 8
This is part of the MD Magazine® Peer Exchange, “Precision Medicine in the Treatment of Severe Asthma.”Click here for Segment 9 and learn about practical considerations for managing severe asthma.
Peter Salgo, MD: When you talk about stepping up and stepping down therapy, the implication is that there’s then a reassessment. How often do you reassess these patients, and what are you looking for?
Neal Jain, MD: To an extent, it depends on how severe they are, right? But, initially, if someone comes in and they’re naive to therapy, if you decide to put them on something, typically you want to see them back in 4 to 6 weeks. You want to make sure that their therapy is effective, that they’re actually using it, and that they’re not having problems with it—that they’re not having side effects, concerns. You’re answering all of those questions. You want to make sure that they’re not actually puffing it on their chest, or around their ears, and that they’re actually taking it properly.
Peter Salgo, MD: How often do you bring them in?
Neal Jain, MD: Initially, at least that once. And then, depending upon their severity, it might be 2 times a year if they’re a mild asthmatic. It might be 3 to 4 times a year if they’re more severe.
Peter Salgo, MD: Now, patients and/or doctors have questions about ICS [inhaled corticosteroid] therapy. We talked about this earlier. “I’m worried about my bones.” Or “I’m worried about opportunistic infections.” Are those concerns real? And which are the phenotypes that respond best to this ICS therapy anyway?
David Rosenstreich, MD: The concerns are real. We maybe tend to underplay it a little bit, but for children, there’s a risk of growth retardation. It may be a centimeter if you use inhaled steroids over a long period of time.
Peter Salgo, MD: But that’s real.
David Rosenstreich, MD: That’s real. In adults, you’re talking about the risk for cataracts or glaucoma. These are real risks, and you weigh them against the benefits. We don’t have all good choices. We have 2 less-good choices. But there are risks, and people should be made aware of them.
Peter Salgo, MD: Again, assessing control. I know we’ve beaten this one. Is it enough to ask, “How are you feeling?”
Raffi Tachdjian, MD: I’m going to answer this question. We always think about quality of life and how it is impacted by the medication or the treatment or the control. And I’m going to add presenteeism. Are you able to attend or predictively say that you’re going to go to this kid’s graduation or that wedding? Can you make plans to say, “I’m under such great control with this therapy. My doctor is so wonderful. I can actually map out the rest of my month or year.”
David Rosenstreich, MD: I think the question, “How is your asthma,” is obviously not enough.
Peter Salgo, MD: It’s too broad.
David Rosenstreich, MD: Some people will say, “My asthma is great,” and it turns out that their FEV1 is 10%. And some people go to work and they can barely breathe. You have to hone in on how much inhaled beta-agonist you are using and how many times.
Peter Salgo, MD: Oh, so you do check medication use and the amount?
David Rosenstreich, MD: Oh, absolutely. The 2 best things for my patients are looking at their peak flow on the same peak flow meter from day-to-day and looking at how often they’re using their inhaled short-acting beta-agonist. Counting that is a good predictor. And then you ask about other things, like nighttime awakenings. How often have they not been able to go to school, work, or things like that? There are good questionnaires. We like the Asthma Control Test, etc. Things like that are very useful in honing in on patients and ensuring that they’re really controlled.
Neal Jain, MD: I would echo what both of my colleagues have said. The other point that I would make is that we really want to know, up front—and I think we put this in all of our notes—if this is an exacerbation-prone individual. In someone who comes in once a year for an albuterol prescription, who takes their low-dose inhaled steroid, it might be alright to ask, “How is your asthma doing?” if they’ve never had an exacerbation, been to the emergency room, or been to the hospital. “How’s your asthma doing?” “I’m doing great.” That’s probably fine.
But if you have someone who has a history of frequent exacerbations, who has had risky events, that’s not fine. They may still tell you, “I’m doing great,” but you need to dig deeper. You need to look at other things, perhaps biomarkers, etc, to identify whether or not they’re controlled.
Transcript edited for clarity.