Challenges in Managing Uncontrolled Persistent Asthma


This is part of the MD Magazine® Peer Exchange, “Precision Medicine in the Treatment of Severe Asthma.”Click here for Segment 4 for a look at how asthma manifests in patients.

Peter Salgo, MD: Let me run down some bullet points of the potential reasons for lack of control. No. 1 is, let’s blame the patient first. Poor adherence. We told them what to do, and they’re not doing it. How common is that?

Raffi Tachdjian, MD: Fairly common.

Peter Salgo, MD: OK. Why?

Raffi Tachdjian, MD: Maybe the miscommunication started in the clinic? The expectations are different. There’s tachyphylaxis and all kinds of reasons for using rescue medication. “I’m using this, and it just doesn’t seem to be helping. I should be using more of this.” That’s where I think the guidelines have improved with this third version. It’s always a work in progress to say that using even once-a-day rescue medication puts you in an uncontrolled path. And so that’s where the control tests come in—to gauge, other than the rule of 2, how the patient feels.

Peter Salgo, MD: What’s the rule of 2?

Raffi Tachdjian, MD: Two symptoms per week, daytime. Or 2 symptoms per month, nighttime. And so on. There is a question that is built into these questionnaires. It asks, “How do you feel your asthma is, as far as under control?” That’s the last chance that the patient has to say, “I feel like a champ. I don’t want to admit to failure here, but I don’t feel good.”

Peter Salgo, MD: We blame the patient, to some degree.

David Rosenstreich, MD: But adherence for all medicines is poor. Once-a-day pills are taken more frequently than twice-a-day pills. How many people finish their antibiotic course? People don’t like taking a lot of medicines. As soon as they feel they don’t need it, they stop it. People also don’t understand or are afraid of their medicines. We give them inhaled steroids that we tell them are perfectly safe, but they hear steroids and they’re afraid that their bones are going to get weak. They don’t want to tell me that they’re not taking it, but they just don’t take it. So there are a lot of misconceptions. It requires a lot of education and teamwork between the doctor and the patient to get it just right.

Neal Jain, MD: With this condition, adherence is unfortunately the norm rather than the exception, as it is with many chronic conditions. But with this condition…

David Rosenstreich, MD: The requirement for adherence.

Neal Jain, MD: Yes, the requirement for adherence is there. But, as we’ve talked about, it’s a variably episodic disease for many individuals. And so they see it as that. And that leads them to not being adherent, feeling as though they can take their medications when they become symptomatic. For many, that may work. But for many, it does lead to them having trouble—seeing exacerbations, hospitalizations, and sometimes fatalities.

Peter Salgo, MD: How many times can we just blame the disease? “This is really severe asthma. You’re doing everything, but this disease is just bad.” Is that viable?

Raffi Tachdjian, MD: It is viable, but why is it bad? We have to blame ourselves. We don’t understand it fully.

Peter Salgo, MD: That brings us to possible suboptimal therapies. The patient is presenting with these terrible symptoms. We haven’t gotten to control yet. How often is that the case?

David Rosenstreich, MD: Well, it depends on whom they’re seeing.

Peter Salgo, MD: They’re seeing you.

David Rosenstreich, MD: It depends on how much time you have to spend with the patient and how much they complain. People are frequently undertreated because either they haven’t reported their symptoms or the doctor doesn’t know for sure what they really need or is uncomfortable with a new medicine. That’s part of the problem with why people are uncontrolled.

Neal Jain, MD: I would say that if you look at severe disease and the underlying pathology that is relatively severe, we estimate that about 10% of the population has severe disease. Among that 10%, there are still many who are nonadherent, who might respond to traditional therapies. But therapies are getting better. Our understanding of the disease is getting better.

Peter Salgo, MD: So that pool should be shrinking?

Neal Jain, MD: It should be shrinking, but even among those of us who are specialists, with improving therapeutics and the use of those therapeutics, the penetrance is still only about 10%.

Peter Salgo, MD: Really?

Neal Jain, MD: Although we have these therapies emerging, we’re not necessarily targeting and identifying the patients who would adequately benefit from them.

Peter Salgo, MD: How many folks out there get devices that should work, but they don’t use them right?

Neal Jain, MD: I think we all have stories of the person who comes in who has had severe disease. You have thoughts running through your head of, “What is going on here? Why is this person not controlled?” You have them show you what they do, and it’s comical.

David Rosenstreich, MD: I had a patient to whom I said, “Show me how you’re using your inhaler.” They said, “I spray it on my lungs.” Really?

Peter Salgo, MD: I hate to laugh, but it’s comical. But it’s our fault too. We didn’t show that patient how to use it.

David Rosenstreich, MD: I think the major cause for asthmatics not doing well is that they don’t use their inhalers properly. They’re hard to use. It’s not like taking a pill or giving yourself an injection. You have to train yourself. You have to do it properly and do it properly each time. In our Severe Asthma Center, that’s probably the No. 1 cause of why people are not doing well.

Raffi Tachdjian, MD: I will add 1 more thing to that. Part of it (as with any other disease state) is, “How well do you feel upon initiation of therapy?” In some of these patients, when we’re using controllers, they’re not getting immediate relief as they do with rescue medication. And so a nicer, more targeted approach that gives you some feedback because everyone is kind of listening to their body, to their lungs, would create a better path for adherence and compliance.

Transcript edited for clarity.

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