Monica Kraft, MD: Steps Leading Up to Treating Severe Asthma


Before biologics are implemented, what should physicians be doing to ensure asthma control in their patients?

Though biologics such as dupilumab have headlined discussions at the 2018 CHEST Annual Meeting in San Antonio, TX, the promising therapies are not necessarily a first-line solution for asthma control.

Really, as Monica Kraft, MD, Deparment of Medicine Chair at the University of Arizona College of Medicine — Tuscon, told MD Magazine® in an interview, biologics are a solution that occur well beyond the initial asthma diagnosis. Everything between the first symptom and the eventual acceptance that a patient is suffering from severe asthma is mapped below:

MD Mag: What's the best approach to treating severe asthma?

Kraft: The best approach when treating severe asthma is, first, you make sure it's asthma. We have a saying: "Not all that wheezes is asthma." And I do spend a fair amount of my time ruling out asthma. You want to do pulmonary function testing, you'll get a good symptom history, previous response to medication, what's the current medication, what's the course been. [Find out if] patients have had exacerbations needing prednisone—getting a sense of what their whole life has been like with this potential disease.

Once you're confident they have asthma, then it's important to look at the comorbidities: what can make asthma worse? There's a very high prevalence of sinus disease in patients who have asthma, gastroenterological reflux disorder, obstructive sleep apnea. Those are probably the big 3. We also worry about upper airway dysfunction, vocal chord dysfunction.

It's important to address each of those and make sure they're being treated appropriately, because just doing that sometimes can make the asthma a whole lot better, and you don't need to move to either oral steroids or expensive biologics.

Once you do that and you've addressed these comorbidities, if the patients are still not well controlled, you want to maximize what their medicines are and make sure they're adherent. That's such a huge topic for all of us who take care of chronic disease—how do you know? Well, there are ways of assessing by pharmacy refills, by dosers on the inhalers, trying to talk to patients in a very non-confrontational way, maybe they will tell you the truth. I get some very honest answers when I ask in that way.

After you've done all of that, if you still feel like the asthma is not going in the way you need it—meaning, 1 or 2 or more oral steroid bursts a year, really poor symptom control, low lung function less than 80% predicted—then that's the time you think about biologics.

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