CHEST 2018 Perspectives - Episode 7

Navitha Ramesh, MD: Recent & Upcoming Asthma Treatments

A wealth of literature on asthma therapies was published in the last year, which showcased the increasing therapeutic treatment options available for patients and the physicians treating them.

However, all of the data can be overwhelming, which is why pulmonologist, Navitha Ramesh, MD, distilled the past year’s data into a literature review on asthma in a presentation while at the 2018 CHEST Annual Meeting in San Antonio, TX.

In an exclusive interview with MD Magazine®, Ramesh highlighted the key takeaways her from her presentation.

MD Mag: What are the main highlights you observed in your review of published literature on asthma?

Ramesh: A lot has happened in asthma in the last year. It’s a very exciting time for asthma.

The studies that came out in the past year looked at patients with asthma ranging from mild all the way to severe. They answered questions [for physicians] as to ‘What should I do with my mild asthmatic? What should I do with my severe asthmatic?’

I think the studies are all ‘real world’ in sense since they look at patients’ medication adherence. The studies asked questions like ‘Are they going to take these medications?’ I think these studies relate more to the patients.

The first 2 studies I reviewed were SYGMA 1 and 2, where they looked at using inhaled cortical steroid/long-acting beta agonist combinations as needed in patients who have asthma. The traditional thought is asthmatics need to be on inhaled cortical steroids on a routine basis.

But how much is that being followed in the general population? It’s not great.

Consequently, they [investigators] catered to that question and asked, ‘If they used this combination treatment as needed, would it help them have less exacerbations and improve lung function?’ These 2 studies showed that yes, you can use them. They’re noninferior to using inhaled cortical steroids on a routine basis.

The other interesting part of these 2 studies was that if you use the inhaled cortical steroid and long-acting beta agonists as needed, the dose of the inhaled cortical steroid is much less than the inhaled cortical steroids on a regular basis, which I thought was interesting.

MD Magazine: What does this data mean for physicians and healthcare providers? What should they be implementing in their practices?

Ramesh: I wouldn’t say it’s ok for patients to be noncompliant— it’s important to stress [medication] adherence—but if they have a compelling reason why they cannot use inhaled cortical steroids on a regular basis, such as if they are unable to afford the medications or for some reason they don’t remember to take it twice a day, this is another alternative.

It’s not inferior for the patients to use the inhaled cortical steroids and LABA [long-acting beta agonist] combination inhalers on a regular basis.

The other complimentary thing to this is the FDA [US Food and Drug Administration] just removed the boxed warning for inhaled cortical steroids and long-acting beta agonists.

The background for this is, in 2003, there was a trial that came out called the he Salmeterol Multicenter Asthma Research Trial (SMART) where the basic conclusion was long-acting beta agonist medications increase the mortality in patients with asthma. Hence, everyone was scared to use them.

The FDA mandated the major manufacturers of the long-acting beta agonist medications to do large-scale studies. They had a joint oversight committee to see if the studies were uniform in nature and if they study came out well.

The results came out in just the past year where they said inhaled cortical steroids and was long-acting beta agonists do not increase mortality.

They basically debunked the [increased mortality] theory, and that made the FDA remove the boxed warning in December of last year [2017]. This is all good news for our patients and us.

MD Magazine: Is there any 1 treatment or combination of treatments you would recommend as the go-to treatment, or does it vary on the case of asthma?

Ramesh: I think asthma is becoming less of a 1-size-fits-all type of a disease. [It is important to] look at each patients and their different phenotypes. More and more is being learned about the pathophysiology of the disease, and recognizing not every patient can be given the same set of treatment is important. We have to cater our treatment based on each patient.

If you have a patient who has very severe asthma and who has symptoms that are uncontrolled, and you exhausted all your inhaler options, there is hope with the new biologic medications that are coming out.

The most recent 1 is the dupilumab, which is anti-IL 4 and anti-IL 13 monoclonal antibody. This medication has shown promise in reducing severe exacerbations in asthma and improving lung function in asthma as well as decreasing the steroid dose in severe asthmatics who are chronically on oral steroids.

If the FDA does approve dupilumab, it’s a ray of hope for the patients because they do suffer from asthma. They have significant morbidity with asthma, despite doing everything they can, like controlling comorbidities, avoiding triggers, and using inhalers.

This population of severe asthmatics sometimes just don’t improve, and they might have some benefit from dupilumab—that’s my hope.

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