Shifting the Treatment Paradigm of Severe Asthma With Novel Biologics - Episode 1

Overview of Severe Asthma

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Sidney Braman, MD, provides an overview of severe asthma and the physiological response a patient will have during an asthmatic episode.

Reynold Panettieri Jr, MD: Hello, and welcome to this HCPLive® Peer Exchange titled “Shifting the Treatment Paradigm of Severe Asthma With Novel Biologics.” I’m Dr Reynold A. Panettieri, a professor of medicine at Robert Wood Johnson Medical School in New Brunswick, New Jersey. I’m very pleased to be joined by outstanding physicians and scientists in their area. This discussion will be with my colleagues Dr Sid Braman, a professor of pulmonary critical care in sleep medicine at the Icahn School of Medicine at Mount Sinai in New York, New York; Dr Geoffrey Chupp, a professor of medicine at Yale School of Medicine in New Haven, Connecticut; and Dr Nic Hanania, an associate professor of medicine at Baylor College of Medicine in Houston, Texas. In today’s discussion, we will provide an overview of recent advances in patient assessment and treatment, with a focus on novel and emerging biologics in the management of asthma. Welcome, everybody. I’m thrilled to be here with friends and colleagues.

Let’s embark on segment 1: An overview of severe asthma. Sid, I want you to take this first question. What happens physiologically during an asthmatic episode that’s an exacerbation? What’s the classification system for asthma?

Sidney Braman, MD: The quick answer to the first question is that for most individuals who are having a severe attack, it will result in severe bronchospasm, induced bronchospasm, larger and smaller airways, hypersecretion of mucus, and mucus plugging up the airways. Status asthmatic is when there’s sometimes very widespread plugging of mucus. Hyperemia of the airways, edema of the airways, and essentially severe airflow obstruction lead to severe ventilation perfusion mismatch and increased work of breathing. This occurs sometimes in more severe attacks, or even hypercarbia. What’s the definition of severe asthma, which is the condition we’ll be discussing today? I like to use—most of us do—the ERS, European Respiratory Society and ATS [American Thoracic Society] definition. Severe asthma is an individual who’s had, over the past year, the need to control his or her asthma or perhaps not control the asthma of high-dose inhaled corticosteroids and a second controller. In addition, their definition goes on to suggest that those individuals who have had the need for oral corticosteroids, and systemic corticosteroids at least 50% of the time would need to be in this classification. Now this is a little different. This definition, what we would also call uncontrolled asthma, is a different group of individuals. The severe asthmatic group will constitute about 4% of the total asthma population and will have much higher and uncontrolled asthma. These individuals—if you look at their symptom control, whether an ACQ [Asthma Control Questionnaire] or an ACT [Asthma Control Test]—test abnormally. They have frequent severe exacerbations of 2 or more in the last year, a serious exacerbation of hospitalization, airflow limitation, and airflow obstruction. That would be the definition of uncontrolled asthma.

Reynold Panettieri Jr, MD: Thanks, Sid. Geoff, my patients with this are having chest tightness, cough, and wheezing that’s unremitting. Do you have any additional comments to what Sid mentioned? Anything to add there?

Geoffrey Chupp, MD: One of the things that can be a bit of a disconnect for providers is this idea about systemic corticosteroid use. There are some of the little conflicts or uncertainties—between the different guidelines and documents that have been put together by ERS [Economic Research Service], ATS, and GINA [Genetic Information Nondiscrimination Act]—about the idea that we consider 2 courses of systemic steroids to be an uncontrolled patient and an individual who’s on systemic steroids more than 50% of the year is considered severe but controlled. There’s a disconnect between these 2 definitions. We need to start to align this and come up with a clear narrative for health care providers of all types that take care of patients with asthma. Then we can start to acknowledge that all patients who are on systemic steroids chronically or have a certain amount should be considered uncontrolled, and that the goal should be to get them off systemic steroids.

Reynold Panettieri Jr, MD: I love that idea. That idea of OCS, oral corticosteroid, burden is substantial. Nic, do you see patients with severe asthma with an OCS burden? 

Nicola Hanania, MD, MS: Yes, of course we do. Also, I want to just comment on Geoff’s and Sid’s elegant responses. Keep in mind that these definitions are based on the fact that you’ve actually diagnosed asthma. We get referrals of many patients on oral steroids with so-called asthma, but when we come back and look at the physiology and take a good history, they may have other things that resemble asthma. A correct diagnosis is very important before you label a patient as severe asthmatic, but also comorbidity. You have to do a big checklist before you label the patient with severe asthma based on their medication that they’re taking.

Reynold Panettieri Jr, MD: That’s a great point. Not all that wheezes is asthma. You’ve got to confirm it. The most common cause of refractory disease is the wrong diagnosis, because we use therapies to treat a disease that we think the patient has when they don’t.

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Transcript Edited for Clarity