Stanley Goldstein, MD: Hello and welcome to this HCPLive Peer Exchange entitled “Biologic Treatment Considerations for Asthma During the COVID-19 Pandemic and the Upcoming Flu Season.” I’m Dr. Stanley Goldstein of Allergy & Asthma Care of Long Island. Joining me today in this discussion are my colleagues, Dr. Giselle Mosnaim, attending physician, Division of Pulmonary, Allergy, Clinical Care Medicine, Northshore University Health System, Clinical Assistant Professor, University of Chicago, Pritzker School of Medicine; and Dr. Shahzad Mustafa of Rochester Regional Health, Clinical Associate Professor of Medicine, University of Rochester School of Medicine and Dentistry.
Our discussion today will focus on available biologic therapies for the treatment of asthma, and we’ll also review best practices to manage asthma in the current COVID-19 pandemic and the fast-approaching flu season. Let’s get started in this discussion. Since this discussion is going to revolve around severe, uncontrolled asthma, it will be helpful to discuss some of the basic pathophysiologic changes that occur during an asthma episode
Giselle Mosnaim, MD, MS:The two basic tenets of asthma are bronchoconstriction and inflammation. When someone is having an asthma attack, they feel that their airways are narrowing and there’s also an influx of inflammatory cells which cause secretions and other issues that can block the airways., which This can lead to symptoms such as wheezing, and shortness of breath, coughing, and chest tightness.
Stanley Goldstein, MD: When you think about uncontrolled asthma and the symptoms you were discussing and the pathophysiology, what are some of the causes of having an asthma episode?
Giselle Mosnaim, MD, MS: Typically triggers for an asthma episode, for some people it’s when they get an upper respiratory infection. They have the flu or a cold, particularly in the winter months, that can trigger an asthma episode. Other people it’s exercise. So, when you exercise, rather than breathing through your nose, you start to breathe through your mouth, and breathing in that dry, cold air through your mouth can cause fluid shifts, which can cause an asthma attack. Then, of course, allergens. Seasonal allergens such as outdoor pollens, and also indoor allergens such as furry pets, dust mite and mold, are typical triggers.
Stanley Goldstein, MD: When we’re thinking about patients who are having asthma symptoms and we begin to think about patients who have uncontrolled asthma, could you give us some idea of how common is uncontrolled asthma is, and also, at the same time, why do people have uncontrolled asthma?
Giselle Mosnaim, MD, MS: If we look at the population of patients with asthma overall, the statistics show that about 40% to 60% have uncontrolled asthma. TSo that is very concerning. If we look at that population of all asthmatics, about 5% to 10% have severe asthma. In terms of causes of uncontrolled asthma in particular, you can have issues such as triggers. If you’re exposed to things that you’re allergic to, if there is high pollution, if there are’s things in the environment, that can cause asthma symptoms. Also, poor adherence to medications. A lot of patients and clinicians are concerned about the use of inhaled steroids. Inhaled steroids are the gold standard treatment for persistent asthma, and they work very well for persistent asthma, but adherence to inhaled steroids is low.
There are’s also technique issues. So even Even if patients are taking their medications, using proper technique can be an issue. There are ’s also issues of health literacy. When you give someone an asthma action plan for their asthma, it’s very important that the clinician go over the asthma action planit and make sure that the patient understands the instructions and feels comfortable with the instructionsthem. Many people are going to useing picture-based asthma action plans, so that the explanation is very clear and understandable.
Shahzad Mustafa, MD: I’m going to dovetail off of two things that Dr. Mosnaim said, Giselle said. Unfortunately, many asthmatics are poorly controlled, that’s 40% to 60%. I think that’s really important as to why we’d want to use objective measures to gauge control for asthma. Often if you ask a patient “Hhow’s your asthma?”T and they tell you “Ookay.”, Bbut then if you dive into the details, they’re using their inhaler more often, they’re not doing things they want to be doing because their asthma is poorly controlled. So, using objective measures, whether it’s asthma questionnaires like the Asthma Control Test, it’s certainly in the office maybe breathing tests, even peak flow may help identify these individuals who have poorly controlled asthma.
Why does it matter? If people have poorly-controlledpoorly controlled asthma, they have a higher risk of exacerbation in the future. Additionally, one important point I think is, again, all the reasons that Giselle said for reasons for poor control are true, and I think we’re really starting to appreciate that asthma is a syndrome and not a disease, and everyone’s asthma is different, and exercise-induced asthma is very different than severe asthma. As clinicians, we need to get a better understanding of understanding everyone’s individual asthma, so we can tailor care to them. I know we’re going to talk about picking the right therapies for asthmatics in this session, but understanding asthma, not treating everyone the same, not having an algorithmic approach, will hopefully help improve our outcomes as we pick therapies.
Stanley Goldstein, MD: We’ve been discussing some reasons why patients are out of control— adherence, allergen exposure, respiratory infections, but we do know that also patients may be doing everything right. They may be taking all their medications appropriately, using inhalers appropriately, being strictly adheradherentence, and yet they still can be out of control. I think, Shahzad, that’s what you’re referring to as far as the different types of asthma.
Transcript Edited for Clarity