Precision Medicine in the Treatment of Severe Asthma - Episode 2
This is part of the MD Magazine® Peer Exchange, “Precision Medicine in the Treatment of Severe Asthma.”Click here for Segment 3 and learn more about challenges in managing uncontrolled persistent asthma.
Peter Salgo, MD: Asthma is a big disease. Lots of folks have asthma, but what proportion of these folks have uncontrolled persistent asthma? Those are the worrisome ones, I would think.
David Rosenstreich, MD: Well, the statistics vary. In the United States, for people (adults and children) whose asthma is not well controlled, it’s sometimes as high as 50%.
Peter Salgo, MD: Fifty percent?
David Rosenstreich, MD: Most asthmatics think that they have well-controlled asthma, but at least half of them do not. If you measure their airflow, make airflow measurements, and measure symptoms, people tend to discount this. Many times, they wake up, or they had to use their puffer during the day, and things like that. So uncontrolled asthma is a major problem.
Peter Salgo, MD: How do you define uncontrolled asthma anyway? We just threw this term around. What does it mean?
Neal Jain, MD: There are several ways that you can define it. You can define it based on the guidelines, and the guidelines have said that if you have X number of symptoms, 2 days a week, where you’re having symptoms and need your rescue inhaler, or 2 nights a month, where you’re having symptoms, if you have low lung function, if you have exacerbations, those would all be ways to define uncontrolled asthma. There are also asthma questionnaires that are commonly used. We all use them in our clinics to help identify patients who are uncontrolled.
Peter Salgo, MD: I am struck by that number you gave me. I’m struck by this 50%. We can do better than that. Why aren’t we?
Raffi Tachdjian, MD: Part of the problem is misconception—both of the patient and the physician.
Peter Salgo, MD: What does that mean?
Raffi Tachdjian, MD: When you look at the various gradients or severity of asthma in the persistent group (mild, moderate, severe), they’re equally misclassified. The patient says, “I’m under control.” Or the physician thinks, “I’ve controlled this patient. Now I can move on or even think about stepping down therapy.” And that’s where the burden of asthma really kicks in, which is fatality. It is a fatal disease.
Peter Salgo, MD: When your patient dies, that’s a bad outcome. I would consider that to be the ultimate poorly controlled asthmatic.
Neal Jain, MD: Absolutely.
Peter Salgo, MD: But short of that, we should be able to do better.
Neal Jain, MD: Absolutely. I would say that 50% is an underestimate, in some instances.
Peter Salgo, MD: Really?
Neal Jain, MD: There’s the Asthma in America survey. All these surveys have been done to sort of assess how controlled our asthmatics are. I think that some of it has to do with the paradigm of asthma, as it was thought. If you look back at the first guidelines (in the late 1980s, in the United States), they talked about asthma being poorly controlled if you needed your rescue inhaler 4 times a day.
Peter Salgo, MD: I remember that guideline.
Neal Jain, MD: And so you were not put on an anti-inflammatory controller therapy at that time unless you needed albuterol 4 times a day. Many of our adult asthmatics have that as their mind-set. If you’re going into that with a mind-set of “This is well controlled, and I should just use my albuterol,” that’s going to lead to this perception that asthma is controlled and that it’s OK to use prednisone several times a year. “It’s OK. This is typical, right?” But we’re starting to see that this leads to poor outcomes. If you are an uncontrolled asthmatic, you’re likely to have a lot of bad things happen, including exacerbations, emergency room visits, hospitalizations, and comorbid conditions that result from the medications that you’re put on—typically steroids.
Peter Salgo, MD: Let me throw this out there. All of what you’re talking about, including patients’ perceptions of their asthma, is our fault? Who told them it’s OK to go fewer than 4 times a day? Who told them that steroids are OK? We did, right?
David Rosenstreich, MD: I don’t agree. I think people who have asthma, or any illness, but asthma, especially, take it for granted that they’re going to be sick. We take it for granted. We do what we want. We run. We work. We do everything. We don’t worry about whether or not we’re going to get short of breath or need medicine. “Am I carrying my medicine with me?” The problem is that patients take it for granted. “Oh, this is natural. I’m going to have to go up the subway steps, so I’m going to have to use my puffer at the end of that time.” The goal for therapy should be that they should be like the rest of us. They should be able to do whatever they want without worrying about it.
Peter Salgo, MD: Yes, but I want to come back to my premise because I think you just made my case—they have these assumptions because we haven’t disabused them of them, right?
David Rosenstreich, MD: OK.
Neal Jain, MD: I would agree. It’s natural for many physicians (and sometimes we’re guilty of this, as well, as specialists) to simply say, “How is your asthma?” And they reply, “It’s great.” And they say, “I just need another albuterol inhaler.” And so you send in that albuterol inhaler. I would say that is far more common in primary care, but we do see it among specialists, and it leads to, unfortunately, patients being uncontrolled, having some of those negative outcomes.
Transcript edited for clarity.