Shifting the Treatment Paradigm of Severe Asthma With Novel Biologics - Episode 2
Geoffrey Chupp, MD, leads a discussion on the risk factors, including patient factors, that may increase the risk of having an asthmatic episode.
Reynold Panettieri, Jr, MD: What are the risk factors? How do you know that an individual sitting next to you is going to have an exacerbation?
Geoffrey Chupp, MD: We know that there are some predictors of exacerbations. Eosinophil [leukocyte] counts and exhaled nitric oxide [FeNO] levels have been shown to correlate with a higher risk of an exacerbation. But these aren’t things that we can really track on patients on a daily basis or whenever we want to. They’re done periodically when individuals come into the clinic. Generally speaking, what we’re trying do in medicine, with the technology that’s available, is identify when patients’ symptomatology is increasing. For example, digital tracking of rescue inhaler use or additional sound analyzers of people’s breathing can allow you to see when somebody is developing symptoms that could lead to an exacerbation. The other thing is that every patient is different. It’s really important to be personalized about a patient’s triggers: their seasonal triggers for allergic asthmatics, work-related triggers, diesel exhaust, and things like that. It’s different for every patient. I’m struck by a case that I have of identical twins, both of whom have severe asthma requiring biologics. But 1 of them is much more severe than the other because this individual is a ceramicist and has a lot more exposure in her life. The other is a yoga instructor who has a much more relaxed, less stressful, low-exposure lifestyle.
Reynold Panettieri Jr, MD: That’s very interesting. That’s a great point. I like that idea that every patient is unique. Every patient is a snowflake. We’d love to lump people in with 1 size fits all, but that just doesn’t work, does it, Nic? What do you do? What do you see when you’re worried about a potential exacerbator?
Nicola Hanania, MD, MS: One of the major risk factors is uncontrolled disease, as we will talk about and have already mentioned. Somebody with uncontrolled asthma definitely is at higher risk of exacerbation. There are host factors like obesity and some races. African Americans tend to have higher risk. As Geoff mentioned, there are some biomarkers that can tell me who may be at higher risk—like increase because of biomarkers, high levels of eosinophils, high FeNO—but history of exacerbation is 1 of the most important predictors. If somebody tells me, “I’ve been to the ER [emergency department]” or “I’ve been on an oral steroid once or even twice in the last year,” that person is at high risk of exacerbation subsequently. Each patient behaves differently, but there are some general rules about who is at risk. I definitely think you can implement, as we do all the time, an Asthma Control Test [ACT] to see who’s uncontrolled and ask about previous exacerbation or need for oral steroid. There are host factors that sometimes are modifiable, like weight loss. Ultimately, there may be a genetic determinant because some patients have a higher risk of exacerbation. Exposures, as Dr Chupp mentioned, are very important. About 20% of my patients smoke and continue to get exposed to secondhand smoke. Those patients are at high risk of exacerbations as well.
Reynold Panettieri, Jr, MD: What I’m hearing is that every patient is a snowflake. Everyone is unique. However, there is a radar screen and blips come up. Which of those blips suggests this is a patient I’m going to have to put on oral steroids for maybe 3 times a year?
Sidney Braman, MD: Speaking of snowflakes, as you know, I relocated to Florida, and a lot of snowflakes are coming down to enjoy the sun here. These are mainly older individuals. Nic and I have had a long-standing interest in asthma in older adults. This is a special group in terms of risk factors because, most of the time, their inhaler technique is a problem. They may have some cognitive issues, or physical issues that don’t allow them to use the devices properly. This is important. There may be some psychosocial issues. They may not be able to afford the medications because they’re on many different medications. These are other signals that you’re dealing with someone who may have exacerbations down the line. We were asking, “What’s going to let me know that the patient might be ready for an exacerbation?” As Geoff mentioned, that little metered dose inhaler—as I discuss with patients—is the best asthma meter they have. That’s where they’re beginning to use their rescue medication. Whether it’s an albuterol inhaler, a short-acting beta-agonist, or in a combination with formoterol [bronchodilator] with an inhaled steroid budesonide. Using those as rescue medications over and over is an important signal. Sometimes you have the ability to get pharmacy records, and many pharmacies would be able to give you that. If you’re seeing a patient using a rescue medication, going through 200 doses in a month, boy, that’s certainly an important signal. Or if that patient is doing, let’s say, 2 or more canisters of the short-acting beta-agonist in a year, that too is a patient who’s in poor control. Using the ACT, the asthma control test, is a good reason to keep an eye on a patient and anticipate exacerbations.
Reynold Panettieri, Jr, MD: I like that idea. The use of rescue inhalers is a clear tip-off.
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Transcript Edited for Clarity