Shifting the Treatment Paradigm of Severe Asthma With Novel Biologics - Episode 6
Nicola Hanania, MD, MS, and Sidney Braman, MD, discuss step-up treatment and when it’s best to practically implement TH2-high and TH2-low into a therapeutic approach.
Reynold Panettieri Jr, MD: What prompts you to step up? Where do you pull the trigger when you see somebody who’s not doing so well? What do you focus on for step-up treatment?
Nicola Hanania, MD, MS: I focus on a couple of things. If I see a patient who’s already on a medium-dose ICS [inhaled corticosteroid], plus or minus a LABA [long-acting beta-agonist] or a LAMA [long-acting muscarinic antagonist], and they’re still uncontrolled, I look at asthma control. I look at exacerbations. I also want to make sure, before stepping up, that the patient is using their inhaler correctly. The other day, I had a patient who I wanted to step up, but then I went back. I work in a county hospital where I can go and look at the prescription refills. The patient hasn’t refilled her controller for 3 months. When I asked her, in a nice way—patients don’t like it when you confront them—it seemed like she hadn’t, and there was no reason because at a county hospital, they’re paid for.
There are lots of reasons why adherence may be a big issue, so I urge my colleagues—and we’re all doing it—before stepping up, ask: Is the patient taking their inhaler? Because we know, even for inhaled steroids, there is a plateau effect. It’s not like the higher, the better all the time. This is definitely a benefit in some patients of doubling the inhaled steroid. At some point, you reach a plateau and you have to ask: What else can I do? By increasing the dose, you may also increase risk of topical adverse effects and systemic effects. To answer your question, I look at asthma control, asthma exacerbation, and adherence. I want to make sure all the comorbidities are taken care of—especially the nose—and then I step up, and I have to bring them back to see how they do. Of course, we can’t just step up and leave them on a high-dose ICS forever.
Reynold Panettieri Jr, MD: I certainly embrace that approach quite well. I’m sure Sid and Geoff have similar aspects. But I’d highlight that when we take that and understand control, we can use objective measures like the Asthma Control Test [ACT] and filter that into our EMR [electronic medical record] so that we longitudinally track the ACT score, which gives us some objective measures. Sid, in that last section, we really drilled down into high T2 and low T2, more in a global physiological or pathophysiological approach. How do you take those learnings and practically implement them in therapeutic approach? What’s your approach, Sid?
Sidney Braman, MD: I’m glad this question came up on the heels of our last comments when we were talking about stepping down. Indeed, many asthmatics, it’s been shown, just don’t respond to those steroids, and they are predominantly in that T2/non-T2 category. One of the things we need to be brave enough to do is step down. Often, they’re on oral corticosteroids. It’s not doing any good. The other thing is, very often, that T2 pathways can be masked by the corticosteroid. For example, eosinophils are very sensitive to the steroids, and they may be high in a patient put on larger doses of oral corticosteroid. For example, you check: Is this a T2 patient? No, eosinophils are low, and FeNO [exhaled nitric oxide] is low. This is another area where you may want to consider that step down. That’s the approach I would take. As we know, we have a really limited armamentarium against the non-T2. When patients, as Nic was saying, are following their Asthma Control Tests and exacerbation rates, you get to the point where you’re looking at a patient saying, “This isn’t working. You’re on high-dose corticosteroids. We need to go to the next step.”
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Transcript Edited for Clarity