Precision Medicine in the Treatment of Severe Asthma - Episode 7
This is part of the MD Magazine® Peer Exchange, “Precision Medicine in the Treatment of Severe Asthma.”Click here for Segment 8 and learn about assessing treatment response in asthma.
Peter Salgo, MD: We discussed how to define significant severe asthma. Can you just do it based on the therapy required to treat it?
Neal Jain, MD: There are a couple of guidelines. There’s the ERS [European Respiratory Society]/ATS [American Thoracic Society] guideline and then there are the GINA [Global Initiative for Asthma] guidelines on the definition of severe asthma. Essentially, if you require step 5 or step 6 therapy, which would be a high-dose ICS [inhaled corticosteroid] plus a LABA [long-acting beta-agonist] to maintain control, or if that is not controlling your disease, then you’re considered to be a severe asthmatic.
Peter Salgo, MD: And once you make this diagnosis, what’s your goal? What are you looking to achieve? And what is the role of a nonpharmacologic strategy in all of this?
Raffi Tachdjian, MD: The main goal to achieve is control, obviously. The problem is that these are uncontrolled asthmatics. Maybe we’re failing in our therapeutics. Maybe we’re misdiagnosing them. We might be missing comorbidities. We mentioned some of them: obesity, pollution, viral infections, and so on. At that point, it’s coming into this century of having more targeted therapy. They might have that little nuance in their pathophysiology that even sets them apart from their family members.
Peter Salgo, MD: How do you gauge this? You’re treating somebody with severe asthma. You want to know if you’re winning or losing. Very quickly, in a couple of bullet points, how do you know that you’re getting to where you need to be?
Neal Jain, MD: There are 2 domains that we talk about: impairment and risk. Impairment is asking, “How much is this affecting me in my day-to-day life? Am I obstructed? Am I needing my albuterol? Am I having symptoms? Am I able to run with my kids or do what I want to do?” That’s impairment. You want to reduce, limit, and minimize impairment, but you also want to reduce risk. Risk is what leads to bad things. And so, you don’t want to have those exacerbations that lead to prednisone use, and steroids, and hospitalizations, and emergency room visits.
Peter Salgo, MD: We’ve been talking about inhaled corticosteroids. Clearly, some people do well, or better, on them. And then there’s SABA [short-acting beta-agonist] therapy. How do you clinically decide what to do about that?
Raffi Tachdjian, MD: Well, according to the Expert Panel Report 3 (EPR-3) guidelines, you have stepwise therapy that guides you to step up therapy. And then, every 3 months, as you reassess the patient and see that they’re under control, you can actually think about stepping down. At certain points, there are nonpharmacologic or old homeopathic therapies, such as immunotherapy. Obviously, as Dr Rosenstreich alluded to, avoidance of allergen needs to be addressed. There are a lot of things that need to be done that are nonpharmacologic. But, unfortunately, we still need to abide by the consideration that medication works in 95% or better of patients at that time.
Peter Salgo, MD: When do you pull the trigger on steroids?
Neal Jain, MD: When they have persistent disease.
Peter Salgo, MD: What about a SABA?
David Rosenstreich, MD: Well, there are 2 different schools of thought: step up, step down. We tend to start upward and then work down. We can make a case where you should start at the lowest dose and work your way up. But in people who come in to see us, we find that they want relief. They want to start living a life. We’ll start them on an inhaled corticosteroid. It’s also a clinical judgment. When they come in, if they’re really bad, you have this clinical sense that they need an inhaled steroid and a long-acting beta-agonist right off the bat. They come back to see you and they’re so grateful with the symptom relief they get. And then, with time, you can start cutting back, if necessary.
Neal Jain, MD: When you look back at choosing a SABA, an ICS, or both, anyone who has documented asthma should get a SABA. They should all have albuterol available to them. If they have intermittent symptoms of obstruction, they can reverse that obstruction using an albuterol inhaler. Inhaled steroids, you can go back to this rule of 2s: “Do you have impairment that causes you to have symptoms 2 days a week or 2 nights a month? Do you have exacerbations?”
You’re allowed to have 1 exacerbation that requires you to use oral corticosteroids in a year. If you have more than that, you should think about using an ICS. This also leads patients to say, “Look, I have this twice a year. You want to put me on a daily therapy for this?” And that’s where I think you see this issue of nonadherence come into play.
David Rosenstreich, MD: But patients sometimes self-regulate. In other words, you put them on an inhaled steroid and they say, “You know what, I’ll just take it when I need it.”
Peter Salgo, MD: That’s not how it works.
David Rosenstreich, MD: No, but it’s not as bad of a strategy as you think.
Peter Salgo, MD: Is that right?
David Rosenstreich, MD: It turns out that the intermittent use of inhaled steroids works as well as daily use. And so, patients are not that dumb. Sometimes they can regulate themselves. They say, “It’s only twice a year. That’s what I’m going to do.”
Neal Jain, MD: In a certain population of patients, that is an effective strategy.
Peter Salgo, MD: But when a patient decides, “I’m going to use my steroid,” what drives that decision? Typically, you start giving steroids before they’re sick. How do they know to take inhaled steroids?
Neal Jain, MD: The assumption is that when you start to feel symptomatic, there is an inflammatory component there. A couple of good studies have been done. In patients who have this sort-of borderline mild persistent disease, using an inhaled steroid on an as-needed basis, if you’re not a risky individual, may be an adequate mechanism to control disease.
Raffi Tachdjian, MD: The best analogy that I use, especially when we go into the inner city with a van, relates to brushing your teeth. Kids will understand this better than their parents. Why do we brush our teeth or use corticosteroids? It’s to control and maintain. When do we use the SABA or the rescue medication? “My teeth hurt. There may be a cavity. I’ve got to go to the dentist.” That’s also a great analogy, or example, for me to say, “Put that thing next to your toothbrush. You might want to brush your teeth or rinse your mouth so that you don’t get thrush or any of the other side effects of the corticosteroid.”
Transcript edited for clarity.