“As physicians, we tend to overestimate the success of treatment and to underestimate the compromise to quality of life (QOL) by the patient,” began William W. Busse, M.D., from the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin, at a presentation he gave at the ACAAI annual meeting. Given the considerable variability in asthma treatment response, how are clinicians able to translate and implement “group data” to the individual patient to achieve maximal control of severe asthma, and also meet the needs and expectations of the patient?
In his presentation, Busse outlined the points for consideration in the treatment of a patient with severe asthma. It is fist necessary, Busse said, to make sure the patient actually has severe asthma. In one prospective study, researchers found that 33.1% of the participants who had received a diagnosis of asthma by a physician within the last 5 years did not have asthma. The greatest contributor to this misdiagnosis was that participants did not have a lung function test at the time of diagnosis. The physician can try to approximate the best treatment for the patient through the development of a patient profile.
Second, Busse said that identifying the patient’s phenotype (asthma pathophysiology) and descriptors of their disease can improve identification of the appropriate treatments. Patients with severe asthma have a phenotype with the greatest disease burden, including the highest costs, greatest compromise to quality of life, and greatest frequency of treatment side effects. Recent developments in biological therapies have improved the treatment options for patients with severe asthma.
Third, biomarkers can indicate the presence of Type 2 or eosinophilic severe asthma, of which eosinophils, FeNO, and IgE are established biomarkers thus far. FeNO is increasingly recognized as a viable biomarker of asthma that is driven by Type 2 inflammation, and the use of FeNO in combination with other Type 2 biomarkers may identify overlapping segments of asthma patients that can then be used to optimize treatment. Biomarkers can be used match the patient to the most appropriate therapy. However, more biomarkers are needed to improve identification and specification of the subgroups of patients that relate to each biomarker.
Fourth, the expectations of the clinician and patient are both important and are not always the same. Most patients want to feel better, reduce the need for medication, avoid systemic corticosteroids, return to a normal life style, and make sure that the treatments they take are safe in the long-term. Physicians want to gain asthma control, prevent exacerbations, normalize lung function, prevent disease progression, avoid systemic corticosteroids, keep their patients safe, and minimize costs. Busse said that there is some overlap between the two, but both are approaching the treatment from slightly different perspectives, so incorporating a shared-decision making tool could be helpful to incorporate both opinions.
Fifth, multiple co-morbidities need to be considered. A study by Denlinger et al. showed that both adults and children with severe asthma and sinusitis had an increased number of exacerbations. Other co-morbidities include: obesity, gastrointestinal reflux disease, vocal cord dysfunction, and nasal polyps.
Sixth, Busse noted that physicians should determine the most appropriate choice of a biologic. He shared some in-press research comparing the three anti-IL-5 treatments by blood eosinophil counts and used and indirect treatment comparison. In the unadjusted comparison, all three treatments were equivalent, but when separated by eosinophil cut-offs, differences were observed. Finally, Busse noted that simply assessing efficacy as early as possible in the course of treatment is important, which can be done by checking for improvement in lung function.
Busse concluded his presentation by noting that the treatment of severe asthma is currently becoming more personalized and moving toward “the right drug, for the right person, at the right time,” adding that the field “is entering a new era that is both exciting and hopeful.”