This year’s CHEST conference generated plenty of conversation about how clinicians should approach severe asthma—not only regarding treatments but also how clinicians should be thinking about the disease in general.

This is critical, as 7.7% of Americans live with asthma, and over 3,500 people die of asthma each year, according to the American College of Allergy, Asthma & Immunology.  And because of climate change’s insidious effects on human health, those numbers are only going to climb, according to CHEST 2024 keynote speaker Vanessa Kerry, MD, MSc, pulmonary and critical care physician as well as the Director of Global and Climate Health Policy in the Department of Environmental Health at Harvard T.H. Chan School of Public Health.

So, how are clinicians thinking outside of the box when it comes to managing patients with severe asthma?

 

Think about a world without steroid dependency

 

With several biologics for severe asthma on the market, steroid-sparing should be a goal. Arjun Mohan, MBBS, told MDLinx.com that for the longest time, clinicians leaned on oral corticosteroids (OCS) as the mainstay for treating severe asthma. They work—but there’s undeniable collateral.

According to Garbo Mak, MD, a patient can easily rack up over a gram of steroids in a year—let alone a lifetime, leading to issues with the skin, skeleton, muscles, eyes, central nervous system, metabolism, cardiovascular system, immune system and gastrointestinal system.

As Dr. Mak says, this is why biologics present such a possibility. “Once biologics are initiated resulting in asthma control, steroids should be tapered. It’s safe and effective to wean off steroids,” she says, with the caveat that clinicians should be selecting which patients to wean carefully. 

“We can’t keep our patients on a set and forget it. We need to identify the right treatment for the right time,” she says.

 

Remission should be a goal, not a fantasy

 

CHEST speaker Njira Lucia Lugogo, MD was adamant that clinicians start examining their perspectives on remission possibility in severe asthma. She says clinicians are no doubt familiar with the concept of remission from oncology, diabetes, or inflammatory arthritis—but that it’s time to think about it with their asthma patients.

She says clinicians need to go after it all: Getting patients to be OCS-free, without any exacerbations, with good symptom control, and with reduced decline in lung function.

 

Taking initiative earlier is key

 

 

Treatment is typically predicated on a patient complaining, but waiting for patients to report symptoms simply doesn’t cut it anymore, Dr. Lugogo says. “[Asking a patient] ‘how do you feel today?’ and then moving on is not adequate. Assessing risk is what’s needed. Patients die from asthma who don’t have or don’t complain of symptoms. So, you cannot assume a lack of symptoms means there’s no disease activity,” she says.

“Make a diagnosis, assess risk, mitigate the risk by treating asymptomatic inflammatory, preserve lung function, reduce airway remodeling, and reduce corticosteroid use,” she says. “Getting here means intervening earlier in the course of the disease.”

 

Embrace new biologics

 

Dr. Khurana says that while there are six biologics in the market, there are new ones in development, like the ultra-long acting anti-IL5 ab (Depemokimab) currently in a phase 3 study. Dr. Mohan stresses the need to give up turning to the same biologics over and over simply due to a sense of familiarity—something that happens commonly. “[A clinician] will note the benefits, fall in love, and pick their agent of choice,” he says. “It’s [also] heavily influenced by how many insurance hoops you have to jump through.”

Switching a biologic or looking closely at the biomarkers associated with each is key. “We don’t have head to head studies to say which biologic is better. Guidelines have come out but are often low quality. So it’s not wrong to have a favorite—but it’s also appropriate to switch a patient if they’re not responding.”

 

Take a patient-centered approach

 

Countless session hosts at CHEST emphasized the importance of taking a patient-centered approach. Gone are the days of a one-size-fits-all approach. 

Dharani Narendra, MD, FCCP tells MDLinx.com that clinicians should be endotyping patients to classify whether they have type 2 or non-type 2 inflammation. “This can be done by evaluating blood eosinophil levels, conducting allergy testing, measuring IgE levels, and assessing FeNO,” she says. “It's also important to assess comorbidities such as nasal polyposis, urticaria, and chronic rhinosinusitis. If the patient experiences frequent exacerbations, poorly controlled symptoms, or requires frequent use of oral corticosteroids, select the appropriate biologic therapy tailored to their specific endotype, comorbidity, patient preference and clinical presentation.”