severe asthma

03 October 2023: We find out what causes asthma, and how one 15 yr old has been struggling with it
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Targeted therapies address the underlying pathways that cause airflow obstruction in patients with asthma, including a number of biologic therapies that have been approved. Omalizumab targets IgE (approved for moderate to severe persistent asthma). Three agents target IL-5, which plays a key role in the activation of eosinophils, and are approved for severe eosinophilic asthma: mepolizumab, reslizumab, and benralizumab. Dupilumab targets IL-4/13 and has been approved for moderate to severe eosinophilic asthma or patients requiring maintenance OCS. All agents are available as subcutaneous injections administered at specific intervals, with the exception of reslizumab, which is available as an intravenous infusion. Selection of which biologic agent to use is dependent on multiple factors, including cost, dosing frequency, delivery route, and patient preference among other considerations. The GINA guidelines suggest a biologic agent should be given a trial of at least 4 months; if treatment response is unclear, clinicians should consider extending the trial another 6 to 12 months. If no response is noted, therapy should be changed to another biologic agent. These biologic therapies are generally safe and well tolerated; however, primary care clinicians seeing patients with asthma must be knowledgeable about common adverse events in order to recognize them.

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Contributors:

Lawrence Herman, DMSc, MPA, PA-C
Adjunct Faculty
Doctor of Medical Science Program
University of Lynchburg School of PA Medicine 
Lynchburg, Virginia
President
Palantir Healthcare, LLC 
Boiling Springs, South Carolina

Samuel Louie, MD
Professor Emeritus
Division of Pulmonary and Critical Care Medicine
University of California, Davis
Davis, California

Asthma is now recognized as a heterogeneous, multidimensional disease that involves numerous pathophysiologic factors, including bronchiolar inflammation with airway constriction and resistance. The identification of distinct patient populations (phenotypes/endotypes) is increasingly being recognized as an important strategy for optimizing the management of patients with asthma. Asthma phenotype is based on clinical symptoms such as respiratory function, onset age, and blood biochemical examination values. 

Clinical studies have shown that asthma phenotypes have specific patterns of inflammation that require different treatment approaches. For example, eosinophilic asthma is characterized by airway and systemic markers of eosinophilia, subepithelial fibrosis, and corticosteroid responsiveness, whereas non-eosinophilic asthma is characterized by the absence of eosinophilia and subepithelial fibrosis, as well as poor responsiveness to corticosteroids. In addition to high immunoglobulin (Ig) E levels in up to 60% of patients, asthma is characterized by tissue eosinophilia, which is mediated in part by interleukin (IL)-5. Because eosinophils produce inflammatory proteins that lead to tissue damage, the eosinophilic phenotype of asthma is associated with greater symptom severity, increased risk of exacerbation, and decreased lung function. The GINA guidelines recommend that asthma should be classified by phenotype, especially when it becomes difficult to treat or refractory to treatment.

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Contributors:

Lawrence Herman, DMSc, MPA, PA-C
Adjunct Faculty
Doctor of Medical Science Program
University of Lynchburg School of PA Medicine 
Lynchburg, Virginia
President
Palantir Healthcare, LLC 
Boiling Springs, South Carolina

Samuel Louie, MD
Professor Emeritus
Division of Pulmonary and Critical Care Medicine
University of California, Davis
Davis, California

Welcome to the emDOCs.net podcast! Join us as we review our high-yield posts from our website emDOCs.net.

Today on the emDOCs cast with Brit Long, MD (@long_brit),  we cover severe asthma and asthma mimics.

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Primary care practitioners play a major role in the management of asthma, providing diagnosis, patient education, and management plans. But when the asthma remains uncontrolled, management can be challenging. On this podcast, Corinne Young FNP-C, president of the Association of Pulmonary Advanced Practice Providers speaks with asthma expert Ann Hefel, FNP-C of Children's Hospital Colorado about what clinicians have in their therapeutic toolbox to help patients with moderate to severe disease whose asthma remains uncontrolled despite adequate therapy. This activity is available for CE/CME credit.

As many as 20% of patients with asthma may not be achieving adequate control of their symptoms, even after they have maximized inhaled corticosteroids and their long-acting beta 2 agonist. If left uncontrolled, patients are at increased risk for serious exacerbations that can lead to ED visits and extended hospitalizations. In this podcast, Corinne Young, FNP-C, president of the Association of Pulmonary Advanced Practice Providers, talks with her colleague Ann Hefel, FNP, an allergy and asthma specialist from Children’s Hospital Colorado about reasons for poor asthma control and how to conduct an effective patient workup to identify the potential causes. This episode is available for CE/CME credits for NPs and PAs.