Asthma Treatments Have Become More Individualized
Author:
John Mastronarde, MD
About 1 in 12 people in the United States have asthma, and the numbers are increasing every year. These numbers highlight the importance for more and better asthma medications and treatment options.
These are pretty exciting times for asthma therapy. In the last several years, we have had some new drugs for specific types of asthma. We are at a point in asthma treatment where we can truly pinpoint more personalized, specific therapies depending on the type of asthma a person may have. The most common, best studied, and most effective therapy for most people with asthma are anti-inflammatory medications, specifically as inhaled corticosteroids. That usually is the drug chosen first for most people with asthma.
There are recommendations to step up asthma therapy if people do not improve with inhaled corticosteroid use. Typically, you would give a patient an inhaled steroid inhaler and see if he or she gets better after 4 to 6 weeks. If the patient does not improve, then one of the first things we want to ensure is that he or she is using the inhaler correctly, if he or she can afford the medications, and if he or she is actually taking the medications. If all those things are true and the patient is still having symptoms, then you start to add other medications.
Treatment regimens can depend on the type of asthma the patient has and the patient’s preference. Typically, there is a step up to having an inhaled corticosteroid combined with a long-acting ß-agonist agent, which is a bronchodilator. Those are typically combined into a single inhaler. If that does not work, then there are other options now, particularly for specific phenotypes like allergic or eosinophilic-mediated asthma.
For those patients who fail standard therapy with an inhaled corticosteroid and a long-acting ß-agonist, the newer medications are monoclonal antibodies to either immunoglobulin E (IgE) or interleukin-5 (IL-5) that improve inflammatory profiles and, in some cases, have quite dramatic improvements in asthma control. Those medications are typically given as an injection once every 4 to 6 weeks, but it varies.
If the patient does not have an allergic or eosinophilic phenotype and does not improve while taking the standard combination therapy, then there are some other options that not quite as well supported by data, but there is evidence for them. We do not yet have a monoclonal antibody that we know will work for those patients, but there are other medications that have anti-inflammatory properties, such as the antibiotic azithromycin.
Tiotropium bromide (Spiriva) is a different classification of a bronchodilator used more in patients with chronic obstructive pulmonary disease but has been shown to be effective for some patients with asthma. Montelukast is a leukotriene-modifying agent that can be prescribed, which again work for some patients with asthma but not consistently for others. And then if the patient has a lot of exacerbations, there is a newer procedure called bronchial thermoplasty, which delivers radio frequency waves to the patient’s airways through 3 serial bronchoscopy tests. The data for this procedure is somewhat controversial, but for patients with a non-allergic phenotype, it may be of value.
Pulmonologists have quite an array of options for patients with asthma, and it is pretty exciting that we can offer more targeted and individualized care for patients depending on the phenotype of asthma.
John Mastronarde, MD, is the lead developer of the Oregon Clinic's Asthma Center at Providence Portland Medical Center. He will be speaking with us today about asthma and chronic obstructive pulmonary disease.