Updates to Guidelines in the Diagnosis, Management of Patients With Asthma
In this video, Albert Rizzo, MD, speaks with allergist and immunologist Juanita Mora, MD, pediatrician John Harrington, MD, and pulmonary and critical care physician, David Hill, MD about updates to the guidelines in the diagnosis and management of patients with asthma.
Additional Resources:
2022 GINA Main Report. Global Initiative for Asthma. Accessed April 24, 2023. https://ginasthma.org/gina-reports/
For more asthma content, visit the resource center.
Juanita Mora, MD, is an allergist and immunologist at Chicago Allergy Center and a national spokesperson for the American Lung Association (Chicago, IL).
John W. Harrington, MD, is the Vice President of Quality, Safety, and Clinical Integration, a General Academic Pediatric Practice Co-Director at Children’s Hospital of the King’s Daughters, and a professor of pediatrics at Eastern Virginia Medical School (Norfolk, VA).
David G. Hill, MD, is Chair of the Public Policy Committee for the American Lung Association, a Clinical Assistant Professor of Medicine at Yale University School of Medicine, and Frank Netter College of Medicine at Quinnipiac University, and a Pulmonary and Critical Care Physician and the Director of Clinical Research at Waterbury Pulmonary Associates (Waterbury, CT).
Albert A. Rizzo, MD, is the chief medical officer of the American Lung Association and a member of ChristianaCare Pulmonary Associates (Newark, DE).
TRANSCRIPTION:
Albert Rizzo, MD:
Hello, everyone, and welcome to our multidisciplinary discussion on asthma. I'm Dr Albert Rizzo, the chief medical officer of the American Lung Association and clinical assistant professor of medicine at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, and also a pulmonologist practicing at Christiana Care in Newark, Delaware.
Really happy to be joined today by three esteemed guests. Dr Juanita Mora is an allergist and immunologist at Chicago Allergy Center in Chicago, Illinois, and is a national spokesperson for the American Lung Association.
Dr John Harrington is the vice president of quality, safety and clinical integration, a general academic and pediatric practice co-director at Children's Hospital of the King's Daughters and a professor of pediatrics at Eastern Virginia Medical School in Norfolk, Virginia.
We also have Dr David Hill, who's currently the chair of the public policy committee for the American Lung Association, is also a spokesperson for the lung association, and a clinical assistant professor of medicine at Yale University School of Medicine and the Frank Netter College of Medicine at Quinnipiac University.
He also is a pulmonary and critical care physician and the director of clinical research at Waterbury Pulmonary Associates in Waterbury, Connecticut. Thank you all for joining us today.
David Hill, MD:
Thank you.
John Harrington, MD:
Yep, thanks for having us.
Juanita Mora, MD:
Thank you.
John Harrington, MD:
Thanks for having us.
Albert Rizzo, MD:
What I'd like to do now is switch a little bit to talk about some of the actual diagnosis and management based on guidelines. Now, we know guidelines are there for a lot of reasons by a lot of societies. Sometimes guidelines are just put on the shelf or sit in an EMR.
But in asthma we have actually two that people tend to talk about. The Global Initiative for Asthma, or the GINA guidelines, which are really updated yearly. Then we also have reports coming out of NHLBI, the expert panel reports, that are not very frequently updated but recently were in 2021.
What I'd like to do both from the allergy and pulmonologist maybe hit some high points as to where we think things may have changed or not and, also, what are some of the basic principles of treating asthma. There, I'm starting really with the inhaled steroids, but I'd like to open it up to maybe let's start with Dr Hill in this situation.
David Hill, MD:
I think when we talk about the guidelines, you've kind of laid it out. The GINA guidelines are updated annually. They actually look at them twice a year to change with how medicine is changing.
Whereas, NHLBI gets together now and again and updates guidelines. Even the 2021 guidelines are out of date because they were looking at 2020 data and medicine changes rapidly. It's almost a frustration of mine because I feel like, and I would bet Juanita agrees with me on this, we manage our asthmatics differently than what the guidelines or what the FDA tells us to do because the literature is ahead of that.
The latest GINA updates, I think the most interesting parts of it are actually on the milder side of disease as opposed to, I know we made reference to biologics a few times, but what they're calling SMART therapy where no one should be using a rescue albuterol inhaler alone.
And everyone should probably be, who's using not maintenance therapy, should be using an inhaled steroid and long-acting beta agonist inhaler as their rescue so that they get some steroid on board. The literature shows that that actually improves outcomes.
That's really driven a lot of what I do with some of the mild cases that get referred to me. I don't see a ton of mild cases, but I do see a lot of adolescents who are having exercise-induced symptoms only.
They're usually sent to me by a pediatrician who says, "I'm not sure if this is asthma or not." We make the diagnosis and say, "Yes, it's asthma." In the old days, I would've given a kid an albuterol inhaler and said, "Use this before exercise or practice and all is well."
Now, I give them an inhaled steroid with a long-acting beta-agonist with the same approach. "Use this before exercise and if you're having problems..." And I know I'm doing evidence-based practice doing that.
I think there is some talk on the opposite side about what I found interesting in the most recent GINA update was about eosinophil and FeNO testing. What it said was, "Check that three times before you make the decision that the patient truly doesn't have those biomarkers."
I think those of us in practice sort of do that. We'll dig back through records to look at patients' prior blood work, we'll see what they were like when they were sick. But I've never really had a hard and fast, "Okay, we're going to have you come back and do it again and see."
Typically, we would do one big push and say, "Okay, this is the potential biologic we should use in your case because your blood work didn't support using another one. I found that part really interesting.
Albert Rizzo, MD:
Dr Mora, anything to add to that?
Juanita Mora, MD:
No, I think Dr Hill was very comprehensive and I completely agree with you, David, on where the guidelines are. One of the beautiful things for the GINA guidelines, though, that I think they did well in their latest update is steps five and six, including the biologics, especially in the children as they're evolutionizing, as well.
Because it allows us to have that conversation with primary care doctors, as well, during teaching rounds, etc., as we're updating what has changed. Teaching the residents, the medical students, as well, because we are a collaborative, disciplinary team and if we show them.
Because suddenly pharmacists are questioning, "Why are you writing... This patient never had an ICS LABA before and now you're writing it and they only had Singulair before?" You explain, "Well, it's SMART therapy. Now we can use it." Even Europe has been using it for a lot of years, SMART therapy. But now, here, we're adopting it in the United States.
That's one of my big goals is as I go and teach pediatricians, family practice, and internal medicine is teaching them about SMART therapy and that being one of the big updates with GINA. Also, introducing the biologics, especially as we're expanding, in both pediatric and adults, the number of biologics we have to treat asthma.
Albert Rizzo, MD:
Right. You teed up my next set of questions here. We know that the main treatment for asthma is inhaled steroids, mainly because there's inflammation in the airways. The terms now T2 inflammation or non-T2 inflammation are being thrown around a lot in the literature because of the different biomarkers that we have and the different biologics that are being used to treat patients with what are considered severe asthma. I think when I last looked, maybe 10%, maybe up to 15% of the patients with asthma might be categorized as severe.
But I would like to talk a little bit more about the role of biologics after the traditional therapies that we've all been talking about now don't seem to be keeping the patient under control. I'll put either Dr Hill or Dr Mora out first to start talking about their approach to using biologics.
David Hill, MD:
What I'd say is the biologics, in general, have been revolutionary when it comes to caring for patients with severe asthma and even patients with moderate asthma. In my practice, the more experience we've had with them, the earlier I try to push to start them.
We've seen great efficacy, minimal side effects and, really, disease control sometimes in patients who hadn't been controlled for years. I have a number of patients who had spirometry with fixed airflow obstruction that, in the old days, I would've called that airway remodeling and said they have chronic obstructive asthma. They get put on a biologic and their lung function after years normalizes. You realize you had never controlled the disease well enough with our inhaled therapies or our oral therapies that we had.
The biggest things that have limited biologic use are the cost. They're incredibly expensive to somebody, usually not the patient, but to somebody. And package labeling, which for some of them says they have to have severe disease, some of them are labeled for moderate disease, it depends on the agent. There's a lot of argument that goes.
The reality of asthma care in 2023 is that our inhaled therapies are incredibly expensive. So the differential between biologic treatment and inhaled steroid long-acting beta-agonist treatment has narrowed.
The biologics are still much more expensive, but when you're talking about complete disease control and keeping patients out of the emergency room or the hospital, it's a no-brainer. I really push the envelope as much as I can with patients who aren't well-controlled.
Lack of adherence is sometimes an issue. When you know the patient isn't filling their regular medicine, to some degree it pushes me to try to get them to take care of their disease better.
But if they're getting sick enough to end up in the emergency room, if an injection of a biologic, the compliance is 100% when they're in my office. As opposed to their inhaled medicine, it's really hard to make sure the patient is taking it.
That's how I approach it. We've got a half dozen biologics available for asthma, and they all have slightly different labeling and indications. But I'd say five out of the six of them I use fairly routinely now.
Albert Rizzo, MD:
Dr Mora?
Juanita Mora, MD:
I completely agree. I think that biologics have been life-changing for so many people when it comes to asthma control. I love the fact that biologics in 2023 now treat overlap syndromes.
I have one biologic that treats a child who has atopic dermatitis or eczema, has nasal polyposis, and asthma all in one, which is really great to be able to block all that inflammation and disease.
I have biologic for allergic asthma alone. I have biologic for eosinophilic asthma that's there, and some for combination in patients, as well. It's really been great and people can administer them at home, which is also so revolutionary.
Because people can take control of their asthma and they don't depend as much on us either or coming into the office all the time. I think that as we move forward in the biologic world, one thing that we're going to be able to see is more overlap syndromes and higher actual pathway cutoff where we're going to be blocking more to get asthmatics under the best control possible.
In AL-LAD, I had a patient who had been intubated seven times in his lifetime. Started him on a biologic, has not been to an ER or emergency room, and no oral steroids required since that time.
David Hill, MD:
We've had omalizumab now for 20 years and the fascinating thing to me is even when it first came out, in my adolescent population, I'd have kids with severe asthma that they didn't care so much that their asthma was better. They were so excited that their skin cleared up and their eczema got better.
You had kids who had mild eczema, wasn't even something I particularly noticed that much and severe asthma. But they were happy about the skin improvements. So the overlap treatments, even for milder disease, can be dramatic. Curing somebody's nasal polyps may be as big a deal as getting their asthma controlled.
Albert Rizzo, MD:
Just a level set, you keep using this term control. I think what we all want to do is most asthmatics want to try to have them get the most normal life they can and maybe use things like the ACT test when they come in for the office visit.
But, also, more importantly, keeping them out of the ER, keeping them out of the hospital and also keeping them off oral steroids which, really, in the long run can be more detrimental than helpful.
We haven't touched on that much but comment a little bit on the role right now of oral steroids in this new era of biologics. Do you still see a number of patients who require that and anything to identify them by?
David Hill, MD:
Certainly for exacerbations oral steroids are still a mainstay when a kid or adult gets a viral infection and really starts wheezing when allergies are out of control. But I look at a single course of oral steroids as a reason to think about biologics.
If the patient is treatment-naive or they've come off of treatment and they're not taking anything else, that may not be the time to address and start biologic therapy but I'm at least starting to think and look.
I think steroids aren't going anywhere anytime soon for asthma or for any of the other numerous things we use them for. But our goal, when we talk about controls, should be minimizing. For the individual patient, the goal is for them never to need steroids.
Albert Rizzo, MD:
Right.
David Hill, MD:
Societal-wise, it's to minimize the amount we have to use it because that's really one of the markers of asthma morbidity-mortality is going on steroids.
Albert Rizzo, MD:
Right. Right. We always talk about step-down therapy at times or step-up therapy and not necessarily with the biologics but the other inhalers. Is there still a role for step-down therapy when you think somebody is under good control with their regimen?
Juanita Mora, MD:
Definitely. I think the guidelines tell us that we should step down. I have a lot of patients who are allergic asthmatics, so they exacerbate in spring and fall, but they tend to be great during summer and even during winter.
I step down their therapies during their summer and winter, they do well, and we step it up again once the spring is about to hit and also in the fall. My markers are always March 15, the Ides of March, and then Labor Day weekend. That's when they up. Then we go down first frost of Christmas or near Christmas time and it usually works. July 4th is my marker for the heat.
David Hill, MD:
I have a similar approach and the guidelines don't really cover the patient who has severe disease three months of the year. But there are patients of mine who are on almost no therapy for six months and then need to be on a lot of therapy.
The other area of step-down that isn't as well described is sometimes we put patients on the biologics and they just need a lot less of their other medicines. Typically, when I have a patient who responds well to biologic therapy, that's the last thing I'm talking about getting rid of.
A lot of times the patient will step down before I even approach it with them where they'll come in and say, "Oh, yeah, I haven't been using that medicine. I didn't need it anymore."
Albert Rizzo, MD:
Right.
David Hill, MD:
It's hard to argue when they've got normal spirometry, normal exam, and no symptoms.
Albert Rizzo, MD:
When you've decided to put an individual on a biologic, how long do you observe them before you decide that maybe it's the wrong biologic?
Juanita Mora, MD:
12 weeks, 12 weeks is usually my marker. Because per a lot of the studies that we have, three months is usually a good time to monitor symptoms to see if they have any side effects, to see improvement, decrease oral steroid use, decrease emergency department visits, decrease albuterol use, as well, increased quality of life. If they're being beautifully compliant with everything and they're not seeing improvement, then I think maybe there's something I'm missing or time for a switch.
David Hill, MD:
I'd say I do the same approach, kids sooner. In adults, I'll give a longer time period maybe up to six months. It's the same thing. I start looking for what I'm missing. I definitely have had some patients where we choose a different biologic agent and they respond. But there's also a group of patients who have the right biomarkers and don't get better with biologic therapy.
I think, as the specialist, that's my measure to say, what else is going on? Maybe this isn't all asthma, or what trigger am I missing? Going back to the questions we asked before, is somebody smoking around you? Are you smoking? What's going on in the environment?
The adults, we haven't really touched on it, but what are you doing at work and what's your workplace like? Because occupational asthma is really common. I work in an old industrial part of the country and I know more about metalworking fluids and ventilation in those settings than I ever thought I would.
Albert Rizzo, MD:
I think the literature is suggesting that once a patient is on a biologic that is helping them, they're probably on that indefinitely. Is that something you would agree with?
David Hill, MD:
Overall? Yes. I think there's some literature that records some patients coming off and having a sustained response, but it's probably a minority. For me, if the patient is doing well, I typically leave them on.
Omalizumab, having been around for 20 years, I can say I have a handful of patients who are on it for a time and for whatever reason came off and did well. I have a lot of others who tried to stop it at one time or another and ended up back on it.
Juanita Mora, MD:
I agree. Sometimes what happens if people are really under beautifully controlled, then they start spacing the biologic out further. So instead of doing it every four weeks, they'll do it every eight weeks. "Dr. Mora, I feel really great. Every eight weeks works for me." So you let them do it.
Where I might do a shorter duration or they might show more response where I might take them off biologic, if I started someone on a biologic and they weren't in their early childhood and suddenly the teenage years hormones kick in, everything starts getting better. Their lung development really fulfills. They start telling me, "I feel like I don't need that medication anymore." I really follow it through and a lot of them are able to get off the biologics, as well.
Albert Rizzo, MD:
Dr Harrington, I don't want to ignore you. I'm coming back to you. I'm assuming that patients of yours that have gone off to see the specialists and may end up on biologics still come back to you for their usual care.
Do you have any comments on the patients you've seen who have gone on biologics? Have you seen differences in their therapy that have made a difference in their day-to-day life?
John Harrington, MD:
No, I don't mind being left out because I'm learning as they go back and forth. But it's true. I'm not trying to... That biologics are going to save the world. But, basically, some of those kids, like the starfish story for that kid, it worked great.
They come to me and now I'm seeing them again, meaning I'm seeing them for their well visit because it's almost, they were never well. It was always, "We'll do your well and sick together today." But they were actually coming in and they're well.
I think what's really nice about it is I can focus on the other aspects of their growth and adolescence, or childhood And I don't have to spend a whole bunch of time on their asthma, or their eczema, or their other stuff because it's all cleared up.
Now we can talk about their mental health, which is really the other issue that could do a whole nother story on that but, basically, their mental health. I think kids with eczema and asthma and stuff like that, they go through a lot of stress and a lot of stuff because they're not "normal." They're not doing normal things. They're not necessarily leading that normal life that they want to.
They think that they are restricted because of their asthma and their issues. It's really wonderful to see them in a situation where you can actually start talking to them as someone who's not dealing with that now.
That's the beauty of really good care that my allergist and pulmonologist will give. It makes it much more rewarding as a pediatrician to have those kids in your practice and see that they went through this process, and now they're better on the other side. They feel much more functional.
That's the beauty of this collaborative effort, to make sure that they make it to that point where they don't have to worry about that in adulthood, or they don't have to worry about that as they move forward.
Albert Rizzo, MD:
I think we've come full circle with multidisciplinary approach to diagnosis and management and now to wellness care for the patient who has their asthma under control. That's a great viewpoint to add there.
I think we've covered a lot of information here. I know there's a lot more detail that individuals could and should look into as far as the specific guidelines that we mentioned, the GINA guidelines, the EPR, Expert Panel Report, updates from NHLBI. Before we close, any other comments that you would like to make or that we did not touch on that you think should be emphasized?
John Harrington, MD:
As a pediatrician, it's a struggle. Sometimes I want to order Symbicort and then the insurance company says, "No, you can't have that." It does play into... insurance companies obviously didn't read the GINA guidelines or they didn't look at some of these things, so they're going, "No, that's too expensive. There's no way they should be on that." Or, "We want them to be on this medicine."
I'm always... And the patient's like, "This is working great." Just because the formulary changed in January does it mean I have to change the medicine? Sometimes it is an equivalent but you're like, "I'm not sure. They're happy taking this medicine."
Anyway, those are just the bane of the existence of having these different issues of brand name and generic names and stuff like that. Because the patient, I think, also has the psychological effect of, this is the medicine that works for me and now you're going to give me another medicine. I do think that that gets us into trouble sometimes.
Albert Rizzo, MD:
We could probably spend another hour on the issues around social determinants of health and access to care, which are truly important to the American Lung Association. Specifically, with Dr Hill being chair of our public policy, we know the struggles that individuals could have either with or without insurance, having trouble getting the right drugs at the right time.
David Hill, MD:
I was going to say, we could probably have an hour of just talking about the multidisciplinary frustrations with healthcare because I was nodding my head to everything Dr Harrington was saying about formulary changes, particularly with inhaled medications. Where the medicine might be similar, but the delivery device is different. The idea that the efficacy is going to be the same, it doesn't make any sense. "It's not good medical care," as my former partner would say.
Albert Rizzo, MD:
Right.
David Hill, MD:
But we don't determine all of that. The social determinants, the cost of care, it's incredibly challenging with asthma. It's been an interesting conversation because I hear what Dr. Harrington is saying and I'm thinking, I love getting people referred to me from their primary care doctor because I look at the primary care doctors and say, "God bless them for being able to take care of every other issue."
Whereas, I can focus on usually one or two things in my limited time with the patient. Part of that collaboration is I am working my little niche to allow the primary care doctor to focus on all that other stuff.
Albert Rizzo, MD:
Dr. Mora, I know in your practice, I know you deal a lot with the issues around access and accessibility being in inner-city Chicago.
Juanita Mora, MD:
Absolutely. They say it takes a village, and I think this conversation was very important because it really highlighted the importance of a multidisciplinary team. It takes the parents to be cooperative, the child, the pediatrician, the pulmonologist, the allergist, ENT. Sometimes it's a full-time circle.
But it also takes access to actual medications, being able to afford them and being able to get them. I often see families who have to choose between buying dinner for their family or getting the inhaler that the child needs.
It's things that we still have to work on as a medical community to get more access to, especially these marginalized communities, and make sure that medications are affordable. That's why I love having samples in my office because I get a lot of patients who have zero insurance.
Albert Rizzo, MD:
Right.
Juanita Mora, MD:
One patient came in with asthma this morning and she was being charged $300 for an inhaler. She said, "Dr. Mora, I just couldn't afford it." I was able to give her samples for three months. I said, "Come back in three months." That's the beauty of it, meaning being able to help, but I wish we had more help.
Albert Rizzo, MD:
Thank you all for important insights that you've given from your specific practices and disciplines. Thank you.