There are differences in how pulmonologists and other clinicians approach the diagnosis and management of patients with moderate to severe asthma, according to a survey conducted by Medscape in collaboration with CHEST, the American College of Chest Physicians. Despite some of these differences, those surveyed do predominantly favor similar treatment options, including inhaled corticosteroids and biologics. Biologics in particular are perceived as a promising therapeutic approach for moderate to severe asthma by clinicians overall, and many are also comfortable prescribing them.
Medscape and CHEST asked 763 clinicians about their views on moderate to severe asthma. Responses came from 100 pulmonologists; 102 allergists/immunologists; 102 critical care medicine physicians; 100 emergency medicine (EM) physicians; 104 pediatricians; 100 primary care physicians (PCPs); and 155 nurse practitioners (NPs), physician assistants (PAs), or registered nurses (RNs).
Inhaled Steroids Top Treatment Choice
Survey respondents ranked an inhaled corticosteroid with a long-acting bronchodilator as the favored medication for patients with moderate to severe asthma; 83% of allergists/immunologists feel this way, as do between 52% and 63% of the other clinicians, including pulmonologists.
Inhaled corticosteroids alone are generally preferred by 23%-28% of clinicians surveyed, with the exception of allergists/immunologists (12%). EM physicians (19%) and pediatricians (16%) tend to more often favor an inhaled corticosteroid and leukotriene-modifying agent than do other clinicians, but notably, none of the allergists/immunologists felt this way.
Biologics Are an Important Step Forward
When it comes to biologic agents for moderate to severe asthma, it is allergists/immunologists (91%) who say they are most comfortable prescribing them. This percentage drops to 59% for pulmonologists, 34% for NP/PA/RNs, 20% for critical care medicine physicians, 16% for PCPs, 7% for pediatricians, and just 2% of EM physicians
Aaron B. Holley, MD, FCCP, program director at the Pulmonary and Critical Care Medical Fellowship, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, and a member of the Moderate to Severe Asthma Center of Excellence steering committee, noted that the latest rage is to personalize treatment by “phenotyping” asthma, with the thought being that certain asthma phenotypes will respond well to some treatments, but not to others. “This sounds good in academic and scientific papers, but remains difficult to operationalize in the clinic,” said Holley.
He also noted that the new biologics all target one specific phenotype: eosinophilic asthma. “This phenotype makes up approximately 50% of all patients with asthma; however, the other 50% have no targeted treatments available, and they don’t necessarily respond well to conventional inhaler therapy,” said Holley.
And for patients with severe, poorly responsive asthma, it’s hard to say precisely what percentage is being treated inappropriately for their phenotype, versus what percentage is noncompliant, versus what percentage is due to socioeconomic status and behavioral health issues, he noted.
The solution? “There is no easy solution,” said Holley. “More specialized, severe asthma clinics? Greater education on inhaler use and disease severity? Concomitant management of behavioral health complaints? All these are necessary, but they’re also resource-intensive.”
Still, in his view, the glass is half-full. “The biologics are an important step forward, and we’re getting better at phenotyping. Compared with 5-10 years ago, we’re in a much better place.”