ORLANDO – Clinicians at the primary care level should learn to distinguish the difference between severe and difficult-to-treat asthma to help facilitate referral to an asthma care specialist, according to a speaker at the Cardiovascular & Respiratory Summit by Global Academy for Medical Education.
Jeff Craven/MDedge News
Michelle R. Dickens
Care providers are seeing patients with severe asthma at their primary care practice, whether they realize it or not, and should therefore learn to recognize and diagnose these patients even if they are not directly treating them for asthma, said Michelle R. Dickens, MSN, RN, FNP-C, AE-C, a nurse practitioner at Ferrell-Duncan Clinic department of allergy, asthma, and immunology in Springfield, Mo., said in her presentation.
“There’s still a lot we can do to get the ball rolling,” Ms. Dickens said. “While you may not be prescribing some of these newer biologics and some of the high-level, $30,000-a-year medications for your asthmatic, you still have a role in this in identifying them and helping us to get to where they need to be.”
Ms. Dickens noted that patients may not even disclose their asthma history with their primary care provider if it is not the reason for the office visit. “Because asthma can be such an episodic disease, it’s not right on the top of their radar,” she said. “They have bigger issues they want to talk about with you, and they forget to mention the asthma part.”
Under Global Initiative for Asthma (GINA) criteria, severe asthma is defined as poorly controlled asthma even after patients demonstrate adherence and good technique. However, before diagnosing a patient with severe asthma, clinicians should first rule out whether the patient has asthma that is difficult to treat, said Ms. Dickens. Difficult-to-treat asthma is characterized by inadequate dosing of medication, noncompliance with medication dose (“spreading out” the medication), poor technique when self-administering the medication, and comorbid conditions. It is also possible that difficult-to-treat asthma is not well controlled because the asthma was misdiagnosed and is actually another condition, she added.
If a patient has difficult-to-treat asthma, ensure they are adhering to the therapy, using proper technique, and that the medicine is being administered at the proper dose. Using Expert Panel Report 3 (EPR-3) and Global Initiative for Asthma (GINA) guidelines, clinicians should maximize the treatment for a patient with severe asthma based on the stepwise approach outlined in the guidelines, and referring out to an asthma specialist for add-on therapy or stepping up therapy when indicated.
Researchers are beginning to explore the genotypes, phenotypes, and endotypes of asthma to learn more about severe asthma and potentially identify asthma subtypes, said Ms. Dickens. “We’re not there yet, but we are learning a little bit about why certain patients have certain types of asthma,” she said.
The Severe Asthma Research Program has found three clusters of likely severe asthma candidates: those with classic childhood asthma onset, those who have asthma with chronic obstructive pulmonary disease (COPD), and patients with both obesity and asthma characterized by “high impairment but mildly abnormal lung function.” Clinicians can use spirometry, complete blood count with differential, total immunoglobulin E, body mass index, allergy testing, and exhaled nitric oxide with these data and biomarkers to gain a better idea of a patient’s asthma situation.
Referrals to an asthma specialist should be considered if a patient experiences a life-threatening exacerbation, is not responding to therapy, has an unusual presentation of asthma symptoms, has comorbid conditions, or needs additional testing or additional education. Patients who are at step 2 or higher in EPR-3 guidelines and ready to move to step 3 and are under 4 years of age, and patients who are 5 years or older at step 4 of therapy or higher should be referred to an asthma specialist. “I think the younger the patient and the more severe the [symptoms], the more likely you should be referring to a specialist,” said Ms. Dickens.
Ms. Dickens reports no relevant financial disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.