Asthma management just got a little more precise and personalized

Clinicians are now learning that asthma, once considered a single disease entity, is a complex inflammatory disease with multiple pathways that affect the cause and severity of the disease, according to Amber Lanae Martirosov, PharmD, BCACP, BCPS, assistant clinical professor at Wayne State University and clinical pharmacy specialist at Henry Ford Health System in Detroit.

“As such, there is an opportunity to personalize asthma management,” Martirosov said.

From updated guidelines and recommendations, to new biologic therapies and diagnostic tools, treating and managing asthma is an evolving practice. Recently published studies and guidelines reflect current information on treating intermittent mild asthma; the role of triple therapy in severe, uncontrolled asthma; and better approaches to therapy for black patients.

Monotherapy no longer recommended for mild asthma

According to Lori Wilken, PharmD, BCACP, TT-S, AE-C, clinical assistant professor at University of Illinois at Chicago College of Pharmacy, physicians at the University of Illinois Hospital and Health Systems adult pulmonary clinic where she practices as a clinical pharmacist are just starting to prescribe as-needed low-dose inhaled corticosteroid (ICS) and formoterol for patients with mild asthma. They are seeing success in patients, too. Low-dose ICS with albuterol is still the mainstay, however.

For patients with mild asthma, this represents a big shift in treatment. Whereas before, patients were prescribed short-acting bronchodilators (SABA) alone for as-needed use, the updated Global Initiative for Asthma (GINA) guidelines from 2019 no longer recommend SABA monotherapy. Instead, as-needed low-dose ICS and formoterol are indicated for mild asthma.

For adults and adolescents with mild asthma, the low-dose ICS is to be used for symptom relief.

“These new recommendations are based on recent literature, which demonstrated adverse effects associated with short-acting bronchodilators and poor adherence to daily inhaled corticosteroids,” said Martirosov.

A recent study from Beasley and colleagues, published May 2019 in the New England Journal of Medicine (NEJM), provides the most support for this new approach to treating patients with mild asthma.

Triple therapy in a single inhaler

Research by Virchow and colleagues published on September 30, 2019, in the Lancet appears to demonstrate the benefit of a single inhaler with triple therapy (ICS/LABA/LAMA) for patients with uncontrolled asthma. For these patients, addition of a long-acting muscarinic antagonist to ICS plus LABA therapy improved lung function and reduced exacerbations. The results are based on the Phase III double-blind TRIMARAN (Triple in Asthma With Uncontrolled Patients on Medium Strength of ICS + LABA) and TRIGGER (Triple in Asthma High Strength vs ICS/LABA HS and Tiotropium) studies.

“The results of this study are exciting, as they demonstrate that there is a role for triple therapy in severe, uncontrolled asthma,” said Martirosov. She said she’d like to see more research to determine if there are specific patient populations that may benefit from triple therapy and the need for personalized asthma management.

Wilken said the research is beneficial for asthma patients who do not have fixed airway obstruction with COPD but still have severe asthma. However, she noted, by excluding patients with asthma and COPD, the LAMA therapy added onto the ICS/LABA was not significantly different from ICS/LABA alone.

Improving asthma care for black children

It’s no secret that racial disparities exist for black Americans with asthma—especially for black children who have an increased risk for asthma, complications from the disease, and asthma exacerbations. According to the Office of Minority Health of the U.S. Department of Health and Human Services (HHS), black children are three times more likely to die of asthma and four times more likely to be admitted to the hospital for asthma exacerbations than are white children.

A study by Wechsler and colleagues published in NEJM in September 2019 suggests that black children may respond differently than black adolescents and adults to step-up therapy for poorly controlled asthma. In contrast to adolescents and adults, almost half of the children in the study with poorly controlled asthma had a superior response to an increased dose of an inhaled glucocorticoid over the addition of a LABA.

Comparing results from two prospective, randomized, double-blind trials—one involving black children and the other black adolescents and adults—study researchers found that 46% of the children benefited from quintupling the ICS fluticasone. They saw the same percentage of children gain from doubling the fluticasone dosage and adding salmeterol. On the other hand, researchers found that more adolescents and adults had a better response to added salmeterol than to an increase in fluticasone.

In both trials, the patients had at least one grandparent who identified as black American and had asthma that was inadequately controlled with low-dose inhaled glucocorticoids. The research also highlights the need for more studies focused on black Americans with asthma.

For the full article, please visit www.pharmacytoday.org for the December 2019 issue of Pharmacy Today.