Lack of access to, ineligibility for, and inadequate response to current approaches leave many patients with severe asthma poorly controlled.1
Significant unmet needs exist for patients with severe asthma1
Improved disease stability and consideration of remission as a management goal for patients living with asthma remains a long-term aspiration to improve patient care14,15
OCS, oral corticosteroid(s).
References
1. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2021. Available from: https://ginasthma.org/wp-content/uploads/2021/05/GINA-Main-Report-2021-V2-WMS.pdf. Accessed 4 December 2023. 2. Global Asthma Network. The global asthma report 2018. Available from: http://www.globalasthmareport.org/Global%20Asthma%20Report%202018.pdf. Accessed 4 December 2023. 3. Rogliani P, et al. Pulm Ther. 2020;6:47–66. 4. Caminati M, et al. J Asthma Allergy. 2021;14:457–466. 5. Wang E, et al. Chest. 2020;157:790–804. 6. Trevor J, et al. Ann Allergy Asthma Immunol. 2021;127:579-587. 7. Ambrose CS, et al. Pragmat Obs Res. 2020;11:77–90. 8. Price DB, et al. J Asthma Allergy. 2018;11:193–204. 9. Chen H, et al. J Allergy Clin Immunol. 2007;120:396–402. 10. Busse WW, Kraft M. Eur Respir Rev. 2022;31:210176. 11. Chen S, et al. Curr Med Res Opin. 2018;34:2075–2088. 12. Bleecker ER, et al. Am J Respir Crit Care Med. 2020;201:276–293. 13. Canonica GW, et al. World Allergy Organ J. 2019;12:100007. 14. Menzies-Gow A, et al. J Allergy Clin Immunol. 2020;145:757–765. 15. Thomas D, et al. Eur Respir J. 2022;60:2102583.
Challenges in the management of patients with asthma
In the USA, asthma affects approximately 25 million people,3 of whom 5–10% have severe asthma.4
Severe asthma is defined by the Global Initiative for Asthma (GINA) as asthma that remains uncontrolled despite adherence to optimized high-dose inhaled corticosteroids (ICS), and long-acting β2-agonist (LABA) therapy and the treatment of contributory factors, or asthma that worsens when high-dose therapy is decreased.2
The long-term goals of severe asthma management include: achieving good symptom control, reducing the future risk of exacerbations, and minimizing lung function decline and airflow limitation.2 In many cases where patients have poor symptom control and/or exacerbations despite medium- or high-dose ICS and LABA therapy, their asthma may appear difficult to treat because of contributory factors, such as incorrect inhaler technique, poor adherence, smoking or comorbidities, or because of incorrect diagnosis.2 For these patients, GINA recommends assessment of these contributory factors and consideration of an add-on therapy.2 If problems persist, referral to a specialist center for phenotypic assessment and consideration for add-on biologic-targeted treatments are recommended.2
Confirming the diagnosis of asthma, assessing contributory factors, and optimizing treatment strategy are the key steps for consideration in the diagnosis and management of severe asthma.2
To date, there has been great progress in the diagnosis and management of severe asthma,5,6 with biologics representing a major advancement in the treatment landscape.7 However, many patients with severe asthma are poorly controlled.
A recent study found that approximately 50% of patients with severe asthma in the USA remained suboptimally controlled despite treatment with standard-of-care medications.8 This significant finding was described following a retrospective and prospective analysis of the International Severe Asthma Registry – a data set including 3286 US patients receiving GINA Step 5 treatment or with severe asthma remaining uncontrolled at GINA Step 4 (December 2014 to December 2017). Poorly controlled asthma was defined in this study according to Asthma Control Test (score 5–15) or Asthma Control Questionnaire (score >1.5) categorizations.8
For a summary of challenges in the management of severe asthma, please watch the first minute of the following podcast presented by Dr. Michael E. Wechsler.
Challenges faced by a patient with severe asthma
Suboptimal asthma control can have a significant impact on patient outcomes:
Overview of challenges in symptom control for patients with severe asthma
What challenges are associated with existing treatments for poorly controlled asthma?
OCS are the primary therapy for resolution of acute exacerbations.15 However, patients with severe asthma are often exposed to multiple courses of OCS,16 and cumulative and chronic exposure is associated with an increased risk of side effects.12,17,18 As little as 0.5–1 g (or four lifetime courses) of OCS can cause serious adverse effects, including cataracts, pneumonia, type 2 diabetes, cardiovascular disease, renal impairment, and osteoporosis.12
In the USA, real-world evidence studies estimate that 8–30% of patients with severe asthma have received long-term or frequent short-term courses of OCS.8,19–22 The annualized cost of OCS-related adverse events in patients with severe asthma on low-, medium-, and high-dose OCS is estimated to be $2712, $4724, and $8560, respectively.23
Major challenges persist owing to lack of access and inadequate response to, or ineligibility for, currently available treatments.1 There are several factors restricting accessibility to treatment, including high cost and poor awareness, and expertise relating to severe asthma and patient identification. This is particularly relevant to the accessibility of biologic treatments for patients with severe uncontrolled asthma, where specialist knowledge is required to phenotype and identify eligible patients.1,24
Globally, approximately 75% of patients with poorly controlled severe asthma (GINA Step 4/5) are not receiving biologics.8 Improved validation and utilization of patient-reported outcome measures in clinical practice may further aid the diagnosis and management of patients with severe asthma.25 To learn more about patient-reported outcomes in severe asthma, click here.
Summary of current challenges in the diagnosis and management of severe asthma
Find out more about the EpiCreator – Professor Louis-Philippe Boulet.
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References
1. Caminati M, et al. J Asthma Allergy. 2021;14:457–466. 2. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2021. https://ginasthma.org/wp-content/uploads/2021/05/GINA-Main-Report-2021-V2-WMS.pdf. Accessed January 2024. 3. Centers for Disease Control and Prevention (CDC). Most recent national asthma data. 2021. https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm. Accessed January 2024. 4. Chung KF, et al. Eur Respir J. 2014;43:343–373. 5. Charriot J, et al. Eur Respir Rev. 2016;25:77–92. 6. Zervas E, et al. ERJ Open Res. 2018;4:00125–02017. 7. Djukanovic R, et al. Eur Respir J. 2018;52:1801671. 8. Wang E, et al. Chest. 2020;157:790–804. 9. Soong W, et al. Ann Allergy Asthma Immunol. 2020;125(Suppl 5):S27 (Abstract P203). 10. Ambrose CS, et al. Pragmat Obs Res. 2020;11:77–90. 11. Pavord ID. Curr Opin Pulm Med. 2019;25:51–58. 12. Price DB, et al. J Asthma Allergy. 2018;11:193–204. 13. Chen H, et al. J Allergy Clin Immunol. 2007;120:396–402. 14. Chen S, et al. Curr Med Res Opin. 2018;34:2075–2088. 15. Chung LP, et al. Respirology. 2020;25:161–172. 16. Papapostolou G, et al. Eur Clin Respir J. 2020;8:1856024. 17. Bleecker ER, et al. Am J Respir Crit Care Med. 2020;201:276–293. 18. Canonica GW, et al. World Allergy Organ J. 2019;12:100007. 19. Broder MS, et al. Ann Allergy Asthma Immunol. 2017;118:638–639. 20. Phipatanakul W, et al. Am J Respir Crit Care Med. 2017;195:1439–1448. 21. Wysocki K, et al. J Allergy Clin Immunol. 2014;133:915–918. 22. Zeiger RS, et al. J Allergy Clin Immunol Pract. 2017;5:1050–1060.e9. 23. Lefebvre P, et al. Curr Med Res Opin. 2017;33:57–65. 24. Caminati M, et al. World Allergy Organ J. 2021;14:100502. 25. Herman E, et al. J Allergy Clin Immunol Pr. 2019;7:1771–1777.