Announcer:
You’re listening to Deep Breaths: Updates from CHEST on ReachMD. This series is produced in partnership with the American College of CHEST physicians. The following episode was recorded live at the 2019 annual CHEST conference in New Orleans.
In this episode, we welcome Drs. Sandhya Khurana and Monica Kraft. Dr. Khurana is professor of medicine and director of the severe asthma program at the University of Rochester medical center. And, Dr. Kraft is professor and chair of the department of medicine, college of medicine Tucson, as well as the deputy director of the asthma & airway disease research center at the University of Arizona.
Now, here is your host Dr. Sandhya Khurana
Dr. Khurana:
Coming to you from 2019 Annual CHEST Conference in New Orleans, I’m Sandhya Khurana, and joining me to discuss the latest updates in asthma is Dr. Monica Kraft. Dr. Kraft, welcome to the program.
Dr. Kraft:
Thanks for having me.
Dr. Khurana:
So, to start us off, Monica, can you tell us more about the advances in severe asthma that have been discussed in this year’s education track at CHEST 2019?
Dr. Kraft:
Absolutely. I think it’s a great meeting because severe asthma is very much being emphasized at the meeting, I think because we have so many advances in the disease in terms of how we approach it and the treatments that we have to offer, and so there is a whole track looking at how we can phenotype our patients, what biomarkers do we have at our disposal and what treatment options, and what can we do before we even get to biologics to really maximize treatment for our patients, because there are some updated guidelines that have some very interesting changes that I think our community needs to know about.
Dr. Khurana:
So true. I agree. I think the world of severe asthma is really dynamic right now with really a sense of optimism amongst people who treat patients with asthma and patients themselves with all that’s available. So, when it comes to personalized treatment in asthma, what can you tell us or share with us about your perspective on the treatable traits?
Dr. Kraft:
Right. So, asthma is a heterogeneous disease. I think we’ve really come to appreciate that. So, we know, especially when we get into the severe space, it’s not a one-size-fits-all phenomenon, and so we need to understand, appreciate the heterogeneity. We actually can use the tools we have available to us to sort out what kind of asthma does your patient have, and those are the treatable traits or what we call the phenotypes, which are really a collection of clinical characteristics. And really, the goal is to not only understand these characteristics but to figure out the biological pathway that is really producing that phenotype, because the good news, given the immunology explosion and understanding that we have of the disease, that is translated to treatments where we can target specific pathways based on what we find with regards to this pheno-endotype being exercise.
Dr. Khurana:
Great, wonderful. And in terms of the sessions that caught your eye in this year at CHEST 2019, are there some that you feel that really brought a lot to the learners?
Dr. Kraft:
Well, of course, I’m a little biased because I put on one of the courses—so in full disclosure. And as you and I know, we put on a postgraduate course this year on difficult-to-treat asthma, and I have to say I was really happy as to how it went. I think we were able to cover a lot of bases about what biomarkers we have, what’s the latest in treatment, and then we had some great case-based discussion. But looking at the track, there are some great sessions about: How do we handle oral steroids with our patients, and how can we taper them off? What other advances beyond spirometry can we use both to look at the physiology in asthma as well as some of our biomarkers? And then, at the end of the day, how do we really think about the patient and what their experience is and how we can really form a partnership with our patients so that they can live the most productive life possible?
Dr. Khurana:
So true. So, if you’re just joining us, I’m Sandhya Khurana, and with me in the studio is Dr. Monica Kraft about new breakthroughs in asthma. We’re coming to you from the 2019 Annual CHEST Meeting in New Orleans.
So, Monica, I’d like to continue exploring these treatment advances because there are some biologic options that are addressing different asthma pathways. Is that correct?
Dr. Kraft:
Right. It’s a dynamic field. It keeps changing. So right now we’ve got 5 at our disposal with many more coming down the pipeline, which is great. And right now I think our biggest advance is in what we call the type 2 asthma space, which is going to be associated with eosinophils, sometimes allergy (not always), sinusitis, nasal polyps. So we have biologics targeting the interleukin-5 pathway. We actually have 3 different choices there. And that’s really focused on those patients who have a lot of eosinophils in their blood and, perhaps, nasal polyps and sinus disease. We also have a biologic that targets the IL-4 receptor, and with that one we’re able to really inhibit both IL-4 and IL-13, which are 2 very important cytokines in type 2 asthma. And so we look at patients who have eosinophils but also have other characteristics like elevated exhaled nitric oxide. It’s a great biomarker for that. And then we also looking at... Of course, Xolair is still available to us, an anti-IgE. We’ve had that for 17 years now, and so that’s a great one for patients where allergy is particularly prominent in their disease.
And so that’s what we have now, but in a couple of years, we’re going to have at least 2 or 3 more, and there’s actually one that inhibits TSLP from the airway epithelium that may have effects in both allergic or type 2 asthma and non-type 2 asthma, so that’s particularly exciting.
So, Sandhya, how are you using these in your clinic?
Dr. Khurana:
You know, I agree with you, Monica. It’s really exciting. The landscape is changing, and now more than ever our patients who suffer from severe asthma have an ever-widening array of choices, and sometimes it’s really hard to pick the right biologic or we don’t quite know what the right one is, but it’s really these treatable traits and combined with patient preferences and the cost that drive a lot of these choices. And I feel like all of us who take care of these patients, getting these updates and learning from our peers is a great way to really advance our knowledge and comfort with utilizing these medications.
Dr. Kraft:
Absolutely. Those are very wise words, and I think it will be interesting to see how the new biologics that are being studied right now like the tezepelumab, anti-TSLP or the fevipiprant, which is really focusing on the DP2 receptor, the prostaglandin pathway, how are they going to fit into all of this landscape, and I think as those of us who care for these patients it’s going to get more complicated, I think, and we’ll have a lot more debate about which ones to choose.
Dr. Khurana:
Well, thank you so much, Monica. This has been enlightening. And before we wrap up, I’d like to know, and I think our audience would as well, what your one call to action would be to those who diagnose and treat severe asthma.
Dr. Kraft:
Thanks, a great question. I actually have two. One is, I think as providers and those of us who care for patients with asthma really across the spectrum with a focus on severe, we need to be very up-to-date with the guideline changes and make sure that our primary care colleagues know about it too because that’s going to affect them in a big way. And so, specifically, any time a patient needs a short-acting beta agonist, that there’s consideration of an inhaled steroid much earlier in the treatment of asthma than we ever thought. That’s an example of something that would really be important for primary care providers. But on the other side, with regards to the biologics, I think that our community really needs to make sure we’re educated on what biomarkers are available, how can we use them in the clinical arena to sort out what kind of asthma our patients have to really make sure we deliver the right treatment for the right patient at the right time.
Dr. Khurana:
Absolutely, and I agree with you. And I would just add a little bit about making sure that it’s asthma that we’re treating and anything that’s modifiable risk factors are treated before we go towards these expensive medications that are so effective.
Dr. Kraft:
Absolutely, absolutely. We can’t forget about that, that the comorbid conditions are critical.
Dr. Khurana:
Well, this has been a fascinating look into the latest treatments for asthma, and I want to thank Dr. Monica Kraft for joining me to explore these updates with us. Dr. Kraft, it was great having you on the program. Thank you so much,
Dr. Kraft:
I really enjoyed it. Thank you.
Announcer:
This was Deep Breaths: Updates from CHEST produced in partnership with the American College of Chest Physicians. To access other episodes of this series, visit reachmd.com/CHEST, where you can be part of the knowledge.
