Transcript
Announcer:
You’re listening to On the Frontlines of Asthma on ReachMD. And now, here’s your host, Dr. Steve Jackson.
Dr. Jackson:
This is On the Frontlines of Asthma on ReachMD. I'm Dr. Steve Jackson, and joining me to help explain why asthma remains uncontrolled for so many patients—and what we can do about it—is Dr. Sujith V. Cherian. He's the Associate Director of the Medical Intensive Care Unit, the Director of Interventional Pulmonology and Pleural Diseases, and the Director of the Bronchoscopy Suite at LBJ Hospital in Houston.
Dr. Cherian, welcome to the program.
Dr. Cherian:
Thank you for having me. It's a pleasure and a privilege to be here.
Dr. Jackson:
So let's start with the big picture, Dr. Cherian. Despite advances in treatment, why does asthma remain uncontrolled for so many patients?
Dr. Cherian:
That's a great question. If you look at asthma, a lot of patients still have symptoms despite the available therapies. And this actually comprises at least 17 to 20 percent of patients who have what is called “difficult-to-treat asthma.” And it's a lot of times because there is a gap in diagnosis, a lack of treatment optimization, and a lack of early diagnosis in several cases. I think that it’s a huge problem. Even though it forms only around, as I said, between 17 to 20 percent of asthmatic patients, it actually comprises at least 60 to 65 percent of the costs involved in the management of asthma patients.
Dr. Jackson:
Now, when we talk about uncontrolled asthma, how is that actually defined in clinical practice? And are there any limitations to how we currently assess the definition of control?
Dr. Cherian:
Again, an excellent question. When we look at uncontrolled versus controlled, control is really assessed based on the symptom frequency, the need for rescue inhaler use, and the number of exacerbations that the patients have. And this is based on the symptoms in a week, the overall symptoms in a month, and the need for such inhalers within this timeframe. While tools like asthma control tests are helpful, these are not always comprehensive. These tests are not enough, a lot of times, to really give a good assessment of this subset of asthma patients.
Dr. Jackson:
And with that definition in mind, what are some of the most commonly overlooked risk factors or triggers that may be contributing to poor asthma control?
Dr. Cherian:
So when we look at uncontrolled asthma, it really implies that, despite the availability of inhaler therapies, the patient's symptoms are not controlled. One of the most important things in assessing a patient who has uncontrolled asthma is to assess how the patient uses the inhaler—if the patient has a proper inhaler technique, and whether the patient is following the right regimen of the inhaler therapies. And that basically refers to this subset of uncontrolled asthma.
The other factors to key in when you look at these patients are the other exposures that the patients may have, which includes allergens; pollution; cigarette smoke, whether it's active or passive; several comorbidities, which include anxiety, depression, and a lot of lifestyle factors, which include what, patients do for a living; and a patient's occupational exposures and workplace-related exposures. These are all factors which are important in evaluating a patient who may have uncontrolled asthma.
Dr. Jackson:
For those just tuning in, you're listening to On the Frontlines of Asthma on ReachMD. I'm Dr. Steve Jackson, and I'm speaking with Dr. Sujith V. Cherian about why asthma remains uncontrolled and how we can better identify its underlying drivers.
Dr. Cherian, now that we have a better understanding of the key contributors to uncontrolled asthma, let's shift our focus now to addressing them in practice. To start, how can we more effectively identify these drivers during routine patient visits?
Dr. Cherian:
As we said before, uncontrolled asthma involves a lot of factors, which result in it being uncontrolled. There are certain modifiable factors and certain non-modifiable factors. And the identification of these modifiable factors really involves taking a good history with regards to several factors, like occupational and exposure history. And basically, the idea is that we want to identify these factors which are causing the trigger and then help control those.
The second thing, as you rightly mentioned, is to really review the inhaler technique. And something that we usually do is, if the patients come in, we ask the patients to actually take the inhaler in front of us and then assess factors which could be modified based on that.
And then the third thing is really to identify with the regime that they're using. Are they actually using it in the right way that we have discussed? And that actually is something that should be identified during these routine patient visits.
Dr. Jackson:
As a follow-up to that, can you tell us about the newer diagnostic tools or biomarkers that are refining our understanding of asthma phenotypes and how they're guiding more personalized treatment approaches?
Dr. Cherian:
Yes, that's a great question. Within the spectrum of uncontrolled asthma, it is very important to identify that there are several phenotypes which may respond better to some therapies versus others which may not respond. And for those things, the use of certain biomarkers such as eosinophils, immunoglobulins, particularly immunoglobulin E, and fractional exhaled nitric oxide—these are all markers of an inflammation, which may help direct therapy in one way or the other. And it may actually identify those patients who may respond to several of these medications that we have available right now. If they are not elevated in several of these, then it may imply that it may not respond to this, and the treatment should be directed in a different manner. It may also help give an idea of the prognosis for these asthma patients. It helps support precision medicine and personalized approaches in these patients.
Dr. Jackson:
To bring all of this together before we close, Dr. Cherian, what key steps can clinicians take to move the needle on asthma control in their day-to-day practice?
Dr. Cherian:
I think, honestly, speaking for all clinicians, when dealing with any patient with uncontrolled asthma, the key is always to start with good patient education. I can't really stress how important that is because, as we said, the adherence to the inhalers—doing it the right way, doing it in the order and the frequency that we describe—and educating the patients about these risk factors, the exposure, or the trigger agents is very important to help in asthma control in day-to-day practice.
And then, when we check on these patients, regular assessment of control and treatment is important. Basically, the idea is we want them to come in more frequently. If they can't come, then at least a follow-up call in order to assess how the symptoms are controlled is important.
And a specialized approach in developing and generating these asthma clinics where we could try to get a personalized approach to several of these patients is very important as we move on in managing this very difficult subset of patients with asthma.
Dr. Jackson:
With those calls to action in mind, I want to thank my guest, Dr. Sujith V. Cherian, for joining me to share these strategies for improving asthma control.
Dr. Cherian, it was great having you on the program.
Dr. Cherian:
Absolutely. Thank you so much again.
Announcer:
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