Choosing the right biologic for severe patients, the continuum of worsening asthma and an exacerbation and treatment options for yellow zone patients

October 28, 2019

Next week many of us will gather in Houston for our Annual Meeting. There will be many learning opportunities, including great information on asthma. I thought I would point out a few more articles in the October issue to recommend for your reading pleasure and information. It is a great way to spend a cool autumn afternoon/evening.

First is a perspective by Mauli Desai, MD, FACAAI from Mt Sinai in New York and John Oppenheimer, MD, FACAAI from Rutgers in New Jersey about choosing the right biologic for severe asthma using precision medicine through the lens of patient-centered decision making. This very thought-provoking article presents the conundrum associated with choosing an optimal asthma biologic for individual patients. They point out the very small percentage of patients with severe T2 -based asthma for whom any one of five approved monoclonal antibodies have been shown to be clinically effective, at least in terms of decreasing exacerbations. There are data that suggest product differences in secondary outcomes, such as specific symptoms and lung function, that could help the clinician decide which biologic to prescribe. They also speak to more pragmatic issues that could influence choice, such as frequency of dosing, route (intravenous versus subcutaneous), approved home administration versus office/infusion center and other factors. Finally, they comment on the increasingly important concept of shared decision making –  where the patient is involved in the complex issue of which, if any, biologic to use.

Another perspective article is by Elissa M. Abrams, MD, Allan B. Becker, MD, FACAAI, and Stanley J. Szefler, MD from Manitoba and Denver who address the provocative question of when does worsening asthma end and an asthma exacerbation begin? This is an extremely important distinction to make for our patients. How we approach this idea is critical to decreasing their risk for potentially life-threatening reactions and optimizing their ongoing asthma management. The authors describe the ambiguity in the definitions of the terms exacerbation and worsening as it relates to asthma. They provide evidence from the literature to advocate for considering worsening and exacerbation as part of a continuum rather than distinct categories. The end result relates to specific interventional strategies as the asthma worsens in an individual patient to prevent more serious or severe exacerbations. This paper will force you, as it did me, to reconsider how you think of these two terms as it applies to your asthma patients.

And finally, as a seemingly natural extension of this worsening/exacerbation spectrum is a review article by John J. Oppenheimer, MD, FACCAI and colleagues from Rutgers who address treatment strategies for asthma patients who are classified in the now classic category of yellow zone. Multiple yellow zone strategies exist, but only a few have been shown consistently effective. The data for such interventions as increased SABA use, increased dosages of ICS, use of additional, as needed, doses of ICS, LTRA and others have all been reported with mixed effectiveness.  Varying study designs and the known heterogeneity of asthma likely account for much of the difference in outcomes seen with the various yellow zone intervention strategies studied. More studies are needed to determine the right yellow zone therapies for the right patients. The authors express that a personalized approach will be needed to provide optimal care paradigms for asthma patients who find themselves in the yellow zone.

I hope you continue to have a great autumn season with family, friends, colleagues and, of course, your patients. Hope to see many of you in Houston.

Gailen D. Marshall, Jr., MD PhD FACAAI