Best practices in managing asthma patients

Asthma not only impairs the breathing and quality of life of more than 25 million people who live with it, it poses an immense financial burden to the U.S. healthcare system. The Centers for Disease Control and Prevention (CDC) estimate asthma’s costs in the U.S. at over $80 billion per year.

While physicians often struggle to keep their asthmatic patients in good health, experts say that new treatment approaches and medications may be able to reduce these costs and improve quality of life for asthma patients.

“This is a very exciting time for asthma management and treatment,” says Fernando Holguin, MD, MPH, director of the asthma program at University of Colorado’s pulmonary sciences and critical care division.

Holguin is particularly enthusiastic about the field’s move toward personalized and precision medicine, where each  patient’s individual needs can be assessed and treated.

For example, even a few years ago, most asthmatics were treated mainly with corticosteroids and bronchodilators, he says. Now, for those patients with especially severe symptoms-and for whom the usual drugs fail-doctors can use blood work and skin testing to determine the patient’s phenotype and allergic profile. Those whose asthma is affiliated with high eosinophils, an allergic cell, may qualify for biologic drugs.

In addition to the biologics, those with severe, hard-to-treat asthma may benefit from the macrolides family of antibiotics, which includes azithromycin. These drugs can act as a powerful anti-inflammatory in the airways for people with severe asthma. “Studies have shown that using azithromycin two times weekly can reduce the rate of exacerbations by as much as 25 to 30 percent,” Holguin says.

While these won’t work for everyone, they can offer relief for people who struggle with severe illness.

Another technique for severe asthma is called bronchial thermoplasty, where a small catheter in the airway emits radiofrequency heat into the smooth muscle, according to Laran Tan, MD, FACCP, the director of Loma Linda University Health’s Comprehensive Program for Obstructive Airway Disease in Loma Linda, Calif.

The radiofrequency heat treats asthma’s chronic inflammation by reducing the airway smooth muscle so it doesn’t constrict so tightly, Tan says.  Studies find the treatment may reduce exacerbations for up to five years after treatment.

Getting to the root of the problem

While new treatments are promising, before trying any remedy physicians should determine if patients really have asthma, says Holguin. “Roughly 30 percent of people that are labeled as having asthma by their providers do not have the disease.”

The confusion often results from the fact that asthma is not just one disease, says Alex McDonald, MD, CAQSM, a family physician with Kaiser Permanente in Fontana, Calif. It’s a set of diseases characterized by chronic inflammation in the airways that creates obstruction, as well as coughing, wheezing, and shortness of breath, he explains. It’s easy to misdiagnose asthma when a patient has just been exposed to an environmental allergen, or is having trouble getting over a respiratory virus.

In order to diagnose asthma, physicians should do a pulmonary function test, using a spirometer, McDonald says. The machine measures the amount of air the patient can exhale over several rounds. Then the patient takes a dose of a bronchodilator to determine if that improves airflow.

But that may not be enough, says Tan, since “asthma tends to be related to allergies and the environment.” Phenotyping through blood work and skin testing can allow physicians to target medications tailored to patients with more severe forms of the disease, he says.

“We’ve realized that a lot of patients with severe allergies have elevated igE [immunoglobulin E]. Now we have biologic therapies that can specifically target the inflammatory response in these patients’ blood,” Tan says.

Phenotyping typically breaks down asthma into three primary categories, McDonald says:

• Mild, intermittent, which is the easiest to treat, most commonly with a “rescue” bronchodilator inhaler

• Mild, persistent, which requires a controller medication of some kind in addition to a

• rescue inhaler

• Moderate to severe, persistent asthma, which may require corticosteroids, long acting beta agonists and potentially more complex treatments such as biologics, macrolides antibiotics or bronchial thermoplasty.

However, treatments may not be effective if physicians haven’t helped the patient determine the root allergens causing their exacerbations, McDonald says.

Many patients aren’t aware of the environmental triggers causing their attacks, Tan says, such as cutting the grass, or snuggling with their cats and dogs.

He says that often when taking histories he learns that a patient has lived with asthma their entire life and accepted the impairments that come with it as normal.

It’s the job of physicians to help these patients understand that an impaired life isn’t normal or necessary, Tan says. “Then we have to try to show them how that better life could be obtained through regularly using inhalers, avoiding specific allergens, etc.”

Additionally, about one third of asthma patients are known as poor perceivers, says Kathleen Dass, MD, FACP, a member of the American Academy of Allergies, Asthma and Immunology. “That means they feel good until they really don’t feel good, so basically they end up in the hospital or just drop dead.”

She stresses to primary care physicians that most of these exacerbations are preventable with the right diagnosis and treatment plan.

Ways to encourage adherence

Even after diagnosis, it can be challenging for physicians to get patient adherence in order to reduce the severity of illness and encourage (or promote) use of healthcare services. Experts agree that developing a strong relationship with patients and being proactive in asking questions can help to achieve both aims.

McDonald takes a lack of patient adherence as a sign that something is wrong and he needs to find out what. “I hate the term noncompliant. That’s medical jargon. I always ask, ‘what’s happening?’”

He says reasons can range from a patient being unable to afford their medicine, to a bad reaction to a medication, to  the patient’s pharmacy not stocking the right medication. Sometimes they’ve simply never been asked why they struggle to take their medications, he says.

For issues related to cost, McDonald points patients to a program called Good RX, which helps them find lower-cost medications.

Dass, who sees a lot of low-income patients, always asks patients if they can afford a medication at the time she is ready to prescribe. She then makes it clear that she will offer them resources if they cannot. She also encourages patients to put their inhalers beside their toothbrushes, as that makes it more likely they’ll use them both morning and night.

Holguin accepts that patients will not always going be able to make dramatic changes to their work or home environments, where they are often exposed to allergens, so he focuses on positive gains to encourage them toward healthy behaviors.

Rather than chiding a patient for smoking, for example, he’s more likely to guide them toward steps they can take to feel better.

He uses the metaphor of treating a wound with a Band-Aid versus antibiotics to help them understand the severity of their disease. “When you put a Band-Aid on a cut, it looks better, but if it gets infected and festers, and you keep slapping a Band-Aid on it, it doesn’t actually fix the problem,” he says.

Holguin finds that patients can relate to that analogy, and he bolsters it with printed information they can read at home to better understand their disease.

The more physicians learn about their patients’ barriers to treatment, the more likely they are to find a treatment that works, Tan says. He uses the example of a single mother who’s going back to school.

“She can’t come in every month to get her injections, maybe she can’t find a ride or doesn’t have childcare. For her, maybe home therapy of bronchial thermoplasty is better than injections. These kinds of discussions need to be had with the patients, rather than just looking at their labs,” he says.

The mental health connection

Along with the physical symptoms of asthma, Holguin says, physicians should be aware of asthma’s impact on mental health. “Anxiety and depression exacerbate asthma and asthma exacerbates anxiety and depression. So you have to manage all the co-morbidities.”

This means developing and maintaining a strong referral network with mental health providers. If providers don’t already have such referrals, they can direct patients to resources such as the National Alliance on Mental Illness; the National Institute of Mental Health; ask patients to contact their insurer for a list of providers, or recommend they see a mental health professional with whom they already have a relationship.

Holguin keeps an open line of communication with his patients. Many of them have his cell phone number and email address and he checks in with them frequently. “Having patients contact me is not a burden. I’d rather have a conversation with someone about what’s going on than them rushing to the emergency room,” he says.

McDonald says that diagnosing and treating a patient is just the beginning of the physician’s job. “Now we start to educate our patients and reinforce that we have to live a healthy lifestyle in order to continue that momentum of good lung health.”