Asthma Management 2022: Strategies to Improve Outcomes in Uncontrolled Disease - PowerPoint Presentation

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Asthma Management 2022: Strategies to Improve Outcomes in Uncontrolled Disease

Amanda Michaud, MMS, PA-C, AE-C

Physician Assistant

Allergy/Clinical Immunology

Family Allergy Consultants

Jacksonville, Florida

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Amanda Michaud, MMS, PA-C, AE-C

has no relevant financial relationships to disclose.

Faculty Disclosures

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These slides may not be published, posted online, or used in commercial presentations without permission.

Please contact

pce@practicingclinicians.com

for details

4

About These Slides

Slide credit: practicingclinicians.com:

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Classify uncontrolled and severe asthma based on phenotypes and endotypesIdentify appropriate treatment options with add-on biologic therapy based on patient- and disease-specific factors

Utilize strategies to enhance adherence to therapy and improve clinical outcomes

Learning Objectives

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High symptom burdenUnpredictable exacerbations

Side effects of medications, especially with OCS

Impacts quality of lifeAffects emotional/mental health

Impact of Uncontrolled/Severe Asthma

NH = non-Hispanic; OCS = oral corticosteroid.

ginasthma.org/wp-content/uploads/2021/05/GINA-Main-Report-2021-V2-WMS.pdf; www.cdc.gov/asthma/asthma_stats/uncontrolled-asthma-adults.htm.

Percentage With

U

ncontrolled Asthma by Demographics: Adults

Male

Female

18-34 years

35-54 years

55-64 years

65+ years

NH White

NH Black

Hispanic

NH Other

0

20

40

60

80

6

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Epithelium

Allergens

Viruses

Bacteria

Smoke

Particulates

T2 Inflammatory

Pathway

Non-T2

Inflammatory

Pathway

APC = antigen-presenting cell;

TSLP = thymic stromal lymphopoietin;

IgE

= immunoglobulin E; ILC2 = type 2 innate lymphoid cells;

TFH =

follicular helper T; TH = T helper; YKL-40 = chitinase-3-like protein 1.

Israel. N

Engl

J Med. 2017;377:965. Kaur. J Allergy Clin Immunol 2019;144:1. Lambrecht. Nat Immunol. 2015;16:45. www.ncbi.nlm.nih.gov/books/NBK7232/pdf/Bookshelf_NBK7232.pdf.

Asthma is caused by chronic airway inflammation, which may lead to:

Airway hyperresponsiveness

Remodeling

Mucus production

Obstruction/airflow limitation

Asthma Is Highly Heterogeneous and Driven by Inflammation

TSLP

IL-25

IL-33

Innate

IL-8

TH

17

APC

TH

0

Adaptive

ILC2

TH

2

TH

1

B cell

TFH

cell

IL-4

IL-13

Neutrophil

Eosinophils

Airway Inflammation

Bronchospasm/Remodeling

Airway

Smooth Muscle

IgE

Mast

cell

IL-5

YKL-40

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Endotype = specific biologic pathway that influences response to treatment

Type 2 Inflammation (T2-high)

Immune response driven (presence of

cytokines IL-4, IL-5, and IL-13, eosinophils)

D

iagnosed by measuring biomarkers (eosinophil counts,

FeNO

, and allergen-specific

IgE)

Non-Type 2 Inflammation (T2-low)

Non-allergic, innate immunity

N

eutrophilic or

paucigranulocytic

inflammation, absence of markers that indicate T2

L

ack of response to corticosteroid therapy

FeNO

= fractional exhaled nitric oxide.

Kuruvilla. Clin Rev Allergy Immunol. 2019;56:219.8Asthma Endotypes

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Phenotypes associated with T2-high endotype:

Allergic/atopic

Eosinophilic; more common

in severe asthma

A

spirin-exacerbated respiratory disease

Late-onset

Phenotypes associated with T2-low endotype:

Non-atopicSmoking-related

O

besity-related

Elderly

Asthma Phenotypes

Phenotyp

e = clinical presentation/disease characteristics

Kuruvilla. Clin Rev Allergy Immunol. 2019;56:219.

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Global Initiative for Asthma (GINA)

Updated 2021

Pocket guide available at:

ginasthma.org

/pocket-guide-for-asthma-management-and-prevention/

AHRQ = Agency for Health Research & Quality.

Evidence-based Asthma Guidelines

National Asthma Education and Prevention Program Expert Panel ReportUpdated 2020

AHRQ reviews omit studies examining the role of biologics (anti-

IgE

, anti-IL-5,

anti-IL-5R, anti-IL-4/IL-13)

Omits specific

recommendations

for biologics in

Steps 5 and 6

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Differentiating Asthma From Other Disorders

ACE =

angiotensin converting enzyme; NSAID = nonsteroidal anti-inflammatory drug.

www.ginasthma.org.

Age

Condition

Findings

40+ years

Bronchiectasis

Productive cough, recurrent infections

Cardiac

failure

Dyspnea with exertion, nocturnal symptoms

Central airway obstruction

Dyspnea, unresponsive to bronchodilators

COPD

Cough, sputum, dyspnea on exertion, smoking or noxious exposure

GERD

Heartburn, epigastric or chest pain, dry cough

Hyperventilation, dysfunctional breathing

Dizziness, paresthesia,

sighing

Medication-related cough

Treatment with ACE inhibitor, beta blocker, aspirin, NSAID

Parenchymal lung disease

Dyspnea with exertion, nonproductive cough, finger clubbing

Pulmonary embolism

Sudden onset of dyspnea, chest pain

Vocal cord dysfunction

Dyspnea, inspiratory wheezing (stridor)

Each of these may also be found together with asthma

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Spirometry is essential to confirm persistent or variable expiratory airflow limitation

Spirometry Is Important for Differential Diagnosis

Normal, or Asthma Between Attacks

Inspiration

Expiration

Flow (L/s)

5

3

0

3

5

7

10

6

5

4

3

2

1

0

Volume

(L)

Uncontrolled Asthma or COPD

Inspiration

Expiration

Flow (L/s)

5

3

0

3

5

7

10

6

5

4

3

2

1

0

Volume

(L)

12

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AE = adverse event.www.ginasthma.org.

Long-term management goals

Achieve good symptom control and maintain normal activity levels

Eliminate future risk of exacerbations, fixed airflow limitation, and AEs

Avoid use of OCS as daily controller

Also important Take patient’s own goals into account Manage comorbidities, consult other specialists as needed

Goals of Management: GINA Global Strategy

Control-based Asthma Management Cycle:

At Every Patient Visit

Assess

Adjust Treatment

Review

Response

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As-needed low-dose ICS-formoterol

or as-needed short-acting β

2

-agonist (SABA)

LABA = long-acting

β

-agonist;

LAMA = long-acting muscarinic antagonist; SABA = short-acting

β-

agonist.

www.

ginasthma.org.

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

ICS taken whenever SABA is taken

Low-dose maintenance ICS

Low-dose maintenance

ICS-LABA

Add-on LAMA

Consider

high-dose

ICS-

formoterol

Refer for phenotypic assessment

± add-on

anti-

IgE

,

anti-IL-5/5R, anti-IL-4R

Low-dose

maintenance

ICS-formoterol

A

s-needed

low-dose

ICS-formoterol

PREFERRED CONTROLLER

Other controller options

PREFERRED

RELIEVER

As-needed

low-dose

ICS-formoterol

Symptoms

<

2x per month

Symptoms ≥2x per month,

but <4-5 days per week

Symptoms most days, or waking

≥1x per week

Daily symptoms, waking ≥1x per week, low lung function

Short course OCS may be needed for severely uncontrolled asthma

Medium-dose

maintenance

ICS-formoterol

Medium/high-dose maintenance

ICS-LABA

GINA: Stepwise Management for Pharmacotherapy in Adults and Adolescents

Aged ≥12 Years

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As-needed low-dose ICS-formoterol

or as-needed short-acting β

2

-agonist (SABA)

LABA = long-acting

β

-agonist;

LAMA = long-acting muscarinic antagonist; SABA = short-acting

β-

agonist.

www.

ginasthma.org.

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

ICS taken whenever SABA is taken

Low-dose maintenance ICS

Low-dose maintenance

ICS-LABA

Add-on LAMA

Consider

high-dose

ICS-

formoterol

Refer for phenotypic assessment

± add-on

anti-

IgE

,

anti-IL-5/5R, anti-IL-4R

Low-dose

maintenance

ICS-formoterol

A

s-needed

low-dose

ICS-formoterol

PREFERRED CONTROLLER

Other controller options

PREFERRED

RELIEVER

As-needed

low-dose

ICS-formoterol

Symptoms

<

2x per month

Symptoms ≥2x per month,

but <4-5 days per week

Symptoms most days, or waking

≥1x per week

Daily symptoms, waking ≥1x per week, low lung function

Short course OCS may be needed for severely uncontrolled asthma

Medium-dose

maintenance

ICS-formoterol

Medium/high-dose maintenance

ICS-LABA

GINA: Stepwise Management for Pharmacotherapy in Adults and Adolescents

Aged ≥12 Years

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PREFERRED

RELIEVER

ACTION ITEM

:

Use an evidence-based, stepwise approach such as GINA as a guide to control symptoms and minimize future risk

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Categories of Step 1 to 4 Asthma Medications

*Theophylline may be used as an alternative adjunctive therapy with ICS but is not preferred.

LTRA = leukotriene receptor antagonist.

www.ginasthma.org.

www.ncbi.nlm.nih.gov/books/NBK7232/pdf/Bookshelf_NBK7232.pdf.

Type

Description

Drug Class

Examples

Controller medications

For regular maintenance treatment

Reduce airway inflammation, control symptoms, and reduce risks such as exacerbations and decline in lung function

ICS

Beclomethasone, budesonide, fluticasone propionate, mometasone furoate

For regular maintenance treatment

Reduce airflow obstruction

LABA

LTRA

Methylxanthines

LAMA

Formoterol, salmeterol

Montelukast, zafirlukast

Theophylline*

Tiotropium

Reliever (rescue) medications

For as-needed relief of breakthrough symptoms

SABA

ICS-LABA

Albuterol, levalbuterol, pirbuterol

GINA 2021: Low-dose

ICS-formoterol preferred over SABA

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UncontrolledPoor symptom control (frequent symptoms or reliever use, night waking, limited activity) or frequent exacerbations requiring OCS at least 2 times per year or hospitalization due to exacerbation

May be due to nonadherence to ICS or poor inhaler technique

Difficult-to-treat

Uncontrolled despite being prescribed medium- or high-dose ICS-LABA or maintenance OCS or requires high-dose treatment to maintain symptom control and reduce exacerbations

May be due to incorrect diagnosis, inhaler technique, nonadherence, comorbidities

SevereUncontrolled despite adherence to high-dose ICS-LABA and treatment of contributory factors or worsens when high-dose treatment is reducedAccounts for approximately 3% to 10% of patients with asthma

Asthma Terminology per GINA

www.ginasthma.org

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International European Respiratory Society/American Thoracic Society Guidelines

Definition of Severe Asthma

Asthma that requires treatment with guidelines-suggested medications for GINA Steps 4-5 asthma (high dose ICS

and LABA or leukotriene modifier/theophylline) for the previous year or systemic CS for ≥50% of the previous year to prevent it from becoming “uncontrolled” or that remains “uncontrolled” despite this therapy

Uncontrolled asthma defined as at least one of the following:

1. Poor symptom control: ACQ consistently ≥1.5, ACT <20 (or “not well controlled” by NAEPP/GINA guidelines)

2. Frequent severe exacerbations: 2 or more bursts of systemic CS (≥3 days each) in the previous year

3. Serious exacerbations: at least 1 hospitalization, ICU stay, or mechanical ventilation in the previous year

4. Airflow limitation: after appropriate bronchodilator withhold FEV

1

<80% predicted (in the face of reduced

FEV

1

/FVC defined as less than the lower limit of normal)

Controlled asthma that worsens on tapering of these high doses of ICS or systemic CS (or additional biologics)

ACT = Asthma Control Test; ACQ = Asthma Control Questionnaire; NAEPP = National Asthma Education and Prevention Program; CS = corticosteroid.

Chung. Eur Respir J 2014;43:343.

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www.ginasthma.org. Louie. Consultant. 2018;58:336.

According to GINA, “the

level of asthma control

is the extent to which the manifestations of asthma can be observed in the patient, or have been reduced or removed by treatment”

Assessed retrospectively after a trial of asthma controller(s),eg, ICS + LABA for ≤3 monthsAsthma control includes

both: Symptom control (current clinical control) and Eliminating future risk, particularly exacerbations and drug AEs

How to Assess Asthma Control

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www.aafa.org/asthma-treatment-action-plan. Gibson. Thorax. 2004;59:94.

A written asthma action plan helps patients recognize and respond to worsening asthma in the short term

Should include when, how, and for how long to increase treatment and when to seek medical help

Supports patient education and provides a consistent

individualized

approach

It is also important for patients to understand and avoid potential triggers to prevent exacerbationsRole of the Asthma Action Plan

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www.aafa.org/asthma-treatment-action-plan. Gibson. Thorax. 2004;59:94.

A written asthma action plan helps patients recognize and respond to worsening asthma in the short term

Should include when, how, and for how long to increase treatment and when to seek medical help

Supports patient education and provides a consistent

individualized

approach

It is also important for patients to understand and avoid potential triggers to prevent exacerbationsRole of the Asthma Action Plan

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PREFERREDRELIEVER

ACTION ITEM

: Help your patients write an asthma action plan that is tailored to their individual needs

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Chung. Eur Respir J. 2014;43:343. www.ginasthma.org.

Drugs: aspirin, NSAIDs,



-adrenergic

blockers, ACE inhibitors

GERD Hormonal influences: premenstrual, menarche, menopause, thyroid disorders

Hyperventilation syndromeObesity

Comorbidities may require consultation or co-management with appropriate specialists

Obstructive sleep apnea

Psychological factors: personality trait, symptom perception, anxiety, depression

Rhinosinusitis/nasal polyps

Smoking/smoking-related disease

Vocal cord dysfunction

Recognizing and Managing Problematic Medications and

Comorbidities

22

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Chung. Eur Respir J. 2014;43:343. www.ginasthma.org.

Drugs: aspirin, NSAIDs,



-adrenergic

blockers, ACE inhibitors

GERD Hormonal influences: premenstrual, menarche, menopause, thyroid disorders

Hyperventilation syndromeObesity

Comorbidities may require consultation or co-management with appropriate specialists

Obstructive sleep apnea

Psychological factors: personality trait, symptom perception, anxiety, depression

Rhinosinusitis/nasal polyps

Smoking/smoking-related disease

Vocal cord dysfunction

Recognizing and Managing Problematic Medications and

Comorbidities

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PREFERREDRELIEVER

ACTION ITEM

:

Address and treat (or refer) comorbidities that may impact asthma control

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MDI = metered-dose inhaler.

Chung. Eur Respir J. 2014;43:343. Spitzer WO et al. N

Engl J Med 1992;326:501. www.ginasthma.org.

Uncontrolled asthma symptoms

For example, ACT

 ≤19

Frequent SABA useMortality increased at least 2-fold if more than 1 200-dose MDI canister used/monthSuboptimal ICSNot prescribed, poor adherence, incorrect inhaler technique Low FEV

1Especially if <60% predictedHigh bronchodilator reversibilityMajor psychological or socioeconomic problems

Risk Factors That Increase the Likelihood of Exacerbations

Exposures

Smoking, allergen exposure (if sensitized)

Comorbidities

Obesity, chronic rhinosinusitis, confirmed

food allergy

Sputum (

eg

, ≥2%) or blood (

eg

, ≥150 cells/µL) eosinophilia

Elevated

FeNO

(≥20 ppb)

Pregnancy

History of being intubated or in ICU for status asthmaticus

≥1 severe exacerbation in previous 12 months requiring OCS for ≥3 days24

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QoL = quality of life.www.ginasthma.org.

Assess whether the following may be the cause of persistent symptoms or exacerbations:

Incorrect inhaler technique

Poor adherence

Persistent exposure to agents such as allergens, tobacco smoke, air pollution, or to medications such as

β-blockers or NSAIDsComorbidities that might contribute to respiratory symptoms and poor QoL

Incorrect diagnosisBefore Considering Any Step Up in Treatment

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QoL = quality of life.www.ginasthma.org.

Assess whether the following may be the cause of persistent symptoms or exacerbations:

Incorrect inhaler technique

Poor adherence

Persistent exposure to agents such as allergens, tobacco smoke, air pollution, or to medications such as

β-blockers or NSAIDsComorbidities that might contribute to respiratory symptoms and poor QoL

Incorrect diagnosisBefore Considering Any Step Up in Treatment

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PREFERREDRELIEVER

ACTION ITEM

: If a patient has persistent symptoms and/or exacerbations despite 2-3 months of controller therapy, correct common problems before stepping up treatment

Slide27

BAMDI = breath-actuated metered-dose inhaler.

Sanchis

. Chest. 2016;150:394.

Preparation

Expiration

Coordination

Slow deep

breath

Breath-hold

Preparation

Expiration

Inhale w/lips on

mouthpiece

Brisk, accelerated

deep breath

Breath-hold

Exhalation

Slow deep

breath

Breath-hold

Preparation

Exhalation

Actuate and

breath-hold

Mean Percentage

34%

38%

39%

45%

18%

33%

46%

48%

MDI + spacer

BAMDI

Brisk, accelerated

deep breath

Not exhaling fully before inhaling the medication is a common error with traditional MDIs and DPIs

Pay attention to inhaler type: if inhaler type is new to patient, they will need new training

60

50

40

30

20

10

27

It’s Important to Teach Good Inhaler Technique:

Errors Are Common and a Major Risk for Poor Control

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www.ginasthma.org.

Ways to Promote Proper Inhaler Technique

Choose

Consider

medication options, available devices, patient skills, and cost

Encourage patient to participate in the choice

For pressurized MDIs, spacers improve delivery and reduce risk of AEs with ICS

Assess for physical barriers (eg, arthritis) that might limit use of inhaler

Avoid use of multiple different inhaler types

Check

Check inhaler technique at every visit

Ask the patient to

show you

how he/she uses the inhaler

Identify errors using a device-specific checklist

Correct

Show the

patient how to use the device correctly (eg, using a placebo inhaler)

Check technique again, paying attention to difficult steps; repeat as necessary

Consider alternative device only if patient cannot use inhaler correctly after several rounds of training

Recheck technique frequently (errors often recur within

4-6 weeks)

Confirm

Be sure you know how to demonstrate correct technique

for each of the inhalers you prescribe

Pharmacists and nurses can also provide inhaler skills training

28

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www.ginasthma.org.

Ways to Promote Proper Inhaler Technique

Choose

Consider

medication options, available devices, patient skills, and cost

Encourage patient to participate in the choice

For pressurized MDIs, spacers improve delivery and reduce risk of AEs with ICS

Assess for physical barriers (eg, arthritis) that might limit use of inhaler

Avoid use of multiple different inhaler types

Check

Check inhaler technique at every visit

Ask the patient to

show you

how he/she uses the inhaler

Identify errors using a device-specific checklist

Correct

Show the

patient how to use the device correctly (eg, using a placebo inhaler)

Check technique again, paying attention to difficult steps; repeat as necessary

Consider alternative device only if patient cannot use inhaler correctly after several rounds of training

Recheck technique frequently (errors often recur within

4-6 weeks)

Confirm

Be sure you know how to demonstrate correct technique

for each of the inhalers you prescribe

Pharmacists and nurses can also provide inhaler skills training

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ACTION ITEM

: Take steps to ensure that your patient understands proper

inhaler technique and can administer his/her medication correctly

Slide30

www.ginasthma.org. Waljee. BMJ

. 2017;357:j1415.

AEs are particularly common and problematic with long-term use of OCS

Frequent short-term use of OCS is associated with sleep disturbances and increased risk of AEs: infection (5-fold, sepsis), bone fracture (nearly 2-fold), and thromboembolism

(3-fold) in US patients

Risks Associated With OCS Use

AEs of Long-term OCS Use

Obesity

Hypertension

Diabetes

Adrenal suppression

Osteoporosis

Depression

Cataracts

Anxiety

30

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www.ginasthma.org. Waljee. BMJ

. 2017;357:j1415.

AEs are particularly common and problematic with long-term use of OCS

Frequent short-term use of OCS is associated with sleep disturbances and increased risk of AEs: infection (5-fold, sepsis), bone fracture (nearly 2-fold), and thromboembolism

(3-fold) in US patients

Risks Associated With OCS Use

AEs of Long-term OCS Use

Obesity

Hypertension

Diabetes

Adrenal suppression

Osteoporosis

Depression

Cataracts

Anxiety

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ACTION ITEM

: Avoid long-term or frequent OCS use due to the risk of AEs

Slide32

GINA Control-based Asthma Management Cycle

www.ginasthma.org.

Confirm diagnosis

Symptom control, risk factors (including lung function)

Comorbidities

Inhaler technique, adherence

Patient goals

Symptoms

Exacerbations

AEs

Patient satisfaction

Lung function

Medications

Nonpharmacologic approaches

Modifiable risk factors

Education & skills training

Assess

Adjust Treatment

Review

Response

32

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*OCS often suppresses markers of Type 2 inflammation; these tests should be performed before starting OCS or on the lowest possible dose.

www.ginasthma.org.

Type 2 inflammation should be considered if the patient has any of the following while on high-dose ICS or daily OCS*:

Blood eosinophils ≥150/µ

L and/or

FeNO

≥20 ppb and/or

Sputum eosinophils ≥2% and/or

Asthma is clinically allergen-driven

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Assessing Whether a Patient Has Type 2 or Non-Type 2 Inflammation

Slide34

Biologic Targets in Severe Asthma

Adapted from: Bice. Ann Allergy Asthma Immunol. 2014;112:108. Ziegler. Nat Immunol. 2010;11:289.

Edwards.

Eur

Respir

J. 2017;49:1602448

Mepolizumab

Reslizumab

Omalizumab

IL-4R

IL-4R/

IL-13R

Benralizumab

IL-5R

Th2 Cell

Eosinophil

IL-4

IL-5

IL-13

IgE

Th0 Cell

APC

B Cell

Dupilumab

Dupilumab

TSLP

Tezepelumab

34

Slide35

GINA Guidelines: Add-On Biologic Therapy for Type 2 Adolescents/Adults

www.

ginasthma.org.

Anti-

IgE

Sensitization or skin prick testing, or specific

IgE

Total serum

IgE

and weight within target range

Exacerbations in last year

Anti-IL5/Anti-IL5R

Blood

eosinophils

≥150 or ≥300/µL

Exacerbations in last year

Anti-IL4R

Blood

eosinophils

≥150/µL or

FeNO

≥25 ppb

Exacerbations in last yearPatient requires maintenance OCS

Trial for at least 4 months and assess response

Little to no response:

Consider switching to different biologic

If still no response, stop biologic and reassess diagnosis/phenotype

Stop ineffective add-on therapies

Continue ICS

Consider chest CT (if not done)Good response:

Re-evaluate every 3-6 monthsTaper/stop OCS (if applicable) first, then consider stopping add-on agents, then consider decreasing ICS to moderate dose

Eligibility may be dependent on insurance coverage

35

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Phenotype

Local payer eligibility coverage/affordability

Patient age

Administration route (SC vs IV); is self-administration covered?

Dosing frequency

Consider comorbidities/additional indications for individual biologics

Patient preferenceHow To Choose a Biologic

Krings

. J Allergy Clin Immunol

Pract

. 2019;7:1379.

www.

ginasthma.org

.

36

Slide37

Available Biologics For Type 2 Severe Asthma

Medication

Age

Exacerbation Reduction

Administration/Frequency

Additional Considerations

Omalizumab

≥6 years

~25% to 50%

SC every 2-4 weeks

Initial dose in healthcare facility

Also approved for chronic spontaneous

urticaria, nasal polyps

Pregnancy data available

Dupilumab

≥6 years

~50% to 70%

SC every 2 weeks

Can be self-administered

Also approved for atopic dermatitis, chronic rhinosinusitis with nasal polyposis

Benralizumab

≥12 years

~40% to 50%

SC every 4 weeks x 3 doses, then every 8 weeks

Can be self-administered

No additional indications

Mepolizumab

≥6 years

~50%

SC every 4 weeks

Can be self-administered

Also approved for eosinophilic granulomatosis with polyangiitis, hypereosinophilic syndrome, chronic rhinosinusitis with nasal polyposis

Reslizumab

≥18 years

~50% to 60%

IV every 4 weeks

Requires healthcare facility administration

No additional indications

Allows for weight-based dosing

Tezepelumab

≥12 years

~50% to 70%

SC every 4 weeks

Requires healthcare facility administration

Can be used regardless of phenotype

Benralizumab

PI. Dupilumab PI.

Krings

. J Allergy Clin Immunol

Pract

. 2019;7:1379. Mepolizumab PI. Omalizumab PI.

Reslizumab

PI. Tezepelumab PI. www.ginasthma.org.

37

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Biologic Considerations Based on Endotype/Phenotype

Benralizumab

PI.

Busse

.

Allergol

J Int. 2019;68:158. Dupilumab PI. Mepolizumab PI.

O

malizumab

PI.

Reslizumab

PI. Tezepelumab PI.

www.

ginasthma.org.

Medication

Weight considerations

Biomarker Considerations

Eosinophil limits

Omalizumab

Use body weight in conjunction with baseline

IgE

levels to determine dosing

IgE

limits based on age:

≥12 years: 30-700 IU/mL

6-11 years: 30-1300 IU/mL

Dupilumab

None for asthma

FeNO

≥25 ppb

Eosinophils ≥150 cells/µL

Benralizumab

None

—

Eosinophils ≥300 cells/µL

Mepolizumab

None

—

Eosinophils ≥150-300 cells/µL

Reslizumab

Weight based dosing

—

Eosinophils ≥400 cells/µL in past year

Tezepelumab

None

__

__

38

Slide39

www.

ginasthma.org.

Adherence issues

Inhaler technique, affordability

Ensure patients know to continue to take their inhaled medications after biologic initiation

Engaging patientsUtilize the ACT™

Inform patients of benefits/risk of optionsEstablish an Asthma Action PlanCounsel on COVID-19 and asthmaKeeping asthma controlled is important (increased risk of COVID-19-related death in those requiring OCS or hospitalization due to severe asthma)

39

Patient Education

Slide40

Slide41

Use an evidence-based, stepwise approach such as GINA as a guide to control symptoms and minimize future risk

Help your patients write an asthma action plan that is tailored to their individual needs

Address and treat (or refer) comorbidities that may impact asthma control

If a patient has persistent symptoms and/or exacerbations despite 2-3 months of controller therapy, correct common problems before stepping up treatment

Take steps to ensure that your patient understands proper inhaler technique and can administer his/her medication correctly

Avoid long-term or frequent OCS use due

to the risk of AEsPCE Action Plan

PCE Promotes Practice Change

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Visit our website for other complimentary, on-demand activities:

podcasts, case challenges, videos, & more

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Learn more at practicingclinicians.com

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Go Online for More PCE Coverage of Asthma Management!