Dr Megan Althoff on the Difficulties Deciding Between Biologics for Patients With Severe Asthma

How do you choose a nonbiologic option versus a biologic option? If you qualify for multiple biologic options, how do you pick which is best for your patient and assess that it's working? And how long do you keep them on it if it is working? These are some of the biggest treatment challenges in managing patients with severe asthma, in light of the guidelines, noted Megan Althoff, MD, PhD, second year fellow, University of Colorado, Division of Pulmonary Sciences and Critical Care Medicine, in this interview for CHEST.

Transcript

What can we expect from the new asthma guidelines?

So the whole and the entire segment, we had discussions on the updates in the GINA [Global Initiative for Asthma] guidelines and then the ERS/ATS [European Respiratory Society/American Thoracic Society] guidelines that came out. My talk was trying to take all those guidelines and highlight some of the challenges that we may see in clinical practice and trying to implement those.

One of the big changes, and we'll get to this in the GINA guidelines, was the talk of doing a single maintenance and reliever inhaler with an inhaled corticosteroid and formoterol. I spoke a little bit about some of the practical challenges in getting insurances to pay for a single inhaler that's both a maintenance and a reliever inhaler and some problems that patients have had getting those refilled early.

And then we spent the bulk of the talk talking about how do we make decisions in our patients with severe asthma? Because there's certainly a paucity of data of how do you choose a nonbiologic option versus a biologic option? And then if you qualify for multiple biologic options, how do you pick which biologic is best for your patient? How do you assess that it's working? And then, how long do you keep them on it if it is working?

The big gist of it was, there's tons of holes in research and a lot of good future directions that we’ll certainly hopefully be investigating in years to come but that there's not a lot of guidance, especially if your patient can qualify for multiple biologic therapies, and trying to pick something that's the most practical for your patient, potentially being able to give it at home, and then know that there are data saying some patients fail initial biologic therapy but do really well on alternate agents.

And then when we looked specifically at duration, which is a question that comes up in clinical practice all the time, for the most part, all the agents, as best we understand, are really safe and effective long term. But that if patients want to trial going off of it, there do seem to be a subset of patients both with omalizumab and with mepolizumab, which are really the only 2 that have been studied so far, there seem to be a subsegment of patients that may do okay off of biologic therapy for a period of time. But we really don't understand who those patients are yet.

So in clinical practice that translates to, if your patient wants to go off of an agent, it's reasonable to try but to expect that at some point they may need to go back on and that you actually can successfully reintroduce your patient to the same biologic.