Practical Considerations for Managing Severe Asthma

This is part of the MD Magazine^® Peer Exchange, “Precision Medicine in the Treatment of Severe Asthma.”Click here for Segment 10 and learn about comorbidities and worsening symptoms in asthma.

Peter Salgo, MD: Listening to you guys, I see that there are, if you’ll pardon the expression, 2 silos here. One is the severity of symptoms, and the other is the number of times they become severe. Can you make the diagnosis of severe asthma with just severe symptoms all the time? How about the person who says they are all right all the time but then sometimes not? Is there a difference here? And is one severe and one not?

Raffi Tachdjian, MD: There is a difference, and that’s part of the construct where clinical trials have been built on—whether it’s exacerbations and reduction of the exacerbations or just the severity and the control of the asthma symptoms. And to echo Dr Jain, really, as a specialist, the small advantage that we still have, which is going away, is our time to spend with that consultation, to chase it to the end, and to say, “Oh, it sounds like you play soccer [or hockey] here. What position do you play?” They might say, “I play goalie.” Well, the next step is, “Why are you playing goalie and not up front?” “Well, I get a little winded.” Until you get someone to be polished to almost say that they are shining or thriving in life, we haven’t achieved our control.

David Rosenstreich, MD: Your point about exacerbations once a year versus severity comes back to the whole issue of phenotypes. There are different asthma phenotypes. There are some patients who are severe just a couple of times a year. But they’re pretty severe, and they could die. And there are some who are severe all the time. They’re just 2 different patterns. You have to pay attention to those and adjust your medications and your approach to them differently.

Neal Jain, MD: I agree.

Peter Salgo, MD: I know that some of our colleagues out there, primary care colleagues, are listening and are saying, “You know, this is really getting complicated. I thought I could manage asthma. Maybe I can’t. When do I call the specialist in?” What patients are worrisome? When do I make that call?

Neal Jain, MD: The guidelines offer a little bit of advice here. They essentially say that if you’re at a medium dose of inhaled corticosteroid (ICS) or more, you should consider referring to a specialist. You should certainly consider referring to a specialist when you’re starting to think about medium-dose ICS plus a long-acting beta-agonist. Or is this someone who needs to be on more therapy? You can bring a specialist in to help assess and identify whether there are things that we’re missing. Are there comorbid conditions? Is this really asthma? Is this one of the 30% without asthma who has vocal cord dysfunction or acid reflux—induced symptoms? Those are the times that I would say it’s worthwhile.

Peter Salgo, MD: Whom do you refer to—pulmonologists, allergists? Who’s the go-to person? I’m asking a bunch of pulmonologists.

David Rosenstreich, MD: Allergists.

Peter Salgo, MD: I’m talking to a bunch of allergists.

Neal Jain, MD: I think it just depends on whom you know in your community who is adept at seeing asthma. I think there are allergists who are really asthma specialists, and there are allergists who really focus more on rhinitis. The same could be said of pulmonologists. Sometimes they are great at asthma, and there are those who are saying, “Well, this is kind of filler for me.” It’s knowing who in your community can be the champion.

Peter Salgo, MD: With the definition of asthma and the amount of parsing that we’re doing to determine what’s driving it, allergic responses and the allergic mechanisms seem to be paramount, even if you’re just allergic to yourself.

David Rosenstreich, MD: Given the state of asthma, understanding now what people do, it probably doesn’t matter whether you go to an allergist or a pulmonologist. Allergists are comfortable with pulmonary function testing, and pulmonologists have now become more comfortable with interleukins. And so you find someone who’s interested in asthma. That person is the best kind of specialist to send them to.

Transcript edited for clarity.