Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: When we hear severe asthma, difficult-to-manage asthma, naturally, the key therapeutics we’re used to hearing about are the oral corticosteroids. Even though we know they work and do a nice job on the inflammation of the asthma, we know that they come with a plethora of adverse effects. In your opinion, Dr Chase, what does that look like? How do you try to veer away and find alternative solutions in that type of patient?
Nicole Chase, MD, FAAP, FACAAI, FAAAAI: This is what differentiates us in terms of the care that we provide for patients with severe asthma. It takes very little thought process about the actual pathophysiology of disease to hand someone a prescription for systemic steroids. When someone is in extremis, breathing is so important, and we can’t really do anything about that. But this idea that steroids fix everything misses the point. What we’ve learned over time is that we historically thought short courses of systemic steroids weren’t so bad. You would have maybe a bit of transient mood swings, or you’d have a blood sugar level increase or blood pressure level increase. But we thought, “It’s just a 5-day burst, no problem.” And what we’ve come to learn is that every time a patient gets a systemic steroid burst, we are very slowly increasing their risk for lots of conditions. Bone health is one that most individuals seem aware of. Bone density is important to check in patients who have severe asthma because we know that over time, risks of things such as osteoporosis go up. However, it’s also been shown that there are lots of other disease states for which repeated courses of oral or systemic corticosteroids increase the relative risk for cataracts and glaucoma, which is well established, but also for things such as type 2 diabetes, gastroesophageal reflux, anxiety, and depression. It’s the idea that in patients on repeated courses, all those adverse effects begin to start catching up to the patient. Overall, it should be our goal that if the patient has an exacerbation that requires systemic steroids, right there, we’re already thinking about what we are missing. Is this the right diagnosis? Is the patient’s current regimen of therapies…appropriate for them? Also, is there some other variable that we’re not fitting into this puzzle? And realistically, if all that pans out and this person’s asthma is worsening, what can we then think about in terms of therapies? Because now that we know better and know these phenotypes, endotypes, we should be using them to treat to control, full control. This is really a stable course of medications at the lowest doses possible that control a patient’s symptoms without the need for systemic steroid bursts.
Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI:So, we talk about step-up therapy, and we have now gotten to an era where we need to step up our level of excellence in delivering this care once we diagnose the…severe asthma.
Transcript edited for clarity