Treatment Landscape of Asthma

Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: We’re going to switch gears and think about considerations of treatment selection. Dr White, I’m going back to you. Give us a little about the landscape of therapies out there, Let’s starting with corticosteroids, whether they’re inhaled or oral. Then we’ll add on other nonbiologic therapeutics and, lastly, the newer biologics.

Andrew White, MD: There are a lot of options for treatment. It’s a little overwhelming to keep track of the various devices and the way they’re used and make sure we understand how to teach patients properly. But the way you can start is with inhaler therapy. This is the tried-and-true first step for almost all our patients. There’s an emphasis to get away from using short-acting beta-agonists alone. We should be pairing that with an inhaled corticosteroid [ICS] because patients do better with that. The inhaled steroid is the cornerstone, and that can be given either with a propellant. The way people tend to typically think about the inhaler is that they’re driven with the HFA [hydrofluoroalkane] propellant. Patients can depress it, breathe it in, hold their breath, and use a spacer device with some of them. There are also options for a dry powder. These are different devices, a different technology delivered a little differently. Those are good first options.

The next step is usually to add on a long-acting beta-agonist [LABA]. Those can be added separately or as a combined inhaler, which is often what’s done. Once you get to that level, when patients are on an ICS and a LABA, if they’re not controlled, then we think about further add-on therapies. There are options to add on a long-acting antimuscarinic agent, called LAAMA. Those can be added on, so patients can be on 3 types of inhaler pharmacology to control their asthma. Then we have some oral options. We’ve got leukotriene modifier drugs. Montelukast is a very commonly used once-a-day drug. It blocks 1 of the receptors that leukotrienes act on, and leukotrienes can be very important in some of our asthmatic patients. There are some other drugs in that same class.

Once you’ve gotten to that level, if patients are on all those therapies, we’re thinking about other options beyond that. That is when we start to think about biologic agents. We’ll talk plenty more about that, but that’s the step where we’re starting to think about that in our patients. There are other options. There’s something called bronchial thermoplasty, which is a way to apply heat energy to the bronchial tubes, done by a pulmonologist. Those are the very broad categories of pharmacotherapy. For most of our patients, as we’re working through this, we’re also dealing with potential adverse effects or difficulty with a specific device. We may be juggling around to a different device. Some patients may have hoarseness or some of the common adverse effects from the inhaler therapies, so we may use some strategies to help with that before we simply escalate up the ladder to something else.

Transcript edited for clarity