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I’d like to get some final comments. I want to start with professor Chupp. Geoff, where’s the wisdom?

 Well, I’m going to have to dig deep to find wisdom, Rey. But I will say that I think this has been a fantastic discussion. I really enjoyed everyone’s insight and your moderation of the discussion. The 1 thing I will say is that I think we will have an opportunity to see a modification of the disease in our lifetime. I believe that there’s a chance we’re going to be able to change progression of the disease. As we know, some of these may be early-life trials, and even if you catch the patient soon enough after this injury or whatever the sentinel moment is for people to develop asthma—whether it’s early in life or as an adult—if we can reverse that, we have a chance of curing the disease. The drugs we have now and our understanding of endotypes is really making me hopeful that we’re going to achieve this at some point in the next few decades.

That would be fantastic. That’s what we’re in the business of doing. We would love to see a cure, or at least decreased susceptibility for your reversible airflow obstruction. Nic, parting comments?

It’s really hard to add more comments. I’m hoping—I may not be as optimistic—that we will see it in our lifetime. I hope I live long enough to do so. But I think we’ve taken good strides in asthma. We’re now thinking outside the box. We’ve really changed our approach from a “one-size-fits-all” disease. We know how to do phenotyping. We know that asthma affects multiple groups of patients. This generalistic approach is changing slowly, but it is changing. We’re seeing this on the other hand with the patients’ outcomes. We’re seeing better control. I can tell you that in the ICU [intensive care unit] of our hospital, Baylor College of Medicine in Houston, Texas, we’re seeing less admissions in the last 5 to 10 years compared to what we have seen when I first started 25 years ago. There is definitely an outcome improvement in whatever we’re doing in asthma—the guidelines, the treatments, the approach, and the thinking of the disease. I am hoping we’ll see 1-time interventions that can change that natural history that I was talking about earlier.

Well, if you remember—at least I remember—when I started out in the space of asthma, asthma mortality was an epidemic. There was a red flag and there were flashing lights saying we were losing in asthma. There was an increased death rate and that death rate was in a diverse population, unfortunately. But we’re seeing marked improvements. Death rate is almost unheard of from asthma now. What a wonderful outcome. Sid, you have the last words.

 Well, you almost took the last words out of my mouth. Nic was reflecting on the last 5 to 10 years. I was going to reflect on the last 30 years. In 1991, the first guideline came out, the NAEPP [National Asthma Education and Prevention Program] guideline. You’re absolutely right. Prior to that time, despite the fact that we were doing things we thought were safer with asthma: we weren’t giving intravenous aminophylline, we weren’t giving ephedrine across the blood-brain barrier, and we were giving more beta-2 specific agents. In the ICU, we were focusing on hypercapnia and not marrow trauma, and all the wonderful things we were doing. Mortality kept going up, up, and up. I think the final word is that we’ve spoken about maybe 5% to 10% of what we call “the severe asthmatic” today. But what about all those other individuals out there with asthma who we’ve helped so much and have had asthma relief? As you just mentioned, asthma mortality now is quite rare. I think that we need to look at the positive side: those extra 90% or so patients that we didn’t really concentrate on today, have done quite well.

 Well, on behalf of Sid, Geoff, Nic, and I, thank you, you’ve hung in there. Thank you for watching this 

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The panel provides their final thoughts on the treatment of asthma and what they see and hope for in the future.  

Asthma

Looking Forward in Asthma Treatment 

We know that giving the right products can sometimes be a challenge. Keri, would you talk about some of the non-pharmacologic approaches and management, trigger avoidance, and how you coach those patients and families lifestyle-wise?

My recommendations are simple. The skin is dry and irritated, so we have to treat both of those components. I recommend that patients moisturize throughout the day, whenever their skin starts to feel dry or itchy—it’s especially helpful after a shower—and that method is called soap and seal. This combats the dry skin and helps to reduce the flares. This is a technique where I have patients shower for 10 minutes, use a gentle cleanser, wash but don’t scrub, their skin then they’ll pat their skin dry and leave it slightly damp and put the topical moisturizer on over that, all over the body. You don’t have to spend a lot of money to get a great product, and these are products that mostly have water and ceramides, no fragrances or dyes. They usually come in a tub, but not always. If spending more money will encourage my patient to use them, then that’s half the battle. 

I have a list of my favorite things that I give to my patients. I write everything down, because this world can be confusing to them, especially when they go to the store and see piles of products. I like common products, things like CeraVe, Eucerin, and Vanicream. Another technique I do often is wet wraps. When patients are itchy, I’ll tell them to put on their moisturizer and do a wet wrap therapy, which is putting a wet towel over that area for 10 minutes. It rehydrates and calms the skin and can boost the effect of topical medications when you use it in combination with that. We also want to decrease the irritants—things like water softeners, air purifiers, and laundry techniques. We need more studies to support those techniques. They’re interesting thoughts, but those aren’t the things that I run to first. I run to my moisturizers. I run to my avoidance of irritants. If patients don’t like topical creams because it’s too cold, I‘ll tell them to float that tub of cream in a bath of warm water. If it burns, I tell them to put it in the fridge to cool it down.

Another problem that we see is that if we don’t give patients the guidance on those over-the-counter products, they’re going to get things that they think are good—maybe homeopathic, or what they call natural products—which sometimes have a lot of seed extracts, oils, fragrances, and other things. We’re all familiar with that. Susan, I know you’re on the West Coast, Douglas is on the East Coast, and Keri and I are in between. What guidance do you give to your patients for accessing the over-the-counter types of things that can be an adjunctive therapy to the prescriptive medicinal products that you’re going to recommend?

 I do a lot of the same things that Keri mentioned. But the other thing I want to interject is that I encourage my atopic patients—or any patient that comes in that has sensitive skin or dry skin—to look for products that have the National Eczema Association seal of acceptance. They’re not endorsing products, but they have a panel of people that have reviewed ingredients for any company that wants to promote their product and have it used for patients with eczema. Aveeno products have it, and Cetaphil, CeraVe, and all those common ones, like Vanicream, also have it. The seal of acceptance from the National Eczema Association means there’s no fragrance, no irritating ingredients, and it should be safe for most sensitive skin and eczema patients. I strongly recommend that. I also like products that come in big jars because people run out of them quickly. I will say, you must find a product that your skin likes and that you can stick with. It has to be a lifetime thing. They’re never going to not be able to get in and out of water and not put something on their skin.

 What about petroleum jelly or coconut oil?

For sure, yes. Coconut oil is a big thing right now. Sometimes I’ll say oils aren’t going to be enough, but if you combine them with something else, sure.

 Susan and Keri, are you guys recommending that they use bleach in their baths, and how much and how often, if you do? I’m curious.

If patients have multiple staph reinfections, the literature doesn’t support that, but it doesn’t say that it’s going to be colonized staph on their skin. But I have used it, yes—maybe, for people who continually get staph infections, regular chlorine bleach in a bath once or twice a week.

 We do a quarter cup of bleach to a full tub of water and have some anecdotal reports of it also helping to reduce itch. 

Let me chime in here, talking about bleach baths, because this is a game changer for me and my patients. After they soak in the water for 15 minutes and apply moisturizers afterward, they then use freshly laundered towels, sheets, and pajamas. That's been a real change for my patients that needed that boost with the help of colonization of staph.

 When we had a day care center for psoriasis and eczema or atopic dermatitis patients at Baylor [University Medical Center] in Dallas, we did the soak and seal techniques for sure. We would have them get their pajamas wet or damp and put that on after they bathed, then put their topical medications and emollients on. Then we would put wet cotton pajamas, particularly on the children, and wrap them in some sort of plastic wrap to try to get that penetration, and we can turn them around within about 3 days of doing that. There are some data in the dermatology nursing literature about how to do it and why it helps. It’s probably 25 years old. The same things that you’re recommending can be helpful and low cost but labor intensive for the family.

 I’ll tell you guys a quick story. I had a patient that came in to see me recently, and he had spent hundreds of dollars on prescription medications and never got better. So, he came to me, I looked at his skin and his skin was incredibly dry. I asked if he had used a moisturizer and he said he had never been recommended that. Now, I simply said, “Let’s go with the techniques that we mentioned. Let’s use something in a tub.” I saw him 6 weeks later, and just by giving him the instruction, he started using a moisturizer, and his skin was 50% better. Patients may forget, when it’s such a critical and important part of therapy.

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Non-pharmacological strategies that can help patients with atopic dermatitis cope with symptoms and advice to help healthcare professionals counsel patients on proper use of these products and techniques. 

Atopic Dermatitis

Atopic Dermatitis condition center page, resources on the topics of medical news and expert insight into eczema can be found. Content includes articles, interviews, videos, podcasts, and breaking news on dermatitis research, treatment, and drug development.

Non-Pharmacological Treatments for Atopic Dermatitis 

 We’ve seen a lot of development and a lot of new drugs coming to market in this space. But I think as we move forward, we have to think of the trifecta for drugs that will be approved. We have very effective therapies that improve the efficacy, exacerbation rates, and patient-reported outcomes. I think as we move forward—and of course, we’re all on corticosteroids—they are a burden. But as we move forward, new drugs have to hit at least 3, if not all 4 of those aspects for them to really surface as a viable benefit to patients with severe asthma. Do you see drugs coming out that are acquiring 2 of those 4 metrics? Or are you in unison with my thought process that you need all 4 metrics to move forward? What’s your sense, Sid?

My sense is the same as yours but I would like to add the fifth. As we’ve already discussed earlier today, many patients, especially patients who were either poorly controlled having exacerbations or perhaps didn’t get their therapy early enough, have an excess of the client of lung function. We call this airway remodeling and understand that it involves a lot of cell types, such as smooth muscle and so forth. Do we have anything that’s effective in blocking this decline and improving? Let’s say we have the decline to improve it. So I would say that I’d like to add a fifth criteria for drugs in the future. I think, so far, we don’t have any of that.

Those are great points. You’re right, that’s going to compel phRMA [Pharmaceutical Research and Manufacturers of America] to do 15- and 20-year-long studies.

I think the bar is very high for clinical trials. As you said, we have good, novel therapies that have been shown, at least in selected population, if we select them right, to improve outcomes. So to come and put in another new agent and to compare it with an existing agent, you have a very high ceiling effect of the ones already available. Clinical trials may be very hard to do because it may be unethical to give a placebo to a patient with severe asthma for a long period of time because we have existing drugs that work. That’s another issue. Another issue I’m going to bring up, and it may be controversial—at least in the era of COPD [chronic obstructive pulmonary disease] now—, is that we may be shifting from phenotyping to tapping into what we call treatable traits. We always like to sort of— and I am from that school—have a cut of this asthma; this is an affiliate of an allergic disease. Maybe we may be too strict in doing this in the COPD arena, for example, we’re shifting to what we call treatable traits: treating traits that the patient presents with. Some of them have cough and shortness of breath. Others have exercised limitation. A third group have more emotional distress, anxiety, and the psychiatric aspect. These are things that have been talked about in the asthma world now. Should we shift to treatable traits and look at interventions based on how the patient presents and what his or her symptoms are? I think it’s all up in the air right now. But I think, from the biologic point of view, it’s very hard to beat drugs that we already have. For the non-T2 [type 2] asthma, we still need a lot. It gets a bit more complicated than it was in that era.

Yeah. I agree with you. We stand on case definitions for everything, but we recognize that case definitions must be dynamic. They must be refined: what we call asthma, and congestive heart failure are really syndromes. Within that syndrome, we must have better approaches that give us insight.

A discussion on the future of emerging therapies and whether they will have an impact on improving lung function in patients with severe asthma.  

Emerging Therapies for Severe Asthma 

At what point do you think patients begin to seek care? We know care can be delivered at the pediatrician, at the allergist, at an urgent care center, in dermatology, and there’s a tremendous number of patients who go to the emergency room when they just can’t take it anymore. What has been your experience, Douglas?

 I see all of the above. The most recent study done 2 years ago shows that only 19% of pediatricians refer patients in the first year, who have severe atopic dermatitis [AD]. They don’t get referred soon enough, in our opinion. But I get a lot of referrals from urgent care, and some are from parents who go online and do their own research and say, “I’m tired of using topical steroid creams or being told that my child has persistent impetigo and is always given antibiotics.” I practice in the area with good pediatrics and people that appreciate our care. I see a lot of 3- to 6-monthers that are getting diagnosed early on. But on the flip side, we see Medicaid patients, and we’re the only Medicaid practice in all of northwest Georgia. We see a lot of patients who come in very late that don’t have that level of care at home. I saw a 15-year-old yesterday with severe atopic dermatitis who had never seen a physician for it before and finally was able to get on Medicaid. I saw her for the first time ever, so she was completely naïve to treatment.

The word needs to get out to our primary care on what atopic dermatitis is and that we have new, exciting treatments that can change lives, beyond topical creams. Get [the patients] into our offices early. We must educate our primary care [physicians] so they know what they’re dealing with. It’s not just impetigo and an allergy to soaps, even though those things can play a role. This is a more complex, multifactorial disease that we get to be the point on. We partner with rheumatologists because it can affect the joints in psoriasis. But here, they’re partnering with allergists and us. I don’t know if you have things to add to that. 

 I agree with Douglas. Patients come in when they’re desperate for answers and for relief. They’re usually in a flare, when their skin is insanely itchy, and they’ve exhausted the options and are wanting more answers. They’re tired and worn out. I’ve seen most of my cases are moderate. They have been suffering for too long. I’d like to think that our AD patients are being seen by dermatology providers, but the majority of them—let’s be real—it’s likely that primary care and pediatricians are diagnosing [more cases] and treating more of our atopic dermatitis patients.

 Susan, you’ve spent decades advocating for eczema and you’ve been president of the National Eczema Association. I’m sure you’ve heard a lot of stories. If you could speak about trying to help patients navigate their way: When they finally are looking for the provider that’s going to give them some expertise in this disease, how do you help them as an organization?

I agree with Douglas and Keri; patients are seen in urgent care clinics and emergency departments because they’re so desperate to get the help they need. Unfortunately, my biggest pet peeve is when patients go to an urgent care clinic and are given a 15-g tube of a topical steroid to treat whole-body eczema. There’s nothing that aggravates me more because those poor patients are left hanging. They become so desperate that they fight their way to get to a specialist. Unfortunately, we are bound by managed care rules and all kinds of preauthorizations and things where patients can’t get in. Patients become desperate enough to push their way in and offer to pay, self-pay, or whatever it might take. These patients are mismanaged or misdiagnosed in those urgent care [clinics] and emergency rooms, and often will be given a course of Prednisone, just to get them in and out quickly, or an injection of Kenalog, which is not good long-term management.

I do feel it is our job as dermatology providers to help educate primary care [physicians] and pediatricians because those patients can be managed in those specialty areas, but they need to have the toolbox to be able to know how to treat them appropriately.

 Yes, and there are school nursing associations that are other opportunities for care.

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Recommendations on educating primary care physicians about atopic dermatitis and the importance of early referral to dermatologists.  

Atopic Dermatitis: Early Referral to Dermatology Clinics 

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Researchers from the Strasbourg University Hospital in France confirmed that a third dose of messenger RNA (mRNA-1273) of the COVID-19 vaccine induced a serologic response in 49% of kidney transplant recipients with no response after the previous 2 doses.

Despite this, 51% of the patients did not develop anti–SARS-CoV-2 antibodies after the third dose, particularly those receiving triple immunosuppression.

Ilies Benotmane, MD, and colleagues conducted the study in response to low seroconversion rates in solid organ transplant recipients who received a mRNA COVID-19 vaccine recorded in earlier studies.

The team investigated the antibody response in kidney transplant patients who received a third dose of the vaccine, a recommendation made by the French National Authority for Health in April 2021.

Of the 159 kidney transplant recipients chosen for the study, all were required to follow up in the outpatient Kidney Transplantation Department of Strasbourg University Hospital between January 20, 2021, and June 3, 2021.

The study population was comprised of 61.6% men, and the median age for participants was 57.6 years. The median time from transplantation was 5.3 years.

Prior to receiving the third dose, participants were required to have a negative history for COVID-19 and SARS-CoV-2 antispike IgG levels less than 50 arbitrary units (AU)/mL on the day of the first vaccine injection and 1 month after the second dose.

Vaccines were distributed from April 9, 2021-May 12, 2021.

Investigators recorded anti–receptor-binding domain IgG responses after patients were administered third doses by using the ARCHITECT IgG II Quant test. Titers greater than 50 AU/mL were considered positive.

The third dose was administered 51 days after participants had received the second dose.

Prior to the third dose, the 159 kidney transplant recipients in the stufy reported IgG levels less than 50 AU/mL. Reports showed that 95 patients (59.7%) had no antibody response after 2 doses, and 64 patients (40.3%) showed a response below the positivity limit.

Roughly 28 days after the third dose, the team reported that 78 patients (49%) had antibody levels greater than 50 AU/mL.

Benotmane and colleagues noted that patients who had a weak response after the second dose were more likely to develop an antibody response after the third dose compared with those without an antibody response (81.3% vs 27.4%, respectively).

Patients who took tacrolimus, mycophenolate, and steroids to cope with the previous dose were less likely to develop an antibody response. Those treated with other regiments were roughly 2 times as likely to develop an antibody response (63% vs 35%).

The number of patients who did not develop antibodies (51%) narrowly surpassed those who did (49%). They believed this suggested a lack of immunity but did not suggest that third doses were ineffective.

“In conclusion, the use of a third dose of vaccine may be considered in organ transplant recipients,” the investigators said.

The study, “Antibody Response After a Third Dose of the mRNA-1273 SARS-CoV-2 Vaccine in Kidney Transplant Recipients With Minimal Serologic Response to 2 Doses,” was published online in JAMA Network.

Articles

Researchers report antibody responses in kidney transplant recipients and the impact of specific regiments utilized by select patients.









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COVID-19 Vaccines Induce Serologic Responses in Kidney Transplant Recipients

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Severe mental disorders had the highest odds ratios for the risk of mortality.

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Previous research has shown that COVID-19 can impact ocular health.

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Study Finds COVID-19 Virus Particles in Retinas of Infected, Deceased Patients

Research showed that the second dose of the COVID-19 vaccine was well tolerated by patients who experienced allergic reactions from their first dose.

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The FDA approved selexipag tablets for PAH in 2015.

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FDA Approves Selexipag IV for Pulmonary Arterial Hypertension 

Studies are needed to determine the best treatment regimen for these patients.

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Women with Acne Commonly Experience Depression and Social Isolation

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Black patients received different opioid prescriptions compared to White patients, even after clinicians were given additional patient-level data. 

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Racial Disparities in Acute Pain Management Not Linked to Treatment Preference  

The FDA noted the extent of the treatment effect of tenapanor is of unclear clinical significance, despite evidence of efficacy. 

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FDA Issues Complete Response Letter to Ardelyx for Tenapanor in Treatment of CKD

The biologic can now be used as an add-on maintenance treatment for patients who have struggled with former treatment and surgeries.

FDA Approves Mepolizumab for Patients with Chronic Rhinosinusitis with Nasal Polyps

Researchers note the severity of the disease significantly impacts patients’ sleep habits, medication intake, and general mental and physical health.

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Poor Sleep Quality Recorded in COPD Patients

Higher microbiome α diversity had an association with less T2D and lower insulin resistance in individuals without diabetes. 

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Looking Forward in Asthma Treatment

Non-Pharmacological Treatments for Atopic Dermatitis

Emerging Therapies for Severe Asthma

Atopic Dermatitis: Early Referral to Dermatology Clinics

COVID-19 Vaccines Induce Serologic Responses in Kidney Transplant Recipients