Biologic Treatment Considerations for Asthma During the COVID-19 Pandemic and the Upcoming Flu Season - Episode 3

Over and Under Diagnosis of Asthma

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Stanley Goldstein, MD: I think we’ve been talking about uncontrolled asthma. I think there are two important issues when you think about uncontrolled asthma.. You may talk about the difficult-to-control asthmatic, and then you may talk about the uncontrolled asthmatic. As we here hear today, Shahzad, Giselle, and myself, see patients that are referred to us for asthma, how often do you see patients that are either underdiagnosed because of their asthma, or may be overdiagnosedover diagnosed? Maybe they don’t have asthma, but someone thinkgs that they do, and they keep getting medications pushed upon them, and even up theto dosages of oral corticosteroids. What are some of those types of patients that you would see in your practice?

Giselle Mosnaim, MD, MS: In terms of the overdiagnosis, I do see some patients that have vocal cord dysfunction. These are patients that don’t have asthma, but their vocal cords close when you want them to be opening. These patients exhibit symptoms of shortness of breath, and for these patients, they often get prescribed repeat courses of oral steroids, which are not indicated for the treatment of vocal cord dysfunction. There are other patients that have vocal cord dysfunction and asthma, so that also, there’s some gray lines there because are you treating the vocal cord dysfunction? A, are you treating the asthma? A, are you treating both?. Also, patients with gastroesophageal reflux disease. We have patients that have cough due to gastroesophageal reflux disease, and that is being treated as asthma when that is not the case.

Then there’s also the comorbidities of allergic rhinitis and sinus disease. Many of our patients that have sinus disease also have asthma, and you’re trying to sort out are these difficulties breathing from the upper airway or the lower airway?. Many times when you treat the upper airway, when you treat their allergic rhinitis with intranasal steroids, or you treat their sinus disease, their asthma does improve. SoSo, you’re really trying to sort out these different symptoms.

Stanley Goldstein, MD: We also speak about the mimickers of asthma. You spoke about vocal cord dysfunction. Are there any other types of patients that you would say have a certain type of other disease process going on that may mimic asthma?

Shahzad Mustafa, MD: Yes, it was touched upon very nicely. One of the most prominent symptoms of asthma is cough, and cough can be caused by a myriad of other things. But allergists always focused on the one airway hypothesis, the upper airway and the lower airway. So allergic rhinitis, sinusitis, can lead to cough. Reflux, gastroesophageal reflux, vocal cord dysfunction has been touched upon. Depending on the setting you’re in, if you’re taking care of adults and there’s multiple comorbidities, you always have to think about cardiac disease also, and you don’t want to miss that as an allergist. WSo we have to work through this.


Asthma can certainly be overdiagnosedover diagnosed due to mimickers, and I think it can also be underappreciated at times, where individuals are under-reporting symptoms, but they’re actually having more significant asthma than they appreciate. I think this goes back to, again, the importance of getting objective measures, trying to measure lung function. The guidelines would say whether it’s somewhere with asthma or it’s COPD [Chronic Obstructive Pulmonary Disease] emphysema. You would like to have at least one recorded lung function testing on record at some point. Again, the importance of objectifying people’s asthma to try to understand how they’re doing and then to move forward with the right therapiesy.

Stanley Goldstein, MD: While you’re talking about mimickers of asthma, and you were talking about the adults, Shahzad. , I just want to talk on the pediatric side because that’s where I came from. You definitely should think about a foreign body in very young children, you may think of other diseases such as cystic fibrosis in young children, even aspiration in young children. So, yes, that’s why objective measurement is important. In young children, you don’t have that tool of objective measurement as well, and that’s why it’s important taking that good history, putting it together as a puzzle and piecing together obviously response or no response, courses of steroids. It’s important to be aware of that in the health care provider.

When you think about health care providers overall, and we know that we are referred difficult patients, one of the areas, Shahzad, you pointed out is those patients who are undertreated. Often, I remember patients coming in saying, “Ooh, I’m using my albuterol often.”, and from their history, it sounds like they may have severe uncontrolled asthma. If you take the history appropriately, do your objective assessments appropriately, see what they’re taking or see what they’re not taking, find out pharmacy records; in this day and age with electronic medical records, it’s very easy to see if patients are filling their prescriptions and looking at all these surrounding parameters because they may have uncontrolled asthma, but there are specific reasons that you could improve their asthma control by putting them on more appropriate medications, dual controller, even now we’re talking about triple controller in certain asthma patients, and making sure they’re being adherent and using their inhalers correctly.

But at what point, I think as a group we should counsel or help our primary care physicians in deciding what are those types of patients that should be referred to the specialist, allergist or pulmonologist? What are your thoughts about that?

Giselle Mosnaim, MD, MS: I can chime in, and Dr. Mustafa, if you also have additional thoughts. If a person has multiple ED visits, so two or more ED visits a year, or if a person has a hospitalization for asthma, then that’s a good time to refer to a specialist. If you think that the person needs counseling on environmental triggers, so you’re thinking that it would be good to do allergy skin testing for environment allergens and counseling on those triggers, that’s a great time to refer to the allergist. There’s also the option of allergy immunotherapy for those patients. If you have patients that you think may not be taking their medicines correctly, so either they’re not taking them because they don’t think that they need them or they forget or other reasons, or they’re not taking them properly and you need some extra counseling on management for these patients, whether it be how to take your medication, when to take your medication, whether it be self-management on other issues, whether it be developing an asthma action plan together, that we go over together, these can all be reasons to refer. And also, if you’re concerned about comorbidities, t. Thehe allergist can be very helpful in examining whether it’s asthma, whether it’s asthma plus allergic rhinitis, GERD [Gastroesophageal Reflux Disease], other issues. TSo that’s a number of reasons.

And also if you’re considering a biologic, it varies across the United States. At our particular health system, the only specialty that administers biologics is the allergist immunologist. We’re very comfortable with administering injectable therapies, we’re comfortable monitoring anaphylaxis. This is something that we do. SoSo, we get referrals from all different specialties for this service.

Transcript Edited for Clarity