Biologic Treatment Considerations for Asthma During the COVID-19 Pandemic and the Upcoming Flu Season - Episode 2
Stanley Goldstein, MD:What are the issues with respect to quality of life in patients who have uncontrolled asthma? What does it mean for the patient? What does it mean for the health care system? What does it mean for the population at large?
Shahzad Mustafa, MD: When people are poorly controlled, there are two things that we really want to talk about. One is their impact on quality of life, and then two, is their functional risk of future exacerbation. So, quality of life. Asthma obviously can affect people, what they can do, exercise Giselle mentioned is a big part of it. TSo things they can do, you know, illnesses, school days missed of work. Asthma obviously can affect all ages. ,Iso if your child has poorly controlled asthma and they’re staying home from school, that affects your job. We’re in a very, very unique time right now with this global pandemic.I So it has huge impact on what you can dodo, and it has huge effects on the ability to, you know, school absenteeism and attending work for missed days.
Then if you’re having symptoms, you end up in places like your primary care doctor, your allergist, your pulmonologist, urgent care, and the ED. There’s a huge amountnumber of asthmatics that are receiving care in the urgent care and ED because they’re having symptoms, they’re having exacerbation, and they’re getting courses of steroids;, oral steroids, which, in the moment, is obviously necessarily, but we all know has its downsides. We don’t want to be complacent about to being okay with treating our asthmatics with multiple courses of systemic steroids in a year. Anywhere beyond one course a year represents poor control, and that gives us an opportunity to help these individuals, to help their quality of life and to decrease their reliance on steroids and future exacerbation.
Stanley Goldstein, MD: We’ve been talking about exacerbations. and Wwhat are the downsides?, Oobviously, the treatment with oral corticosteroids and the downside and the long-term effects of that. But, how would a health care provider recognize a person that is at risk of having these exacerbations or at risk of being poorly controlled? What are some of the signs that they could see within a history or an objective measurement that can pick out that patient and say, “I need to step up therapy in that patient.”?
Giselle Mosnaim, MD, MS: If you look at the number of courses of oral steroids in a year, Dr. Mustafa was talking about how if you have to go on two or more courses of oral steroids in a year, that is a concern for poorly controlled and high risk asthma. If a patient has to go to the emergency department, if the patient is hospitalized for asthma, those are all high risk and we have to pay special attention to our patients in this situation. Then there’s also the impairment of quality of life. If someone is missing a significant amount of school, that affects academic performance, and if someone is missing a lot of work, that can also put their job at risk. TSo there’s educational and economic concerns. It also can lead to comorbidities. If someone isn’t able to be physically active because of their asthma, it can lead to weight gain, it can lead to other issues. W So we really want to make sure that we talk with our patients and counsel them about these different risks and these different situations.
Shahzad Mustafa, MD: One more thing, we hear it right now. , Wwe hear a lot about health care costs, and at the end of the day, well controlled asthma is actually less expensive to manage for the health care system than poorly controlled asthma. . So that’sThat’s just one more thing, t. The bill, you rack it up when you end up in the emergency room and, unfortunately, hospitalized for asthmatics which continues to happen. That’s just one more factor, one more reason to really strive for getting our asthmatics under the best control possible.
Stanley Goldstein, MD: What are some of the objective measurements that a health care provider can do in order to help determine whether that person is at risk of having an exacerbation?
Shahzad Mustafa, MD:WSo we can start very crudely. We can ask people how often they use their rescue inhaler, albuterol. Typically, we say using it less than twice a week represents good control. Most albuterol inhalers, canisters, have about 200 doses in them. If you’re really well controlled, you shouldn’t be going through more than one in a year. So that’s a very crude measure of how often you’reare you reaching for your rescue inhaler. Then beyond that, we can certainly use peak flow. This is an interesting time with this global pandemic because it is more difficult to get objective measures of lung function like breathing tests, spirometry, pulmonary function tests, so if sometimes we’re using peak flow. But under normal circumstances, doing lung function testing I think is very important- spirometry, full PFTs, [Ppulmonary Ffunction Ttesting]. Then we also measure inflammation in the airway with a validated biomarker for asthma, which is exhaled nitric oxide. These are all opportunities to get objective measures of someone’s asthma, and for them to be in good control of asthma, you really want to hit all those criteria. If you’re missing any of those, that may be an opportunity to improve asthma care and improve outcomes.
Stanley Goldstein, MD: One of the things I would add to that is patients can do the Asthma Control Test, the ACT test. That’s a simple measurement that we all have available, health care providers, whether a primary care, internal medicine, allergist, pulmonologist, can have available for their patients. It’s a measurement of control. Just very simply put, if their total score, it’s five questions, if the total score is less than 20, it means they’re at risk of having exacerbation and they’re poorly controlled. We talk about, we all have electronic medical records, at least most of us at this point in time, there’s also a measurement called the ACQ, [Asthma Control Questionnaire]. It is an objective measurement that can be done. A lot of us don’t use it on a daily basis, it’s obviously spoken about in the medical literature, but it’s something else that can be used in order to help look at control.
Then I know we’re talking objective measurements, and I think, Giselle, you pointed out, or Shahzad, you also pointed out, lung function. Lung function is a fantastic tool for objective measurement of what’s going on. I know Shahzad, you just mentioned in this pandemic, a lot of us are not doing a lung function test because of the concerns of obviously exposure to the people and the other health care providers in that area. But peak flow is another objective measurement.
Transcript Edited for Clarity