Biologics Treatment Selection in Patients With Moderate-to-Severe Asthma - Episode 15
Experts discuss the use of biologic treatment in asthma by primary care physicians vs pulmonology specialists as well as overcoming barriers to biologic use through patient and physician education.
Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: Let’s switch gears to barriers in the use of biologics in clinical practice. Dr White, do you see any trends or utilization differences, with the penetration of therapeutics, into the lives of patients with severe asthma, moderate to severe asthma, eosinophilic asthma, and difficult-to-treat asthma, among primary care providers or physicians vs the specialists?
Andrew White, MD: In terms of thinking about how you titled this section, the barriers, I haven’t seen much of a trend of use in primary care physicians for biologics. There are multiple reasons for that. There’s a lot of what we’ve outlined, how complex it can be to decide what agent you might start a patient on. There’s going to be a barrier there. There’s definitely going to be a barrier in the ability to get insurance approval because these require some specialization in terms of the office staff and nursing staff shepherding it through the approval process. A lot of primary care practices may not have that infrastructure built in. I haven’t seen a big uptake in my area with primary care physicians using respiratory biologics.
But what I have seen is a lot more willingness to use these biologics at the point where it’s determined that they’re necessary. Because previously, 5 or 6 years ago, there was this sense that you’d start 1 or 2 of your worst patients on this and see how things would go for them, if these made a big change. In the allergy and immunology space, I definitely think we’ve seen a lot of comfort, recognizing that once a patient is poorly controlled, we need to think about these biologics. We have a lot of comfort using them now. They’re very safe. They’re very effective.
The other group I’ve seen a lot of uptick in is with our pulmonary colleagues, who also see a lot of asthma. Before these newer biologic agents, they may not have been using omalizumab in their practices for a variety of reasons, but now they’re much more willing and comfortable using these. It’s the same idea, reserving it for not just the very worst of the worst or the steroid-dependent asthmatics but also starting to more routinely consider this. At my institution, Scripps Health, it’s been great. We have a lot of sharing patients. Patients may have some confusion about what might be the best biologic, so they consult with us and still have a lot of their care directed by pulmonary. Those are the trends. I’ll bet it’s different in different parts of the country. Dr Chase and Dr Siri, I’m curious if you’ve noticed anything or any trends in your own practices.
Nicole Chase, MD, FAAP, FACAAI, FAAAAI: Overall we’ve seen similar trends with primary care providers. There’s a better awareness among primary care providers, who know that patients are coming and asking about these medications. Some have been talking with family members or friends who may have exposure to them. Others have been seeing television commercials of individuals breathing better, and wondering how they can be in that same category. The uptake has been higher with pulmonary colleagues over time. I hope they’ve learned that everyone in allergy is very friendly. A call to inquire about whether this patient is a good candidate for a biologic is much more common than ever before.
Dareen D. Siri, MD, FAAAAI, FACAAI: There’s increased recognition from allergists that we’re allergy, asthma, and immunology experts. We’ve seen a lot of good collaboration with our pulmonary colleagues as well as our primary care doctors. Primary care has so many challenges, such as limited time. It’s helpful that there has been an increased movement toward biologics. There’s more understanding and education into what’s considered uncontrolled, what we accept as a number of exacerbation rates and corticosteroid systemic burdens over time. It’s been really helpful.
Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: A couple of weeks ago, I had a patient come in on a follow-up with his wife and son. I thought, “They must be on their way to go shopping or to a restaurant.” It was the son who said, “Thank you for giving me my father back, because now I can play sports with him. He can breathe.” My patient was nodding; he’s a man of a few words. Those scenarios validate why we’re doing this and pushing the science to get better outcomes. Better outcomes, but not at the risk of worse adverse effects.
Dr Chase, earlier you described that give and take, the benefits and risks with the corticosteroids. With that in mind, what can be done to increase the availability of biologics in scenarios where patients need them and suffer from the deleterious effect?
Nicole Chase, MD, FAAP, FACAAI, FAAAAI: That’s a great question. This is on all of us to educate our patients right off the bat. I love to tell patients, “Don’t worry.” I always have a couple of backup plans if we think they’re going toward the point of needing more assertive therapies in terms of biologics. That education is great. With settings like this, we all get to talk together, engage one another, learn from one another, and think more about how we can better educate our colleagues on the fact that these biologics exist. They’re there for us to use, and we wield them all the time. Let us be helpful to you if we can.
Access has always been an issue. For many individuals, access can be getting to a provider in an area that’s within a reasonable distance. We’ve seen some uptake with telemedicine with the pandemic, and that’s been lovely. But for an issue like asthma, we sometimes need to see patients in the office. However, all these biologics now, with the exception of reslizumab, can be self-administered. That’s huge. That’s what patients want: to take medication in the comfort of their own home, on their own time, knowing that there aren’t safety concerns about it.
With this group here, we’ve gotten very quickly comfortable with biologics being another step in the armamentarium we use to treat patients. We look at someone as they walk in the door and think, “I’ll bet they’re going to need a biologic at some point.” We’ve all done that. Now we have lots of years of safety and efficacy data. Hearing stories from patients validate that this was the right decision to make the right approach.
Finally, there’s the overall thinking about being part of the conversation. We need to let others know that this isn’t a field that’s stagnant. We’re getting new breakthroughs all the time. We need to encourage research further on asthma as a main issue for individuals in the United States and worldwide. There are even more to come. There are barriers, but there are lots of reasons to be excited about the future of asthma.
Transcript edited for clarity