Effective Strategies for the Management of Patients with Asthma

Important goals in the effective management of patients with asthma include achieving symptom control, maintaining normal activity levels, keeping pulmonary function as close to normal as possible, preventing exacerbations, and avoiding treatment-related adverse effects.

In an interview with Respiratory Practice Management (RPM), Cathy Vitari, RN, BSN, AE-C, a clinical research nurse at the University of Pittsburgh Asthma Institute at University of Pittsburgh Medical Center/University of Pittsburgh School of Medicine, discussed strategies for improving outcomes in patients with asthma, including making an accurate diagnosis, evaluating patients for coexisting conditions, personalizing therapy, and providing patient education to ensure adherence to prescribed treatments.

RPM: What are some of the assessments that need to be performed to personalize therapy for patients with asthma?

Ms Vitari: It is important to categorize a patient’s asthma since there are several different types of asthma. Pulmonary function tests are critical for evaluating how well a patient’s lungs are working. These tests help us to determine whether the issue is asthma, vocal cord dysfunction, chronic obstructive pulmonary disease, or a combination of these. We perform an exhaled nitric oxide test, which allows an indirect measurement of eosinophilic inflammation in the patient’s airway. We also order blood tests to check for eosinophil counts and elevated IgE antibody levels, allergy panels to determine whether there are any allergic components or markers of inflammation. In some cases, we may order chest and sinus CT scans. In addition, we use asthma control questionnaires.

There are several comorbidities that can make an individual’s asthma more difficult to control, so we also make it a priority to assess patients for these conditions so they can be managed accordingly. Some patients ask how these other problems are related to their asthma, and I explain that their airway goes all the way from their sinuses to their vocal cords, lungs, and esophagus, so it is important to address these issues to improve outcomes.

For example, gastroesophageal reflux disease (GERD) can cause inflammation in the esophagus, which, in turn, can trigger inflammation in the lungs. We ask patients with GERD to tell us how often they are experiencing symptoms and what types of medications they are taking. We may suggest that they try a protein pump inhibitor such as esomeprazole (Nexium) or omeprazole (Prilosec) to reduce stomach acid and relieve GERD symptoms. We also discuss some commonsense measures, such as sleeping with their head elevated, avoiding spicy and fried foods when possible, and refraining from eating 3 hours before bedtime. If patients do not respond to these measures, we refer them to a gastroenterologist.

Post-nasal drip can also play a role in exacerbating asthma, so we assess patients for this condition. We may tell them to try over-the-counter sinus rinses to reduce symptoms and, in some cases, we may recommend a nasal steroid spray. If patients are experiencing sinus issues that do not respond to these measures, we refer them to an ear, nose, and throat specialist.

In addition, if blood work results indicate that the patient has an autoimmune condition, such as rheumatoid arthritis, we refer them to a rheumatologist.

RPM: After these assessments are done, what is the next step in creating an effective treatment plan?

Ms Vitari: We use a shared decision-making approach. Unfortunately, I think there is a tendency for many providers to say, “OK, this is the issue. This is what we are going to do. Do you have any questions?” Then, they send their patients out the door. In our practice, we believe it is very important to involve patients in their treatment plans. We discuss the medicines they are currently using or have used in the past and ask whether they have been effective. We then provide them with detailed information regarding available treatment options, based on their symptoms and preferences.

RPM: Can you discuss the role of biologics in the treatment of patients with asthma?

Ms Vitari: Biologics can be very effective in managing asthma-related symptoms for some patients. However, there are several factors to consider when incorporating a biologic agent into a treatment plan, including patient preference.

Different biologics have different routes of administration, and providers must consider the patient’s comfort level when discussing treatment options. Reslizumab (Cinqair) is an intravenous infusion, which requires patients to travel to an infusion center for treatment. Mepolizumab

(Nucala) and benralizumab (Fasenra) are subcutaneous injections, which are also given at an infusion center. These 2 drugs now come in autoinjectors so that patients can give themselves the medications at home. Dupilumab (Dupixent) comes in a prefilled syringe that is self-injected. However, it is challenging for some patients to use a syringe to give themselves injections.

An additional factor that comes into play is the cost associated with biologic therapies and whether these agents are covered by a patient’s insurance. In our practice, I am responsible for obtaining authorization for biologics. If coverage is denied, we submit an appeal and often, a second appeal. The drug manufacturers have patient assistance programs that can help patients who cannot afford the costs of treatment, so we facilitate enrollment in these programs.

RPM: How important is patient education in promoting adherence to an asthma treatment plan?

Ms Vitari: It is extremely important. I am responsible for most of the patient education. Sometimes, patients are hesitant to tell the physician that they do not want to do something or follow through on something. My role is to explain to patients why the physician wants them to try a specific medication and then find out their concerns.

I show patients a model of an asthmatic airway. If patients have eosinophilic asthma, I show them a diagram illustrating how certain medications block eosinophils to reduce inflammation. The challenging part is that I have a limited amount of time during the in-person appointment to provide all the necessary patient education. Oftentimes, I call patients on the phone to follow up with them and provide further information.

It is also important to assess how they are using their inhalers and then reinforce correct techniques. We use a device called an In-Check DIAL that measures a patient’s

inspiratory flow, because different inhalers have different inspiratory flow ranges that must be achieved for maximum efficacy.

Most of the patients we see in our practice have severe asthma and are on more than one medication. I stress how important it is for them to be compliant with all their medications to control their symptoms. I tell them that they need to take their controller medications consistently for the biologics to be effective. It is also necessary for them to use their controller medicines as prescribed to obtain insurance approval for the biologics.

If they are not filling their prescriptions for a biologic, I try to find out why. Is it a matter of cost? Is it a matter of not liking it? Are there some fears or concerns about it? I help them work through all these issues.

I think the most important thing is to get patients involved in their care. Using a shared decision-making approach fosters medication adherence and helps patients develop accurate expectations regarding outcomes.

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