Asthma healthcare providers should consider other treatments for severe asthma besides the regular use of oral corticosteroids and conduct testing to better diagnose asthma severity, according to a new article.
"We felt strongly that, before regular use of oral corticosteroids, because of the numerous complications with their chronic use, that other medical interventions should be considered related to the patient's asthma phenotype," says Bradley Chipps, MD, an allergist, president of the American College of Asthma, Allergy and Immunology (ACAAI), and coauthor of the article, published in the Annals of Allergy, Asthma & Immunology.
Regular or high doses of oral corticosteroids should not be the first point of treatment—for multiple reasons, Chipps says. “We use doses that are too high. There is very little evidence that doses over 60 mg to 80 mg a day are effective, and there is a very poor understanding of the downside of using two or more doses per year. That definitely leads to a greater risk of hip fractures, bruising, and elevated blood sugar.”
It is very important for clinicians to fine-tune their asthma management strategies and “make sure we use the least toxic drugs to control asthma, and get the right drug to the right patient,” Chipps said.
Recommendation: Perform asthma phenotyping sooner
To determine the best methods for diagnosing asthma and the use of various treatment options, including brachial thermoplasty, a roundtable meeting of seven asthma experts reviewed select literature. “Participants acknowledged that the body of evidence needed to develop strong guidelines for the use of newer biologic therapies or bronchial thermoplasty is limited,” the authors wrote. “However, guiding principles for practicing clinicians could be derived from available clinical trial evidence, experience in practice, and clinical logic.”
The panel concluded that asthma phenotyping—determining the clinical characteristics of asthma—should be carried out at diagnosis, and not after the patient’s condition is severe. “Our hope is to prevent potentially poor outcomes before asthma symptoms worsen,” they wrote.
Alternative treatment options
Bronchial thermoplasty, which delivers therapeutic radio frequency energy to the airway wall, was presented as one alternative treatment option for severe asthma. A five-year follow-up of patients in trials using bronchial thermoplasty showed a sustained decrease in exacerbations, decreased health care resource usage, and no further decline in lung function, the authors wrote.
“Overall, bronchial thermoplasty has proved an effective therapeutic option (in addition to macrolide antibiotics and OCS, which can be considered under certain circumstances) for patients with a non-TH2 type inflammation asthma phenotype,” the authors wrote. “Furthermore, bronchial thermoplasty has shown similar efficacy in patients with other asthma phenotypes and airway smooth muscle hypertrophy.”
The panel also said that clinicians need a better definition of severe asthma, and agreed to the following definition: “asthma that, despite patient adherence, requires high-dose ICS plus LABA and/or additional controller medication or requires oral corticosteroids to prevent it from becoming uncontrolled or that remains uncontrolled despite this therapy.”