While the typical symptoms are unchanged, asthma diagnosis is complicated – and patients are commonly misdiagnosed. Allergist and immunologist Monica Tang, MD, discusses keys to distinguishing asthma from other disorders; when certain tests, such as pulmonary function testing, are useful; news on drugs, such as Spiriva and Singulair, as well as biologics; the importance of lessening steroid dependency; and which patients might benefit from allergy immunotherapy. Bonus: what to tell patients interested in alternative therapies or clinical trials.
um And so I was going to take us through some updates on asthma, which actually there are quite a few of my slides, old ones. Okay, so the learning objectives for today's talk first, just going through some clinical pearls um like pixie was mentioning, I attended the severe asthma clinic at UCSF and so there are some key signs and symptoms, key things that I'm seeing in my differential diagnosis. And then some questions I think that had come up about whether to obtain spectrometry or allergy testing and who that would be good for um to do so we'll talk a little bit about that. Um And then um we're going to spend the bulk of our time talking about the 2020 focused updates to the asthma management guidelines um that were published by the N. A. P. P. N. H. L. B. I. Um groups since they actually do have quite a bit of difference from the previous guidelines which were made in 2000 and seven. So 13 year gap meat meant there were a lot of changes that were made. So first going through those clinical pearls, So I wanted to frame it in terms of a case. So I got a 55 year old male who comes in and he says he's had worsening shortness of breath, coughing, wheezing, chest tightness, especially when um walking outside in the fall. He said he's had asthma as a child and he thinks he has seasonal allergies as well, an exam. You notice he doesn't have any wheezing, but he does have a prolonged exploratory phase. He also has some pale swollen turbulence and a pretty hippo nasal sort of congested sounding voice. So what would be your next steps? Does he need? Is this a guy who needs pulmonary function testing? Does he need allergy testing? Would that be helpful or relevant for him? So, first off key signs and symptoms um, that um, you know, pick up so the cardinal symptoms for asthma are the ones that I noted in the case. So shortness of breath, coughing, wheezing and chest tightness. And um, you know, a lot of the guidelines now define asthma by a history of respiratory symptoms that vary over time and intensity with reversible airflow limitation. That being said this sometimes actually kind of challenging to make sure somebody has diet asthma. And I think this came to attention. Um, I remember this journal article coming up I think in 2017 it was published in Jama that essentially they randomly called patients are randomly called adults, I think in Canada. Um, and so they got about 600 adults who had had a diagnosis of asthma in the last five years. And then they took them through um doing a lung function testing and then actually tapering medicines and then having a pulmonologist take a look at them and saying to confirm or not whether they had asthma, about 33% of them had no evidence of current asthma. Um and 87% of them were on meds. So a lot of patients were able to come off of the meds that they were prescribed. So making sure someone has asthma is definitely worth doing. Especially if we talk about this, but especially if things don't quite make sense, it probably means it doesn't make sense. So for this patient or patient's in general, one of the questions that um I was sent before the presentation was. So we have these patients they have a past history of asthma or childhood asthma but they haven't ever had PFT S as an adult. So do they need PFT s? And what if we don't know if they've ever had PFT s and we can't get the records from before? What do we do with that? So on the left here, I'm showing that we now know that asthma is sort of a heterogeneous um categorization that has a bunch of different peanut types and ended types in it. So there are different types of asthma. So it honestly depends. Um you know, natural history studies have shown that there is a subgroup of Children, especially who are less than six year old years old who have wheezing um just with borrow your eyes and sort of never get asthma. There are patients who do have more persistent symptoms and develop asthma. They tend to be a little bit more a topic. So that might be one, you know, um thing to help um define, but it's not perfect. Um people who tend to have symptoms as adolescents tend to persist into adulthood, but again, it's like I said, not 1, 2, 1, Perfect. And then there is adult onset asthma as well. So I think it really depends on the goals and on the patient. So if they have a history of asthma but have mild or even no symptoms anymore, yeah, I don't know that getting a PFT really makes sense. It is necessary to manage them. But if they do have persistent asthma symptoms, I typically do obtain a PFT and you know, maybe not only setting up the covid 19 pandemic, but now maybe once things are calm down and doing aerosol generating procedures is not as big of an issue anymore. Um, but it is always nice to have a baseline is what I tell patients. So, you know, if they feel like their asthma is pretty controlled on the medications that they're on currently, that's great. But we all know that pFT s they have percent predicted that are based on, you know, age, gender, race, ethnicity matched cohorts. And so for an individual patient, it's hard to know whether whether what they're noticing today is different than what they were at a year ago, unless you have a baseline measurement to start with. So it's always helpful even if someone is doing pretty well to have an idea of what their baseline is. So that if they had worsening symptoms in the future or worsening asthma, um, you can actually measure and see if there are some objectives, findings of careful obstruction. So then another case. Um so this is a 20 year old woman who has a history of Asthma who comes to the clinic and she's having worsening wheezing despite taking inhaled corticosteroid inhaler for the past few months. The squeezing is more pronounced with inspiration, doesn't respond to bronchodilators, and she points here, she points her upper chest when she describes the wheezing. What's the next best step does this patient have asthma? Probably not. Um so this is probably a paradoxical vocal full motion disorder, which is the new name that the, you know, certain doctors have given vocal cord dysfunction because they said it's not always the vocal chords and it's not always dysfunction. So they decided to rename um, the entire disorder but same concept. Um and so they're, like I said, some of those, like he red flag symptoms that I look for for this sort of diagnosis is patients who point here, when they point up here, I'm like, that's not where asthma, you should be able to hear things in asthma up here should be down in your airways, it should be you know on expiration. Um And so and it should respond to bronchodilator. So if all of those things aren't true then what you're describing probably as it isn't asthma specifically. And the hard part is that these diseases can often be co morbid. Um You know the case presentation they gave was more stereotypical one. It tends to be younger women but it can present and different ages and different genders uh that I've seen as well. So another common thing that I find or diagnosing patients with asthma. So this is a 338 year old woman who has four months of persistent non productive cough after a cold. It's worse with cold air, strong fragrances and talking. And she describes that she gets this tickle in our throat and then she has to cough. You've tried everything, you've tried Flonase PriLOSEC albuterol cuba or nothing is helping. Um You've given her you've done a chest X. Ray of chest C. T. Pulmonary function testing. It was all unremarkable. So what is the most likely diagnosis and what do you do now? So we're actually finding more and more fake patients have what is now called cough hypersensitivity syndrome. Um And this is a clinical syndrome that is characterized by troublesome coughing often triggered by thermal mechanical or chemical exposure. And so the classic history is that this onsets after a viral you or I. Um And then it's triggered by a lot of irritant things so changes in air temperature, strong smells. Um Dry foods, talking, laughing, singing. They often described that urge to cough in there um Like they get a global sensation or a tickle or an itch in the back of their throat and then they just cough and cough and cough. Another key. Um. Um Symptom that I often find is that patients said that they'd never cough while they sleep at night. Coffee never wakes them up at night. It's only during the daytime they start to talk and then they're cough comes back again. Um So this is from any damn um working up a chronic cough. And so it describes first steps taking you know a medical history and clinical examination for obvious causes potentially doing a chest X ray and spectrometry and then going through the most common causes of chronic cough. So asthma, reflux and Reiner sign. You say this these are the steps that I think we've taken for a long time. Um potentially doing some more investigation to exclude rarer causes like R. S. C. T. Scans, bronchoscopy if needed. But then if all they have is all you're left with is a cough. Maybe the issue is the cough itself. And so you really have to knock out that cough. And there are a couple of therapies and more actually coming but that have found some benefit in these patients. Um So they talk about low dose slow release morphine which I'll be honest I've never prescribed in the United States. Um But is in a lot of being sort of like global um recommendations. Um In the United States I've used gabapentin or pregabalin usually gather pension and then I have refer patients to speech therapy to do sort of cost suppressive therapy. Um And the you know certain doctors also even have a bunch of other things that they'll potentially like. I had them to inhale by two came from patient that she said worked like a charm. So they have sort of tools to help these patients who really like the most notable thing about these patients as they just, they really described the cough. They have less of the wheezing shortness of breath, chest tightness, all those other characteristics there. Like I just can't cough, I can't stop coughing. And um the last patient that I had been diagnosed with this, she just like she couldn't make it through her exam or her. Um it was actually a video visit every three words I think she coughs. Um So it was just a lot of coffee and I was like yeah something is triggering this cough. She's like yeah and if I stop talking, the cough goes away. It's just when I talk. So um it can be pretty um but clinical history can actually be pretty telling. So like I was saying the biggest thing that I've noticed in my asthma clinic is honestly I don't have to work too hard usually to diagnose with patients with asthma. Asthma has a pretty good clinical history and um pretty good, you know, um testing in terms of lung function testing to help diagnose. So if someone has a typical features, if they are needing a lot of step up therapy or they're just not responding to therapy, then I usually I'm like I got to rethink this diagnosis of asthma because I'm I'm not sure that's the correct one. And if they have persistent symptoms and their lung function is completely normal, then I'm like, we also have to make sure that there isn't something else going on as well. So in these cases I'm often one of the first steps I often do when I get patients into the clinic is do lung function testing. Um I'm often characterizing their asthma, which we'll talk a little bit about um sort of their markers of inflammation to see if that could be a reason why they sort of are poorly controlled. But what we do know um about treatment of asthma sort of before the updates was that they we did recommend sort of avoiding triggers which included allergens, smoke Um making sure they get booster vaccinations. We should probably include COVID-19 vaccination to this, although I don't know that it's particular to patients with asthma, honestly particular to anybody. Um and then treating any co morbid conditions as well. So I brought this up only to sort of frame our discussion on allergens and spoke specifically. Um Oh one other question I think um I was asked was your patient self screen for asthma control with a questionnaire or be a discussion in the clinic. And if you have them self screen. Is there a format you found most helpful for patients? Um I do in the allergy immune oncology clinic. We do scream with the asthma control test which is a very easy, readily available tests that you can find essentially it asked in the past four weeks if they have any activity limitations or um work disruptions, work school disruptions, if they've had shortness of breath symptoms waking up at the night, rescue medication use and how would they rate their asthma control? And a score grade of the 19 indicates well-controlled. Asthma score less than 16 means that they have poorly controlled asthma and I do find that that can be helpful. Um You know all the format that we do it in our clinic is that patients are actually handed the questionnaire by the front desk if they say that they're here to see um somebody with asthma or if they can see that it's been um given before in the past. Um And um we also use it for our allergy immunotherapy injection patients. So patients who are coming for allergy shocks um we don't want to give them an allergy shot if their asthma is poorly controlled. So we actually send it to them the day before or the day before are the days before the clinic appointment. Um So that they can fill it out. And if they have poorly controlled asthma were like you already are showing signs that you should probably skip your shot this week or this month because um you're showing that your asthma's too poorly controlled for your shot itself. Um So it can be very helpful as just you know, overall screen. And I think sometimes patients aren't necessarily the best perceive er of their symptoms and so the overall say my asthma is doing great but when they actually take it apart by these specific questions um then you know you can find more in depth why their husband who might not be doing as well as I think it is. Um So I think it could be helpful especially in a primary care setting. I imagine that it would be nice to have sort of a quick go oh this person looks like they're pretty doing pretty well and you know, follow up on a few questions, make sure they don't need refills etcetera etcetera. But at least having an overall glimpse um I think would be potentially helpful um in my personal asthma clinic. I actually don't use a self screen. But that's because it's such a sub specialized clinic that I'm going to go into this pretty in depth. So I don't use a questionnaire itself. So I think if you to that to that credit if you're like having a specific asthma clinic appointment you might not necessarily need the screen because you're going to ask them all the questions about asthma anyways. Um But I do think it might be a helpful adjunctive thing that could be worked into your clinic if if it is possible. Um The next thing that I want to talk about was allergy testing. So what role does adult allergy testing playing someone with asthma? So first I wanted to talk a little bit about what allergy testing is. So it's to test test specifically for allergy antibody or what's called I. G. E. Or immunoglobulin E. And so the test really serve as a confirmatory diagnostic tool because they reflect sensitization so that you've made an allergy antibody and don't buy themselves make a diagnosis of allergy. So to diagnose somebody with allergy, I have to have a history and a confirmatory allergy diagnostic test. Um So for patients who have a history consistent with an allergic reaction, then I do send allergy testing. It can help identify what triggers that I need to direct and optimize their therapy against. And if someone is doing allergy immunotherapy, so we'll talk a little bit about this. But there's both shots in now. A few sublingual tablets, I do have to confirm which things they're sensitized to in order to prescribe them the appropriate therapy that being said. You know, doing adult allergy testing isn't necessarily completely necessary in every single patient. So for example, a couple of scenarios I can think of as you know, you have somebody who has pretty well controlled asthma and they're like, I've gotten tested before and I know I'm allergic to dust and pollens. Um, do I really need to repeat their testing? It's true. Most patients tend to continue to be sensitized to what they were sensitized to before. So if they already were tested before, they sort of have an idea of the allergen avoidance, it doesn't seem to be triggering their symptoms. So it's pretty well controlled. Yeah, allergy testing probably isn't super necessary in that patient. But for someone who's like, yeah, my allergies seem to be triggered by these specific things, but I'm not sure if it's cats or dogs or pollens in which pollens in which seasons I should be taking, medicines are stepping up therapy because I'm not sure what I'm allergic to. Then. I do think allergy testing as an adult can be useful, especially when patients with asthma. So a little bit more about allergy testing because you may have a little bit of the familiarity. There's actually now two ways we can do allergy testing. One is via skin protesting and then the second is with specific IgG antibody. Um So which is through the blood. Um The different tests have different test characteristics. Um And it does depend on the type of allergen. So in general we think that skin protesting is probably more sensitive but specific allergy antibody in the blood is more specific. Um That being said for inhaling so arrow allergens, trees, grasses, weeds, cats don't estimates coverage. Mouse red horse, rabbit, guinea pig is our typical panel. Um Skin's pretty equivalent to blood. Um They match almost perfectly about 80% of time sense to be specificities like ranging 80 90%. That's pretty well either test. But for food the testing is actually not very good at all. So without any history at all, your specificity is only 50 50 50%. So you're actually no better than a flip of a coin. So someone doesn't have a history that sounds concerning for an I. G. Needed food allergy. We don't recommend doing food allergy testing for this reason because you'll get answers that don't make any sense. And then for venom and drug um a there are only specific venoms and drugs that we have good testing for. But in general the blood testing actually didn't do very well at all. And so we do have to do skin testing for the most part for these patients. Another couple of things just about the testing so skin protesting um they do have to have clear skin. Um It's where we test is usually the upper arms or the upper back. Um And so I guess no lower arm upper back. Um And that area needs to be uninvolved, so not have terrible eczema in those areas, not have a huge tattoo that takes up the entire area. Um So if that's the case, then we might need to do blood testing. They also do have to hold anti histamine type medicine that would block the histamine response. And so if they are not able to do that, then maybe blood testing might be a better approach. So you might see us if you send someone to us do one or the other and that might be some of the talking that we're doing to with them about which test we want to send. Another quick thing that I often get asked by people is what what relevance does the size of the wheel, how big the bump is or how high the allergy and a body? What does that mean? Actually doesn't tell us how severe the reaction is at all. So a lot of people tell me I have very severe allergy based on my number doesn't quite work that way. It does tell us how likely you are to react to that thing. So if you have a 52 dust mite and a 25 to trade than both of them might cause sneezing, runny nose congestion using all the same things, but you're more likely to cause it's more probably the dust mites causing more issues than potentially the trees. Okay, next, what recommendations do you have to patients for wildfire smoke exposure? Um The american lung Association actually had some great recommendations for this sort of borrowed from them. So to do as much preparation as you can, sort of beforehand. So making sure they have enough supplies, food, water medications and we'll talk a little bit about medications about maybe different approaches they could use to their medications based on the new guidelines, um that they would have enough on hand to sort of step up therapy if they needed to in the setting of um wildfire, smoke exposure or honestly anything that would be triggering the asthma. Um If possible, designating a clean room that is sort of sealed off and may have an air purifier with a HEPA filter can be helpful, but if your patients don't have access to that, then at least a clean room is nice. Um If possible, having some sort of protective equipment, like an N 95 if they do have to then drew outside of their home, but to minimize that much as much as possible in the first place and then if they live in a fire zone, making sure that they have things prepared for evacuation so that they have sort of their supplies ready to go. But they have their prescriptions, their insurance cards, everything they would need um if they needed to leave their home in a hurry during obviously to monitor air quality and local news and weather reports, so they're sort of savvy as to what is going on. Um And in general to stay indoors and protect that indoor air. So if there is quite a bit of smoke in the air, they can add damp towels along doors and windows. Um to try to re circulate any air, especially in the car. For example, you can usually change the settings for that um in the home as well if they do have that happening and as a reminder not to burn anything in the home. Um Also a thing that does sort of impact air quality in the home is vacuuming, actually stirs a bunch a bunch of the, you know it actually works in for example, dust mite, allergen quite a bit so not to vacuum sort of in right when they're worried about their their air in their home and then afterwards there's still quite a bit of particulate matter in the air and so it will continue to wear protection and try to reduce their exposure from dust and sit which is going to um sort of increase their risk of exacerbation. Okay so now I was going to go through the updates on asthma management so I'm sure you're all familiar with The 2007 expert panel report Um three which had guidelines on asthma in this um figure. Might look very familiar to you where it has different steps depending on um they're intermittent, mild, moderate severe, persistent asthma. So 2020 came along and they used that same step um figure. So it looks very similar but there are a few very specific things that they have added to that to this in terms of what is preferred as sort of first line management. And so we're going to step through each of these and sort of go through the evidence for for each of them. So first um you can see that step one they actually didn't examine at all. So still pure and sabbath. So you're very mild asthmatics just tell them to take as needed albuterol. But step two there is an option for daily low dose I. C. S. NPR. And civil which is what we probably already do. Um But there is also an option for pr and can comment I. C. S. And Savage. So this the rationale here is that There was quite a bit of exacerbation risk even in patients who have very infrequent citizens. So about if you look at the c. d. c. about 45% of patients with asthma say they've had an asthma attack in the past year. So that's almost everyone you know almost half of them which means that we're doing good. We say as long as they're not having to exacerbation a year they're not considered persistent. But that's still quite a bit of morbidity associated with asthma. Um And we know that traditional daily inhaled corticosteroids help. But in general adherence is pretty poor. And so this study was one that showed the benefits and it was called the Beckham method Zone plus salbutamol treatment or the best study. And so essentially you can see here in the figure they compared as needed combination therapy. So it was as needed I. CS plus saba regular Bet Climate zone therapy. So that's daily Beckham with his own daily A. CS plus pure in Sabah regular combination therapy so that's daily I. CS plus daily Sabah. Um And then as needed I'll be wrong. Um Which is just parents abba and this is a Kaplan meier curve of patients without asthma exacerbations so declining is bad. You don't want them to have more asthma exacerbations. You can see that as needed. Combination therapy and regular Beckel methadone therapy actually were like overlapping lines. Um But did do a lot better than as needed albuterol therapy. So using I. C. S. Plus saba reduce exacerbations compared to Sabah alone and generally was able to do that reducing the dose of I. C. S. Compared to daily I. C. S. So how do you actually do this in practice? Um so they recommended doing 2-4 puffs of albuterol filed by their dose of um uh inhaled steroid. So in the study for example was 82 to 50 micrograms of beckley methods Own every four hours as needed for asthma. Um Right now unfortunately those do need to be in two different inhalers because there's no combination albuterol plus I. C. S. That's in the United States but maybe there will be in the future. Who would this be good for? Um This would be good for patients who um sort of are cognizant of their symptoms. So people who have low perception of their symptoms like I'm always doing fine. This might not be the best option for people who have overly high perception of the symptoms. They're always really they have asthma might also not be a great patient for. But patients who feel like they often are able to tell when their asthma is triggered and can take a medicine at that time. Um This might be a helpful medicine. Um It also probably is not good for people who have persistent symptoms. So if you're having pretty regular symptoms where you'd be using I. C. S. Hasaba pretty much every day or twice a day. Then essentially you're doing you know the top half of this. So might not be a good option for you. Um But for people who have intermittent symptoms who really might be able to some of their therapy accordingly. This is a nice adjunct and honestly is how a lot of patients were taking their medicines to begin with. And now we just have some data to back them up on it. Um They do recommend doing the concomitant I. CS. Plus SaBA because as you all know the I. CS. Doesn't make them necessarily feel better at that time. But the sava well so I recommend putting the two together to give them that quick relief from the albuterol from the bronco dilation. But then add on the I. CS to hopefully reduce their risk of exacerbation as well. Okay so then the next updates were in step three and step forward where they now prefer that you use a daily NPR in combination low dose or medium dose I. C. S. For Motorola. So essentially that is Daily Plus Prn Symbicort is what was the most studied but technically DeLara also has moment its own for motor oil in it. So those two medicines would have the promoter on it. So let's talk through that. So rationale is they called this single maintenance or reliever therapy or smart therapy because it's one inhaler. So they figured we could improve compliance by giving the single inhaler but they would still get that immediate relief compared to I. C. S. Alone. Um and for Motorola has a fast onset of action within 3-5 minutes. Similar child funeral but then obviously has longer action. Um and so can provide that relief versus so metro which is slower maybe 15 minutes or so until it on sets in action. So I don't recommend doing this at least hasn't been studied yet in Advair or weak. So unfortunately at this time And there's actually now enough papers um that they could do this jam a review, a systematic review. So include 14 randomized control trials. Um and they were able to summary reduce exacerbations, improve symptom control, improve lung function and reduced need for rescue medication. Um And it did it while you know reducing exposure to corticosteroids and really no difference in harm's. You know there used to be that box warning on ice es la bas. But they actually removed it in 2017 because they've had so much sort of follow up study um in adults and adolescents and in Children that there really wasn't increased harms when you combine ISIS with alaba and patients with asthma. So it seems to do very very well for patients. Um I do just want to point out one thing is if you do look at the other big group that puts out guidelines is the Global Initiative for Asthma or the gina. And they put out a report and they actually put one out every single year. So they have been updating from from 2007 even though the NHL. V. I. Has not been. Um And there are slight differences here. So you may see some patients who use therapies as recommended by the gina report. The biggest one is that the gina report actually also recommends as needed. Low dose I. C. S. For Motorola. So this is like as needed Symbicort. So it would be another adjunctive thing you could potentially think about using in patients that would it would seem like it would be helpful for um instead of the as needed I. CS. Plus saba. So the advantage here is it's a single inhaler. You don't have to be like you gotta go find your Q. Bar. Plus your albuterol. It's like you just use as needed your Symbicort. Um Which patients have also done. And there actually is quite a bit of data along this as well. Here's where I put my rapid onset of action um rationale and um these three studies um big randomized control trials which did show the again reduction in these observations um reduced dose of I. C. S. Um There is one note which is in this sigma, one study um and sigma to study that when you compare abuse descended maintenance it does have better control and it does have better lung function. So if somebody has persistent symptoms then they should be on a controller medicine which makes sense because they have ongoing airflow airway inflammation that they need to control. So if someone has poorly controlled symptoms um then they should probably still be on a maintenance inhaler. But if they have intermittent symptoms then I. C. S. For material may be an option for them. So how do you again how do you do this in practice? And who do you use this in? So in the study they used um Symbicort Um and they had them take 1-2 inhalations as needed and had them take up to 12 and a day. So essentially I tell people if you already if you're doing daily NPR and you're doing maybe up to four and a day. Eight extra doses throughout the day to take. I've never had anyone get close to eight yet. So there is a lot of extra essentially I. C. S. For material that they can use to help control their symptoms and using that potentially can reduce their risk of an exacerbation and reduce their need for oral steroids. So can be very helpful objectively in patients who have poorly controlled asthma. Um So the patients I use this in a lot of patients are doing incredibly well already. Yeah I might not be switching them all over. Especially if the inhaler is already pretty well covered. Um But if somebody has poorly controlled symptoms that it seems like if they just got a little more medicine that might help them out or if they're having exacerbations despite their therapy, then I am switching them over to this and for new patients who don't have two inhalers already to bother and deal with and all of that, I am like, hey, I think you're a single inhaler that you use all the time and will simplify your life. And I find that a lot of patients are very receptive to having a single inherit. They have to use to manage the biggest practical challenge. As of this point in time, I have found is insurance coverage is not cut up to the guidelines, hopefully it will soon. Um But it is surprising sometimes I have found that Symbicort is actually pretty well covered um and is better covered than the generic quicksilver and some of my patients, so I definitely try and sort of appeal based on the newest guidelines. Um But occasionally I've had some patients who I have had to be like okay well for now we're going to continue on this Because you can't pay $200 a month for your inhaler quite yet. But I totally understand. So I think this kind of does add to this question. So some patients believe their ISIS doesn't work and rely heavily on albuterol inhaler for non using. How do you address this in your own practice and what tips can you provide for PCP management? I think it depends but this might be a good example of that. They may be should be adding a beta agonist plus their I. C. S. As needed or their Symbicort as needed. Um For therapy. So what patients were describing to us that they didn't want to take their inhalers might actually be that we have some now data that they can do that. Obviously that's not right. If they have poor perception of their symptoms or if they have persistent symptoms then they should be using a daily maintenance inhaler. Um And I think for patients I think it obviously depends on the patient but some patients I sort of made contracts with them and I'm like, hey look your symptoms are pretty for you don't feel like this medicine works but I need you to work with me. I need you to take this for two weeks straight. You know take it for two weeks straight and if it doesn't work then yeah we'll move on. But if for two weeks straight and then you come back to when you say, oh that did work when I took it all the time, then you now know that you have to take your medicines regularly because I will help their symptoms. Um The other thing that I often do is if patients sort of don't know if they're I. C. S. Is working or not or if they have obstruction or not and they're using now being around Hiller a lot but it's unclear I obtained spectrometry to sort of give me an objective measure exactly of their airflow obstruction because that can help me give an idea of been like, no they're using they're beautiful whenever but they don't have that many symptoms. So I'm not as worried about it as they're using their beauty quite a bit. But they have a lot of airflow obstruction. They definitely need to be stepped up on there. Be if they feel like they're ISIS doesn't work. I need to step up Maybe two and I see us for Motorola and they then they might feel improvement or even beyond that. So what's beyond that? So the newest thing that they have beyond that in step five is they now have approved Areva or T. Opprobrium for asthma as well. So this has been used in asthma or COPD but you know hadn't been tried a lot and actually in a lot of the asthma COPD overlaps patients. Those were often excluded from the studies and trials. So you know in part what might have been what held up use of this medicine. Um But triple therapy. So I see this llama llama is associated with improved symptom control and lung function didn't technically show a decrease in exacerbations. But definitely if I'm stepping somebody up because they're I. C. S. For motor all now usually what I'm using I. C. Is for Motorola isn't working. I will add spring especially if they have poor symptom relief. Um And it's now approved for patients six and old older. So it's actually pretty well covered. My uh team is usually able to get coverage with this pretty easily. So then what's beyond that the good news is they didn't really talk a lot about in this guideline because they they you know when they sort of the people writing the guidelines came out and sort of had some discussion afterwards. They said yeah you know when we structured these questions five years ago when we were deciding what we're going to talk about. We did we were not aware that biologics we're gonna blow up the same way that they have post. There's actually now quite a few biologics there's five biologics that have been approved for people who have um what's called Type two high asthma. This is a very busy slide. I do not expect you to remember this but essentially as we now understand some of the inflammatory things that happen in asthma. So I. G. Allergy antibody aisle four aisle 13 which sort of turn on the allergic pathway and I. L. Five which is sort of the survival signal for the chemicals that we now understand that these are key pathogenic determinants of um developing airway, you know um allergic or airway inflammation. And so if we turn off these signals were able to make huge impacts on people's asthma. So it's honestly a whole different world now taking care of patients with severe asthma than has been before because historically we haven't had that much therapy for them and now patients are able to take medicines that they now feel like they finally have control of their asthma that they've never been able to do in the past. It's actually a very satisfying now to be an asthma doctor. Honestly there are differences in these different medicines. You don't have to remember them all because it will be a little bit challenging. But some of the decisions that I make in order to determine which therapeutic protein or biologic medicine I'm going to prescribe is that they have slightly different indications depending on sort of the mechanism of action. So in general this is where I said I usually characterized patients. What I'm doing is I'm usually giving an I. G. And then measuring their absolutely sinful count to see if they're either eosinophilic or if they have an Ellen really veggie that I'll be able to target with one of these therapies. Um They also have differences in there. Dozing. So many of them are subcutaneous. Which is very nice because um a lot of them actually can be administered at home which is incredibly nice and useful for our patients. Um And also there's one even that can be administered up to every eight weeks. So it's very easy for some of our patients to use these medicines. Um And they even have come out with these like fancy pen devices that really are very simple for patients to use. They literally just have to press straight down in the medicine Injects. They don't have to like draw it up in a syringe or anything anymore. So most of the people that I have had not had issues actually taking their medicines anymore, they also all may be used for other processes as well. So I kind of can kill two birds with one stone sometimes. So they have chronic hives. Zoeller works for that too. If they have nasal polyps or they have eczema um then maybe Zoeller or do you kill a man will be best if they have a hyper eosinophilic syndrome or E. G. P. A. Um church house. Um Then maybe um Embolism Avenue call it would be helpful. So sometimes that is also playing a role in how I decide between these different things. Um So when would I think about sending a patient? Honestly it's never wrong if you're worried and you're starting to think down this path definitely send them. We're happy to do think about it. Tell you which one to use all that prescribing and everything. But often if they're failing moderate or high dose I. C. S. Lava. So if they're failing sort of this new new Symbicort smart single maintenance and relieve the therapy, they're probably on the road to needing a therapeutic protein. They're having a lot of exacerbations. This can make a huge difference if they're scary dependent. So they're like I'm doing pretty well but I'm on chronic predniSONE every day for my asthma. Yeah, that's not a great way to treat asthma anymore. Let's try to get them off that pregnant zone. And um what could you do potentially to help us out beforehand, especially if there's some time to the referral and you can obtain an I. G. And A Cbc because that would help help us know if we can target it. I will obviously if they're on steroids there C. B. C. D. Like their A. C. They're absolutely snf account could be zero because the steroids sort of knocked all their yes and fills out um but depiction is actually approved specifically in that patient population and there are new up and coming even further up the pathway medications that also might be approved for patients to. So um this is as of right now, but they're starting to approve more and more medicines um that target these pathways to help us out. So these are great medicines for patients who have honestly, you know, who's who are on a lot of medicine and you're wondering about or who are having a lot of exacerbations. I think those are really ones that I would try to target. Um these were somewhat smaller things, so I didn't bring it up as sort of highlighted before, but I think are helpful for my primary care perspective because these are things that you might see it quite a bit. So one is that they've moved down um daily lucca train receptor antagonist to the alternative category. And that's in part because they added a black box warning, I guess they don't call it black box anymore. A box warning for Singular Montella test in March of 2020. So I know this because I see it quite a bit. But if you weren't aware, your patients might be seeing this message from their pharmacy or when they actually look at the medicine. So there's this morning for serious neuropsychiatric events. Again, this is a rare um side effects. So it doesn't happen to everybody probably won't happen to most, but certainly is something that can be concerning for a number of patients. Um And you know, I think it ranges which makes it hard to the most common symptom I heard from my patients has been vivid dreams. They tell me they get like technicolor or nightmares, um dreams. But I've had patients who have had mood changes or behavioral changes. I haven't had anyone with suicidal thoughts yet. But certainly those would all be reasons to stop the medication. And because of this, they determined that it probably shouldn't be first choice therapy, especially when patients allergy symptoms are mild. That being said, I essentially counsel patients on this. I also find that in either works or it doesn't. So if patients want to try and I'm like, hey, let's again do these little contract. So let's try it for four weeks. If you start noticing symptoms, side effects, you stop the medicine. If after four weeks to reassess you, we see if it helped. If it helped, you can totally continue the medicine, it can be helpful, I think, especially in patients who have more mild allergies and mild asthma, sort of that combination patients who have exercise induced. Um, asma, this is singular is classically worked a bit better in those populations. Um, so might be patients to think about for this. But for just general patients, I often and are I'm not starting singular because the benefits there's like questionable benefit might not work and then potential risk and some risk benefit ratio. I want to put you on a medicine I think is going to actually work. And honestly either I. C. S. For Motorola or isIS possible is probably going to work a lot better. So let's try that first. Um And then the other thing that's um in the guidelines is about using subcutaneous immunotherapy. So really briefly about allergy immunotherapy um It alters the allergic response and induces long lasting tolerance. So who do we do this in? So ideally this is a mild moderate controlled asthmatics where they feel like um allergies are triggering their asthma. Um we actually have a contra indication to start allergy immunotherapy and someone who's f. e. v. 1% protected as less than 70%. So if somebody has poorly controlled asthma we are not reality shots essentially. Every single time we give him the shot they go into an asthma exacerbation. So it's not a good patient to do it on. We really need them to have pretty well controlled asthma before we can put them on allergy immunotherapy. But in patients who have multi moderate disease that is controlled but it's triggered by their allergens we can knock down that triggering so potentially they can decrease their medicine um Overall so it can still be a very helpful therapy in patients. Um But we just have to sort of choose the right time to do it in them. There is generally better evidence for subcutaneous immunotherapy which are shots but just so you know there are some newly approved some sublingual immunotherapy which are tablets that go under the tongue and then I was absorbed. Um So there's rag biotech for ragweed, grass tech or oral, there for northern pasture grasses and the node actor for dust mites. So these are really nice because first doses in clinic, but after that they go home and take their pill every day by themselves at home. So this is a new adjunctive therapy that I'm finding a lot of patients really are receptive to because they, it's a lot easier and a lot less commitment than doing allergy shit shots were, you know, an extended period of time where they have to come into the clinic, um quite frequently. Um, but right now it's only for single things, it's only fair, the ragweed only for the national northern past aggression, It's only for dust mate. So it works for mono sensitized if you're only allergic to one thing or you feel like that's sort of the most problematic and then because they're quite new they can be pretty expensive. Um So in terms of for technically for asthma purposes we think subcutaneous immunotherapy is the right way to go. Um But you might see us doing something going to therapy if they're not able to commit to subcutaneous immunotherapy your allergy shots. Oh and then I thought this was a really great question. We have many patients who prefer alternative or integrative options. So you have recommendations for um things to avoid any that are low risk of harm to patients and you might actively recommend. Um So the N. C. C. I. H. I'm gonna forget what this stands for but the NIH is like complimentary integrative medicine health um component to it actually has a website specifically for asthma. Um Unfortunately do say that you know they've tried a lot of different approaches and none of them have shown clear benefit in trial. So there's none that they actively recommend at this point in time. But I think there are a couple supplements that have been tried and theoretically have some plausibility as to why they would work. So things that would be antioxidants like vitamin C. E. There's been quite a bit of data actually that there are low vitamin D. Levels and patients who have severe asthma. But unfortunately they've done pretty robust randomized control trials and where they supplemented vitamin D. And it didn't improve symptoms. So it's hard to say that that's sort of the cause and not some sort of like you know confounding factor. Um As well as omega three fatty acids, magnesium that they're still studies going on in. Um There's also some work on biofeedback and breathing exercises. Um This I've actually seen quite a bit of recently um that I've had patients want to do. And I think in general breathing exercises for somebody who has an asthma, chronic lung condition make perfect sense to me. So I don't see any reason why that's like harmful acupuncture is always. So I think I found this sort of how to like structure, when to talk to patients about supplements or alternative integrated products that I thought were, you know, was helpful. So if there's good quality of the product, if there's efficacy and safety, then obviously we recommend it. But when you're uncertain about the quality, uncertain about the efficacy, uncertain about the safety, maybe you talk to them about it and then caution them about it. And then if the quality is poor, it's definitely shown to be ineffective or unsafe, then that's when you should actively discourage it. So, from my perspective, the things that I've seen that are sort of like unsafe are I've seen a number of patients who have come to me and they've tried something that has like fragrances um like essential oils or something like that. Yeah, they're like it seemed to take my asthma or some like Yeah, that makes sense. Like respiratory irritants. People with asthma generally don't do well with. I've also seen a number of patients with substances containing the pollen of some sort who have actually reacted to that bee pollen and I'm like, huh, I didn't know that could be a possibility like Yeah, unfortunately that is um there's quite a bit of I think sort of lore about using local unprocessed honey because there would be pollen in that honey to help with asthma or help with allergies in general. Um We haven't shown in good clinical trials that it is very effective and that's in part because we think a lot of the pollen and honey is is from um bee pollination. So insect pollinated, but the ones that cause allergy symptoms are actually wind pollinated. So trees grasses, weeds um And so there's not as much pollen that would actually be beneficial in the honey itself. Um So but again, unless it's causing the problems, I have no problem with them trying it. Um I just don't know how efficacious it will be for them. And then the other thing is I do just remind patients that default because I do have pretty good medicines that are going to work. And so you know, they actually did a study where they looked at patients who were receiving placebo, um Even our placebo sort of complementary medicine and they reported improvement in symptoms, but their lung function didn't improve at all, so they might feel better but they actually might have quite a bit of disease still. And so in that case we still definitely want to treat them and we now have quite a bit of medicine that could actually make them better. So if they feel better and they're doing totally fine, I have no problem with them, sort of stopping therapy and trying other things. But if they're doing poorly then uh you know, let's work together and sort of compliment there are their typical medicines with these other approaches as well um in the hopes that it might work. I have no problem. So then I just this is less like, you know, I'm running a little bit behind. Um uh and so I just wanted to show this one more time and then just use a couple, you know, rapid fire cases. So exercise induced asthma or would you put someone? So I think this is one, you know someone who is purely exercise induced asthma. Yeah I'm probably not going up in therapies and probably they're using pure and Sabah if they don't use if they feel like they have more persistent symptoms than pure and Sabah sure they could try and we try and receptor antagonist but if they don't then I'm probably doing I. C. S. Hasaba maybe as needed if they really know that their triggers exercise, I think it totally makes sense. Um someone who just had an exacerbation on Q bar 82 puffs twice daily. This is someone, I'm probably gonna go up to this new smart therapy or I'm going to give them a daily apparent combination ISIS for Motorola and be like, hey, the next time you notice that your symptoms are flaring, start using more ISIS for motor all in the hopes that it will reduce your risk of an exacerbation. So the person who says yeah, every wildfire season, my asthma gets worse and I have a flare. They're like, hey, I need you to make sure you have enough Symbicort this year. And when you start noticing your symptoms later start taking more Symbicort. And let's see if we can actually decrease your need for your yearly oral predniSONE around that time because we might be able to replace that. And then someone who's on Symbicort two puffs twice daily is still using the Oberon daily. That's someone you should definitely refer because I might be able to start them up biologic and really make a difference in their lives. So here is all the providers and the asthma clinic. Um you know, we specifically focus on asthma, which is great. We've got a lot of um ability to diagnostic testing with spam a tree allergies, optimize their medical management, talk to them about how to manage their asthma bit better. And then we also have a number of ongoing research studies that they might be eligible, which can be very helpful for patients. And I actually find that a lot of patients really like being involved in asthma clinical trials, they're like I really want to like sort of contribute to the overall understanding of asthma because this is how a bunch of the advances that we've made in the last years um have been made possible by people contributing in this way. Um I also attended the our technology clinic and so we see a lot of patients there, we do skin testing, we do even if therapy. Um and we also treat patients who have immune deficiencies, so patients who have frequent infections as well. Um here's the sort of information about me. I know my asthma Clinic probably has a lot of openings are allergy, immunology clinic, um gets a lot of referrals. So we're very sorry for some of your patients has been waiting for the referral. We are actively hiring more people to try to sort of address that.