Why Don’t More Patients with Asthma Use Biologicals?

Last month, I shared several videos with you that pertained to treatment of #asthma with biologicals. I hope you listened to the lives of patients just like you who can now “do life” with their family and friends not having to fear the next asthma attack. But it’s not so easy to change our habits on treating asthma. We’ve been trying for years to get patients to use preventative care (ie, inhaled steroids) and that method even in clinical studies is no more than ~50% effective. So what’s next?

Continue reading

#american-academy-of-allergy-asthma-and-immunology, #american-college-of-allergy-asthma-immunology, #biologics

New Biologicals are unknown

What is the magic bullet of medical treatment? How about a biological that treats two or more diseases at one time? Dupilumab (Dupixent) is one such medication and I agree with Dr. Castro’s interpretation of the data on dupilumab–after all, he wrote the study. Here’s what I like about Dupixent:

  1. Blocks 2 cytokines, both IL-4 and IL-13
  2. Treats 3 different diseases: asthma, nasal polyps, and atopic dermatitis.
  3. If you can’t get approved through your insurance, the company has a very good patient assistance program that makes Dupixent affordable for most patients.

Xolair, xolair, xolair. This biological has been around since my days back in Kansas. I have to admit, when Xolair was first released 20 years ago, I thought “who would use this type of medication?” Not only was I wrong, but Xolair has now set the standard for the use of monoclonal treatment of allergic disease, asthma, and urticaria. But I can’t compete with the video on Xolair….enjoy!

The last biological I mention is one that wasn’t the first on the scene, but has made it’s impression with a unique mechanism for getting rid of allergic inflammation: why not block the eosinophil IL-5 receptor directly? What do I like about Fasenra?

  1. Gets rid of eosinophils quickly–you notice within several weeks many times when Fasenra makes you feel better.
  2. After the first 3 doses, you only have to use Fasenra every OTHER month–pretty cool schedule compared to a daily inhaler.
  3. Reduces both exacerbations of asthma AND the need for corticosteroids.

Time for correct use of spacers

Ok..it’s time we learn the “why” of using spacers, because most patients don’t use them on a regular basis. Spacers do several things for your pocketbook and your asthma:

  1. This spacer below can be purchased for < $10 on-line at Amazon. That’s almost better than a used toilet roll cardboard! Yes, we used to use and recommend I might add this “makeshift” spacer for patients because the others were too expensive.
  2. Your asthma inhaler is much more effective when you use a spacer, because the aerosol is delivered deep into the lungs where you need it–in the small airways. Make sure you don’t use a spacer with dry powder –not needed here. For example, Advair has both dry powder and aerosol; the choice is yours, but no spacer for the dry powder.
  3. If you’re using an aerosol or MDI, you may find that only 1 puff is needed–you save money with similar results, but check with your doctor first before making that kind of switch.
  4. Now you know why we harp on you to use your spacer–saves money and better results.

Go out (or order from home) and get you one today! Leave me a note on how it works. Happy breathing–Dr. Wiens

Scientists “Speak” on Mold Allergy

Background

  • Allergic bronchopulmonary aspergillosis is a pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus, and rarely other Aspergillus species, and is characterized by chronic asthma, recurrent pulmonary infiltrates, and bronchiectasis.
  • An ABPA-like syndrome called allergic bronchopulmonary mycosis is indistinguishable from ABPA but is caused by other fungi.
  • The condition occurs almost exclusively in patients with cystic fibrosis (CF) or asthma.
  • The global prevalence of allergic bronchopulmonary aspergillosis is reported to be 2.5% (range 0.7%-3.5%) among adults with asthma and reported to be 2%-15% in patients with cystic fibrosis.

Evaluation

  • Suspect allergic bronchopulmonary aspergillosis (ABPA) in patients with asthma or cystic fibrosis who have symptoms consistent with ABPA, such as:
    • difficult-to-control asthma
    • new or worsening cough
    • dyspnea
    • increased sputum production
    • expectoration of brown-black mucus plugs
    • wheezing
    • hemoptysis
  • ABPA may also be suspected in patients with computed tomography (CT) findings of bronchiectasis, especially central bronchiectasis.
  • Multiple sets of diagnostic criteria exist, all of which include a combination of clinical signs, imaging findings, and serologic features.
    • Rosenberg-Patterson diagnostic criteria for patients without cystic fibrosis (most commonly used):
      • major criteria for diagnosis (at least 6 required for diagnosis):
        • asthma
        • transient pulmonary opacities on imaging (fleeting shadows)
        • positive skin test for Aspergillus (type 1 immediate hypersensitivity)
        • peripheral blood eosinophilia (> 1,000 cells/mcL)
        • precipitating antibodies (immunoglobulin [Ig] G) against Aspergillus fumigatus in serum
        • elevated total IgE > 1,000 units/mL
        • central/peripheral bronchiectasis with normal tapering of distal bronchi
        • elevated A. fumigatus-specific IgG and IgE
      • minor criteria:
        • Aspergillus in sputum
        • brownish black mucus plugs in expectorate
        • delayed type III skin reaction to Aspergillus
    • Cystic Fibrosis Foundation diagnostic criteria for patients with cystic fibrosis:
      • classic case (all criteria required):
        • acute or subacute clinical deterioration (cough, wheeze, exercise intolerance, increased sputum, decrease in pulmonary function, exercise-induced asthma) not attributable to other cause
        • serum total IgE > 1,000 units/mL (2,400 ng/mL) in patient not on corticosteroids
        • immediate skin reaction to Aspergillus (wheal > 3 mm diameter with erythema in patient not on antihistamines) or positive serum IgE antibody to A. fumigatus
        • precipitating antibodies to A. fumigatus or serum IgG antibody to A. fumigatus
        • recent or new infiltrates or mucus plugging on chest x-ray or bronchiectasis on chest computed tomography (CT) that does not clear with antibiotics or chest physiotherapy
      • minimal diagnostic criteria:
        • acute or subacute clinical deterioration not attributable to other cause
        • serum total IgE > 500 units/mL (1,200 ng/mL) (if disease suspected and serum total IgE is 200-500 units/mL, repeat testing in 1-3 months)
        • immediate skin reaction to Aspergillus or positive serum IgE antibody to A. fumigatus
        • 1 of following:
          • precipitins to A. fumigatus or IgE antibody to A. fumigatus
          • recent or new infiltrates or mucus plugging on chest x-ray or bronchiectasis on chest CT that does not clear with antibiotics and standard chest physiotherapy
      • diagnosis of ABPA in cystic fibrosis should not be based in serology and skin tests only(2)

Management

  • Treatment goals include:
    • control of symptoms of asthma and cystic fibrosis
    • prevention or treatment of pulmonary exacerbations of allergic bronchopulmonary aspergillosis (ABPA)
    • reducing or remitting pulmonary inflammation
    • avoiding progression to end-stage fibrotic or cavitary disease
  • No large randomized trials have evaluated efficacy of various treatment options as of September 20, 2017.
  • Refer patients with suspected or known ABPA to a pulmonologist or an allergist-immunologist.
  • Systemic corticosteroids are considered the cornerstone of therapy for ABPA.
    • In patients with asthma:
      • typical initial therapy is prednisone 0.5 mg/kg/day (or equivalent) with tapering dose as symptoms improve
      • for patients with mild exacerbation – inhaled corticosteroids and bronchodilators may help control symptoms
      • for patients with acute exacerbation – prednisone 0.5-1 mg/kg/day for 1-2 weeks, then 0.5 mg/kg every other day for 6-12 weeks following remission, then tapering dose to preexacerbation dose
      • for patients with refractory disease with multiple asthmatic exacerbations – chronic corticosteroid therapy suggested, usually > 7.5 mg/day
      • dosing may be increased based on findings from routine monitoring of serum immunoglobulin E (IgE) levels, pulmonary function tests, and chest imaging, such as:
        • significant increase of IgE levels (such as doubling of baseline IgE level)
        • imaging evidence of infiltrates, mucoid impaction, fibrosis, worsening bronchiectasis, or worsening physiology
    • In patients with cystic fibrosis:
      • oral corticosteroids indicated for all patients except those with corticosteroid toxicity
      • typical initial dose prednisone (or equivalent) is 0.5-2 mg/kg/day orally to maximum 60 mg/day for 1-2 weeks, tapering to 0.5-2 mg/day every other day for 1-2 weeks with attempt to taper completely within 2-3 months
      • in patients with relapse, increase corticosteroid dose, add itraconazole, and taper corticosteroids when clinical status improves
  • Inhaled corticosteroids and methylprednisolone IV pulses may be used in some situations.
  • Consider antifungal agents in adults with severe, poorly controlled asthma and ABPA (Weak recommendation).
  • Combination antifungal/corticosteroid (nebulized amphotericin B and nebulized budesonide) may reduce the incidence of exacerbations.
  • Omalizumab may reduce exacerbations but may not improve or affect lung function or quality of life.
  • For refractory cases, consider evaluating the patient’s environment for significant mold exposure that can be modified (Weak recommendation).
  • Consider adjunct leukotriene antagonists for some patients (Weak recommendation).
  • Follow-up could include imaging at 4-8 weeks and total serum IgE monitoring.
 2017 Aug;13(8):823-835. doi: 10.1080/1744666X.2017.1324298. Epub 2017 May 17.

Mold allergy: is it real and what do we do about it?

 

Abstract

fungi produce substances that contain pathogen-associated molecular patterns (pamps) and damage-associated molecular patterns (damps) which bind to pattern recognition receptors, stimulating innate immune responses in humans. they also produce allergens that induce production of specific ige. Areas covered: In this review we cover both innate and adaptive immune responses to fungi. Some fungal products can activate both innate and adaptive responses and in doing so, cause an intense and complex health effects. Methods of testing for fungal allergy and evidence for clinical treatment including environmental control are also discussed. In addition, we describe controversial issues including the role of Stachybotrys and mycotoxins in adverse health effects. Expert commentary: Concerns about long-term exposure to fungi have led some patients, attorneys and fungus advocates to promote fears about a condition that has been termed toxic mold syndrome. This syndrome is associated with vague symptoms and is believed to be due to exposure to mycotoxins, though this connection has not been proven. Ultimately, more precise methods are needed to measure both fungal exposure and the resulting health effects. Once that such methods become available, much of the speculation will be replaced by knowledge.

New medications for Asthma–are we at the end of the line?

Watch my FOX 23 interview about new asthma meds

Jane (fictitious name, of course because of HIPPA regulations) is now 56 years old and just last year was diagnosed with #asthma. She thought, “no big deal, there are plenty of inhalers for me to use so I don’t wheeze”.  Little did she know that 2019 would put her in the hospital 3 times and multiple visits to the emergency room because of asthma. In fact, she even missed her grandson’s graduation from kindergarten because of her asthma. Now if that doesn’t motivate you, nothing will! Continue reading

#allergies, #tulsa-oklahoma

911–Can We Prevent Trauma from Asthma?

 

Childhood trauma–it happens all around us, but rarely do we take the time to observe it’s devastating effects on our society and culture. Kudos to #Tulsa World for addressing this very complicated and at times hopeless situation. Doris Franstein, who recently retired as Continue reading

#allergic-rhinitis, #allergy-medication, #asthma

September is more than just football

Ask the Allergist: When Allergies Keep You Awake

Myth is, after all, the never ending story Part 2

When it comes to asthma, it’s not easy fighting the myths of Facebook, Google, or e-mail campaigns. And why are we so resistant to the diagnosis of asthma for our kids and ourselves? For asthma, if you don’t make the correct diagnosis, you’ll never implement the proper treatment. By that I mean, you’re not likely to use prevention, but instead will wait for an asthma attack and then rush in to treat the symptoms. Health care providers are responsible for this phenomenon just as much as patients. Go to any emergency room or urgent care with an asthma attack and you’re likely to receive steroids, antibiotics and the admonition to “see your primary care doctor”. The problem is that patients feel better after steroids and guess what? they never seek medical attention for the prevention of #asthma. After practicing asthma medicine for over 25 years, consider the following reasons for why our asthma treatment often fails to meet the “standard of care” according to published #asthma research:

  1.  Asthma attacks don’t happen all at once. If I can get through an asthma attack in September, what’s the big deal of one course of steroids per year? This paroxysmal nature of asthma makes proper treatment very difficult because we tend to have a very short memory about our last asthma attack. 
  2. As a general rule, we all resist preventive care. Do you miss a regular dental floss or exercise session? As difficult as it seems to continue with good preventive care, think how much more difficult it is to take an inhaler everyday to prevent asthma! Antibiotics are so successful after 10-14 days that we can stop therapy and recover back to our original health. Asthma isn’t the same disease process and many times one attack leads to never ending asthma.

Can I get over asthma? The short answer is usually not. Asthma is a disease of inflammation which means the airways over react to allergy, infections, or irritation. In short, this means lungs with asthma are forever inundated with “triggers” that cause wheezing, coughing, and typical asthma symptoms. If you don’t use preventive inhalers for the next attack, you can be assured it will come.

#respiratory-disorders

Take a break and learn more about asthma!

Something about numbers

I for one am tired  how my health score is tied to my existence as a person rather than who I really am.   “How to keep up your credit score, what income bracket I’m in, what’s my IQ” are nagging reminders that I may not be anything more than just a number and not a unique person on this planet. Health care is fast approaching this same pigeonhole similar to banks and retailers, but it’s not all bad. Ever heard of personalized medicine?

#Personalized medicine has some pretty awesome benefits on the horizon, but “what’s the catch?”  My cholesterol has to be below 120, cigarettes at zero, and my daily cups of coffee can’t be over 5 if I have any hope of living past 80;you just can’t get away from numbers.

According to Wikipedia, Personalized medicine, also termed precision medicine, is a medical procedure that separates patients into different groups—with medical decisions, practices, interventions and/or products being tailored to the individual patient based on their predicted response or risk of disease. So if numbers and health are an integral part of the future of health care, is there such a thing as an allergy or asthma number? Wouldn’t it be nice to find out which asthma inhaler is best for you based on “personalized medicine?” Or what if you suffer from chronic hives and can’t find the cause? Personalized medicine involves many more diseases that just asthma and allergy–just look at the link below, but I have a list as well. Continue reading

#asthma, #atopic-dermatitis, #cinquair, #dupixent, #fasenra, #nucala, #personalized-medicine, #xolair