Tackling the Challenge of Treating Severe Asthma: Taking Aim at the Airway Epithelium
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Chair Professor Andrew Menzies-Gow, prepared useful Practice Aids pertaining to asthma for this CME/MOC activity titled “Tackling the Challenge of Treating Severe Asthma: Taking Aim at the Airway Epithelium.” For the full presentation, downloadable Practice Aids, and complete CME/MOC information, and to apply for credit, please visit us at https://bit.ly/3sEiEC3. CME/MOC credit will be available until May 3, 2023.
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Tackling the Challenge of Treating Severe Asthma: Taking Aim at the Airway Epithelium
- 1. Algorithm for the Assessment and Treatment of Adults With Uncontrolled Severe Asthma1 Full abbreviations, accreditation, and disclosure information available at PeerView.com/MRW40 1. Brusselle GG, Koppelman GH. N Engl J Med. 2022;386:157-171. Assess and address the following • Confirm asthma diagnosis • Improve adherence to IGs • Correct inhaler technique • Identify and avoid exposure to risk factors and triggers (eg, allergens, irritants, smoking) • Assess and treat coexisting conditions • Determine blood eosinophil counts and FeNO • Assess coexisting conditions (eg, severe atopic dermatitis, CRSwNP, allergic rhinitis, eosinophilic pneumonia, EGPA) Difficult-to-treat asthma Severe asthma (without daily OC) Allergic asthma and perennial allergy? Anti-IgE or anti-TSLP Anti-TSLP Yes No Allergic asthma and perennial allergy? Integrate clinical characteristics, biomarkers, and coexisting conditions Assess response (after 4 to 6 months), adverse events, and patient satisfaction Rule out parasitic infections, hematologic diseases, and other hypereosinophilic conditions Current or historic evidence of increased blood eosinophil count? Taper OC gradually Monitor for adrenal insufficiency Monitor for unmasking of EGPA Assess response, adverse events, and patient satisfaction FeNO <25 ppb FeNO ≥25 ppb Blood eosinophils 150-1500 cells/µl Blood eosinophils >1500 cells/µl OC-dependent severe asthma Severe asthma despite high-dose IGs + LABA and adequate management Anti–IL-4Rα, anti–IL-5, or anti–IL-5R Anti–IL-4Rα Yes No Anti-IgE, anti–IL-4Rα, or anti-TSLP Anti–IL-4Rα, or anti-TSLP Anti–IL-5 or anti–IL-5R Anti-IgE, anti–IL-4Rα, anti–IL-5, anti–IL-5R, or anti-TSL Yes No Blood eosinophils <150 cells/µl Good response • Decrease in exacerbation rate of ≥50%, decrease in symptoms, and improved asthma control • Continue add-on treatment with biologic agent Poor response • Reassess differential diagnosis, adherence, coexisting conditions, phenotypes, and biomarkers • Stop ineffective biologic agent • Consider switching to a different biologic agent • Share the decision-making Good response • Decrease in OC dose of ≥50% and decrease in exacerbation rate • Continue add-on treatment with biologic agent
- 2. The Role of TSLP in Severe Asthma1-19 Full abbreviations, accreditation, and disclosure information available at PeerView.com/MRW40 1. Corren J. J Allergy Clin Immunol Pract. 2019;7:1394-1403. 2. Lambrecht BN et al. Nat Immunol. 2015;16:45-56. 3. Menzies-Gow A et al. Respir Res. 2020;21:268. 4. Ying S et al. J Immunol. 2005;174:8183-8190. 5. Corren J et al. N Engl J Med. 2017;377:936-946. 6. Ziegler SF et al. Nat Immunol. 2010;11:289-293. 7. Gauvreau GM et al. Expert Opin Ther Targets. 2020;24:777-792. 8. Brusselle GG et al. Ann Am Thorac Soc. 2014;11(Suppl 5):S322-S328. 9. Pelaia G et al. Nat Rev Drug Discov. 2012;11:958-972. 10. Pasha MA et al. Allergy Asthma Proc. 2019;40:138-145. 11. Brusselle GG et al. Nat Med. 2013;19:977-979. 12. Li Y et al. J Immunol. 2018;200:2253-2262. 13. Liang Y et al. J Allergy Clin Immunol. 2019;144:1025-1035. 14. Tanaka J et al. Clin Exp Allergy. 2009;39:89-100. 15. Chesné J et al. Am J Respir Crit Care Med. 2014;190:1094-1101. 16. Lambrecht BN et al. Immunity. 2019;50:975-991. 17. Erle DJ et al. J Cell Biol. 2014;205:621-631. 18. Corren J et al. Nat Immunol. 2019;20:1603-1609. 19. Shikotra A et al. J Allergy Clin Immunol. 129:104-111. Pathogens Insults Airway epithelial cells TSLP Pollutants Allergens TSLP signals the presence of danger and can trigger a cascade of immune responses Allergic inflammation Asthma symptoms and exacerbations Eosinophilic inflammation Potential neutrophilic inflammation Effects on airway smooth muscle