Program Profile

A Better Way to Breathe: Combining Allergy and Pulmonary Care Into One Clinic

Fed Pract. 2023 January;40(1):16-21 | doi:10.12788/fp.0352

Author(s):

Background: The use of biologic agents for severe asthma has transformed management, decreasing asthma exacerbations, improving lung function, reducing corticosteroid use, and decreasing hospitalizations. However, numerous financial and logistic barriers have complicated the implementation of biologic agents, including long wait times to see specialists and insurance coverage.

Observations: A retrospective chart review was performed for 15 patients enrolled in this severe allergy clinic at the Washington DC Veterans Affairs Medical Center over 30 months. Outcomes examined included emergency department visits, hospitalizations, intensive care unit (ICU) stays, forced expiratory volume (FEV₁), and steroid use. The average use of steroids decreased from 4.2 to 0.6 tapers per year following the initiation of biologics. There was an average 10% improvement in FEV₁ after starting a biologic. Thirteen percent of patients (n = 2) had an emergency department visit for an asthma exacerbation since starting a biologic agent, 0.6% of patients (n = 1) had a hospital admission for an asthma exacerbation, and no patients had an ICU stay.

Conclusions: Biologic agents have significantly improved outcomes for patients with severe asthma. The model of a combined allergy/pulmonology clinic can be particularly efficacious in the treatment of severe asthma, as it reduces the need for multiple appointments with different specialties, reduces wait time before starting a biologic agent, and offers the perspective of 2 specialists.

PDF Download

References

1. Lambrecht BN, Hammad H. The immunology of asthma. Nat Immunol. 2015;16(1):45-56. doi:10.1038/ni.3049

2. Moore WC, Bleecker ER, Curran-Everett D, et al. Characterization of the severe asthma phenotype by the National Heart, Lung, and Blood Institute’s Severe Asthma Research Program. J Allergy Clin Immunol. 2007;119(2):405-413. doi:10.1016/j.jaci.2006.11.639

3. Barnes PJ, Jonsson B, Klim JB. The costs of asthma. Eur Respir J. 1996;9(4):636-642. doi:10.1183/09031936.96.09040636

4. Bourdin A, Charriot J, Boissin C, et al. Will the asthma revolution fostered by biologics also benefit adult ICU patients?. Allergy. 2021;76(8):2395-2406. doi:10.1111/all.14688

5. Lloyd A, Price D, Brown R. The impact of asthma exacerbations on health-related quality of life in moderate to severe asthma patients in the UK. Prim Care Respir J. 2007;16(1):22-27. doi:10.3132/pcrj.2007.00002

6. Eisner MD, Yelin EH, Katz PP, Lactao G, Iribarren C, Blanc PD. Risk factors for work disability in severe adult asthma. Am J Med. 2006;119(10):884-891. doi:10.1016/j.amjmed.2006.01.016

7. Nurmagambetov T, Kuwahara R, Garbe P. The Economic Burden of Asthma in the United States, 2008-2013. Ann Am Thorac Soc. 2018;15(3):348-356. doi:10.1513/AnnalsATS.201703-259OC

8. McGregor MC, Krings JG, Nair P, Castro M. Role of biologics in asthma. Am J Respir Crit Care Med. 2019;199(4):433-445. doi:10.1164/rccm.201810-1944CI

9. Bice JB, Leechawengwongs E, Montanaro A. Biologic targeted therapy in allergic asthma. Ann Allergy Asthma Immunol. 2014;112(2):108-115. doi:10.1016/j.anai.2013.12.013

10. Darveaux J, Busse WW. Biologics in asthma--the next step toward personalized treatment. J Allergy Clin Immunol Pract. 2015;3(2):152-161. doi:10.1016/j.jaip.2014.09.014

11. Inselman JW, Jeffery MM, Maddux JT, Shah ND, Rank MA. Trends and disparities in asthma biologic use in the United States. J Allergy Clin Immunol Pract. 2020;8(2):549-554.e1. doi:10.1016/j.jaip.2019.08.024

12. Gelhorn HL, Balantac Z, Ambrose CS, Chung YN, Stone B. Patient and physician preferences for attributes of biologic medications for severe asthma. Patient Prefer Adherence. 2019;13:1253-1268. Published 2019 Jul 25. doi:10.2147/PPA.S198953

13. Centers for Disease Control and Prevention, National Center for Environmental Health. 2019 National Health Interview Survey (NHIS) data. Accessed December 6, 2022. https://www.cdc.gov/asthma/nhis/2019/data.htm

14. Zelaya CE BP, Moy E. Crude and age-adjusted percent distribution of respondent-assessed health status among adults aged 20 and over, by veteran status and other selected characteristics: United States, 2015-2018. National Center for Health Statistic. Updated June 19, 2020. Accessed December 12, 2022. https://www.cdc.gov/nchs/nhis/veterans_health_statistics/tables.htm

15. Szema AM, Peters MC, Weissinger KM, Gagliano CA, Chen JJ. New-onset asthma among soldiers serving in Iraq and Afghanistan. Allergy Asthma Proc. 2010;31(5):67-71. doi:10.2500/aap.2010.31.3383

16. Yi SW, Hong JS, Ohrr H, Yi JJ. Agent Orange exposure and disease prevalence in Korean Vietnam veterans: the Korean veterans health study. Environ Res. 2014;133:56-65. doi:10.1016/j.envres.2014.04.027

17. Huetsch JC, Uman JE, Udris EM, Au DH. Predictors of adherence to inhaled medications among veterans with COPD. J Gen Intern Med. 2012;27(11):1506-1512. doi:10.1007/s11606-012-2130-5

18. Mundell L, Lindemann R, Douglas J. Monitoring long-term oral corticosteroids. BMJ Open Qual. 2017;6(2):e000209. Published 2017 Nov 8. doi:10.1136/bmjoq-2017-000209

19. Van Staa TP, Leufkens HG, Abenhaim L, Zhang B, Cooper C. Use of oral corticosteroids and risk of fractures. J Bone Miner Res. 2005;20(8):1487-1486. doi:10.1359/jbmr.2005.20.8.1486

20. Warrington TP, Bostwick JM. Psychiatric adverse effects of corticosteroids. Mayo Clin Proc. 2006;81(10):1361-1367. doi:10.4065/81.10.1361

21. Miller DR, Safford MM, Pogach LM. Who has diabetes? Best estimates of diabetes prevalence in the Department of Veterans Affairs based on computerized patient data. Diabetes Care. 2004;27(suppl 2):B10-B21. doi:10.2337/diacare.27.suppl_2.b10

22. Acharya T, Tringali S, Singh M, Huang J. Resistant hypertension and associated comorbidities in a Veterans Affairs population. J Clin Hypertens (Greenwich). 2014;16(10):741-745. doi:10.1111/jch.12410

23. Dupixent (dupilumab). Prescribing information. Sanofi and Regeneron Pharmaceuticals; 2022. Accessed December 6, 2022. https://www.dupixenthcp.com/asthma/efficacy/safety-data

24. Li L, Wang Z, Cui L, Xu Y, Guan K, Zhao B. Anaphylactic risk related to omalizumab, benralizumab, reslizumab, mepolizumab, and dupilumab. Clin Transl Allergy. 2021;11(4):e12038. Published 2021 Jun 3. doi:10.1002/clt2.12038

Asthma affects more than 300 million people worldwide.¹ While many of these cases can achieve control with standard therapy, 5% to 10% of these cases are classified as severe asthma, remaining poorly controlled despite treatment with inhaled corticosteroids (ICS) and long-acting β agonists (LABA).² These patients also account for the majority of morbidity and mortality associated with the disease, with increased hospitalizations, intensive care unit (ICU) stays, detrimental adverse effects of oral corticosteroids (OCS), and lower quality of life.^3-6 Additionally, the financial repercussions of severe asthma are notable; in the United States, the estimated cost of asthma management is $82 billion annually, with $3 billion accounting for asthma-related work/school absences.⁷

In the past several years, the use of anti-immunoglobulin E (IgE), anti-interleukin-4 (IL-4), and anti-IL-5 biologic agents for severe asthma has been shown to decrease asthma exacerbations, improve lung function, reduce corticosteroid use, and decrease hospitalizations, especially for type 2 helper T cell (TH2-high) asthma.^8-10 However, clinicians have observed significant barriers to the implementation and widespread use of biologics, including insurance coverage, long wait times, follow-up, and limited access for lower income groups.^11,12

This article describes a unique model for a severe asthma clinic located at the Washington DC Veterans Affairs Medical Center (WDCVAMC) that is dually staffed by an allergist and pulmonologist. This clinic uses biologic agents for patients with difficult-to-treat asthma, many of whom require repeated or prolonged steroid use, in addition to prolonged and recurrent hospitalizations for exacerbations. The objective of this clinic is to provide a standardized approach to the management of severe asthma with the perspective of both an allergist and pulmonologist, thereby reducing the need to schedule appointments with multiple specialties and reducing delays in initiating biologics. This article presents the preliminary findings of 30 months of severe asthma management with various biologic agents, examining the impact of these therapies on hospitalizations, asthma exacerbations, ICU stays, and OCS use. The findings of this study support the benefits of biologics and suggest that the use of these agents within a dually staffed clinic may be a particularly effective model through which to manage severe asthma.

Background

Asthma affects approximately 20 million adults in the United States.¹³ Veterans are a population particularly impacted by asthma. Between 2015 and 2018, 10.9% of all veterans reported being diagnosed with asthma and 5.1% stated that they currently have asthma, compared with 13.4% and 8.0% of nonveterans, respectively.¹⁴ Veterans are susceptible to many of the factors that can trigger exacerbations while engaging in military service, such as chemical and environmental exposures both abroad and domestically.^15,16 Additionally, medication adherence is often challenging among the veteran population, particularly with more involved therapy, such as inhaler use.¹⁷ Such factors contribute to asthma exacerbations, with 2.9% of veterans reporting at least 1 asthma exacerbation in the past 12 months.¹⁴

Over the past several years, the development and use of biologic agents have transformed the management of severe asthma.⁸Before the development of biologic agents for severe asthma, treatment options for patients were limited. While OCS are frequently used for asthma exacerbations, they are associated with a multiplicity of undesirable adverse effects, including weight gain, mood lability, gastrointestinal upset, hyperglycemia, risk of bone fractures, and hypertension.^18-20 The regular use of OCS are particularly problematic among other medical comorbidities commonly affecting the veteran population, such as diabetes and hypertension.^21-22

The WDCVAMC severe allergy clinic used 3 biologic agents: omalizumab (anti-IgE), benralizumab (anti-IL-5), and agent dupilumab (anti-IL-4). These medications have shown significant improvements in quality of life, reduction in asthma exacerbations and hospitalizations, and decreased use of OCS.^8,9 While research has firmly established the medical benefits of the use of biologic agents in severe asthma, several barriers exist in implementing widespread use.^11,12

References

1. Lambrecht BN, Hammad H. The immunology of asthma. Nat Immunol. 2015;16(1):45-56. doi:10.1038/ni.3049

2. Moore WC, Bleecker ER, Curran-Everett D, et al. Characterization of the severe asthma phenotype by the National Heart, Lung, and Blood Institute’s Severe Asthma Research Program. J Allergy Clin Immunol. 2007;119(2):405-413. doi:10.1016/j.jaci.2006.11.639

3. Barnes PJ, Jonsson B, Klim JB. The costs of asthma. Eur Respir J. 1996;9(4):636-642. doi:10.1183/09031936.96.09040636

4. Bourdin A, Charriot J, Boissin C, et al. Will the asthma revolution fostered by biologics also benefit adult ICU patients?. Allergy. 2021;76(8):2395-2406. doi:10.1111/all.14688

5. Lloyd A, Price D, Brown R. The impact of asthma exacerbations on health-related quality of life in moderate to severe asthma patients in the UK. Prim Care Respir J. 2007;16(1):22-27. doi:10.3132/pcrj.2007.00002

6. Eisner MD, Yelin EH, Katz PP, Lactao G, Iribarren C, Blanc PD. Risk factors for work disability in severe adult asthma. Am J Med. 2006;119(10):884-891. doi:10.1016/j.amjmed.2006.01.016

7. Nurmagambetov T, Kuwahara R, Garbe P. The Economic Burden of Asthma in the United States, 2008-2013. Ann Am Thorac Soc. 2018;15(3):348-356. doi:10.1513/AnnalsATS.201703-259OC

8. McGregor MC, Krings JG, Nair P, Castro M. Role of biologics in asthma. Am J Respir Crit Care Med. 2019;199(4):433-445. doi:10.1164/rccm.201810-1944CI

9. Bice JB, Leechawengwongs E, Montanaro A. Biologic targeted therapy in allergic asthma. Ann Allergy Asthma Immunol. 2014;112(2):108-115. doi:10.1016/j.anai.2013.12.013

10. Darveaux J, Busse WW. Biologics in asthma--the next step toward personalized treatment. J Allergy Clin Immunol Pract. 2015;3(2):152-161. doi:10.1016/j.jaip.2014.09.014

11. Inselman JW, Jeffery MM, Maddux JT, Shah ND, Rank MA. Trends and disparities in asthma biologic use in the United States. J Allergy Clin Immunol Pract. 2020;8(2):549-554.e1. doi:10.1016/j.jaip.2019.08.024

12. Gelhorn HL, Balantac Z, Ambrose CS, Chung YN, Stone B. Patient and physician preferences for attributes of biologic medications for severe asthma. Patient Prefer Adherence. 2019;13:1253-1268. Published 2019 Jul 25. doi:10.2147/PPA.S198953

13. Centers for Disease Control and Prevention, National Center for Environmental Health. 2019 National Health Interview Survey (NHIS) data. Accessed December 6, 2022. https://www.cdc.gov/asthma/nhis/2019/data.htm

14. Zelaya CE BP, Moy E. Crude and age-adjusted percent distribution of respondent-assessed health status among adults aged 20 and over, by veteran status and other selected characteristics: United States, 2015-2018. National Center for Health Statistic. Updated June 19, 2020. Accessed December 12, 2022. https://www.cdc.gov/nchs/nhis/veterans_health_statistics/tables.htm

15. Szema AM, Peters MC, Weissinger KM, Gagliano CA, Chen JJ. New-onset asthma among soldiers serving in Iraq and Afghanistan. Allergy Asthma Proc. 2010;31(5):67-71. doi:10.2500/aap.2010.31.3383

16. Yi SW, Hong JS, Ohrr H, Yi JJ. Agent Orange exposure and disease prevalence in Korean Vietnam veterans: the Korean veterans health study. Environ Res. 2014;133:56-65. doi:10.1016/j.envres.2014.04.027

17. Huetsch JC, Uman JE, Udris EM, Au DH. Predictors of adherence to inhaled medications among veterans with COPD. J Gen Intern Med. 2012;27(11):1506-1512. doi:10.1007/s11606-012-2130-5

18. Mundell L, Lindemann R, Douglas J. Monitoring long-term oral corticosteroids. BMJ Open Qual. 2017;6(2):e000209. Published 2017 Nov 8. doi:10.1136/bmjoq-2017-000209

19. Van Staa TP, Leufkens HG, Abenhaim L, Zhang B, Cooper C. Use of oral corticosteroids and risk of fractures. J Bone Miner Res. 2005;20(8):1487-1486. doi:10.1359/jbmr.2005.20.8.1486

20. Warrington TP, Bostwick JM. Psychiatric adverse effects of corticosteroids. Mayo Clin Proc. 2006;81(10):1361-1367. doi:10.4065/81.10.1361

21. Miller DR, Safford MM, Pogach LM. Who has diabetes? Best estimates of diabetes prevalence in the Department of Veterans Affairs based on computerized patient data. Diabetes Care. 2004;27(suppl 2):B10-B21. doi:10.2337/diacare.27.suppl_2.b10

22. Acharya T, Tringali S, Singh M, Huang J. Resistant hypertension and associated comorbidities in a Veterans Affairs population. J Clin Hypertens (Greenwich). 2014;16(10):741-745. doi:10.1111/jch.12410

23. Dupixent (dupilumab). Prescribing information. Sanofi and Regeneron Pharmaceuticals; 2022. Accessed December 6, 2022. https://www.dupixenthcp.com/asthma/efficacy/safety-data

24. Li L, Wang Z, Cui L, Xu Y, Guan K, Zhao B. Anaphylactic risk related to omalizumab, benralizumab, reslizumab, mepolizumab, and dupilumab. Clin Transl Allergy. 2021;11(4):e12038. Published 2021 Jun 3. doi:10.1002/clt2.12038

Error message

A Better Way to Breathe: Combining Allergy and Pulmonary Care Into One Clinic

References

Recommended Reading

A Better Way to Breathe: Combining Allergy and Pulmonary Care Into One Clinic

References

Background

Pages

Recommended Reading