ASTHMA Asthma Season - Autumn 2020

Asthma Season - Autumn 2020

Written by Sergei Belenky, MD, PhD – Office of Allergy, Asthma, & Immunology

Highly unusual and grim circumstances are set-

ting the stage for this year’s asthma fall season which is full throttle underway across the United States. COVID-19 has created an all year round viral season with staggering consequences for communities around the country and worldwide. Autumn is commonly associated with numerous respiratory viruses, like rhinovirus, metapneumovirus, adenovirus, and influenza virus. The latter and the former are the most important groups triggering seasonal exacerbations of asthma. Asthma exacerbations or flare-ups are events in the course of the disease when utilization of care is at its utmost level, when healthcare resources are maximally employed, and medical, social, economic impact of asthma are felt the most. The toolkit that can prevent asthma exacerbations includes optimal asthma control achieved with effective and safe asthma treatment.

Asthma is a common inflammatory condition of the airways affecting 340 million people worldwide, and up to 10% of the population of the United States. Seven million children are diagnosed asthma sufferers, with millions more undiagnosed. Clinical characteristics of asthma include wheezing, shortness of breath, tightness in the chest and cough. Reversible or variable airway obstruction is its main physiologic feature, and airway inflammation is the hallmark of its pathobiology. The goal of any asthma therapeutic plan is achieving asthma control. Ideally that involves reduction or elimination of daytime symptoms, nocturnal awakening with any difficulty breathing, improvement of the quality of life by increasing functional capacity including recreational and sports activities. Maintaining lung function at normal or near normal level as well as reduction of the risk of exacerbation are the ultimate parameters of overall success in asthma management.

For the past almost 50 years inhaled corticosteroids (ICS) have been the cornerstone of asthma treatment representing so-called asthma controller therapy, whereby short-acting beta-2 agonists (SABA) being a reliever therapy - indicated for relief of symptoms whose very prevention is one of the most important therapeutic goals. Frequent use of SABA is a reliable marker of poor control of asthma with increasing risk of exacerbation. Unbridled use of SABA in the 1980s is believed to be associated with a spike in asthma mortality. And conversely wide use of ICS as the mainstay of asthma control led to decreased asthma mortality. along with many other benefits like daytime and nighttime symptom control, improvement in lung function, and decreased frequency and severity of exacerbations.

Since the mid-90s ICS combination therapy with long-act- are targeting difficult- to-treat and severe asthma patients whose ing beta-2 agonists (LABA) has been used widely and found to be prospects previously were dismal at best. superior to high dose ICS. ICS/LABA combination therapy is currently recommended by all latest guidelines in adolescents and adults, as PEDIATRIC ASTHMA DURING well as children 6 years and older in situations where ICS mono- COVID-19 PANDEMIC therapy is insufficiently effective. LABA agents however should NOT Risk associated with COVID-19 as it pertains to asthma in general be used as single controllers as FDA 2010 public health warning is not quite clear, however in March of 2020 about 25% of young emphatically stated. adults hospitalized with COVID-19 had a history of asthma. Risk of

There’s certainly the role for other classes of asthma medications COVID-19 in asthmatic children is even less well known, but does not that are used in pediatric and adult asthma populations. They include appear to be high. Nonetheless asthma control is extremely importleukotriene receptor antagonists (LTRA) and long-acting muscarinic ant during the pandemic. receptor antagonists (LAMA). Montelukast is widely used in children No step down strategy is to be applied to avoid breakdown of (1 year and older) for the treatment of mild asthma and allergic asthma level of control, where possible nebulized ICS and SABA rhinitis. FDA recently issued a ‘black box’ warning about possible should be switched to MDIs or dry powder inhalers. But never at the neuro-psychiatric adverse effects of the drug with no removal from expense of losing asthma control, therefore if necessary nebulized the US market. Spiriva Respimat is the only LAMA agent approved for form of asthma drug delivery should be continued. Spring time shortasthma monotherapy for children 6 years and older and adults. ICS/ ages of SABA appear to have been resolved. All basic approaches to LABA/LAMA combination therapy long available for COPD patients has asthma treatment are unchanged including use of ICS, ICS/LABA, and recently been approved for moderate to severe asthma ages 18 and biologic agents. Systemic steroids whose role in COVID-19 remains older - TRELEGY ELLIPTA available in 2 different strengths. to be controversial in children should be used unequivocally for

Despite significant progress in achieving measurable results in asthma flare-up treatment. asthma control, 5 to 10% of all asthma patients belonging to so-called severe asthma remain to be poorly controlled comprising Fractional exhaled nitric oxide (FeNO), blood eosinophils, and the group most vulnerable to crippling effects of the disease and death. Over 20% total as well as antigen-specific IgE are widely used biomarkers of all asthma patients are in the group of of T2 inflammation allowing to select most appropriate of FIVE so-called difficult to control, requiring addi- available biologic agents approved as an add-on treatment for tional resources and increased attention to adherence to therapeutic regimen. different endotypes of asthma.

In the last decade significant strides have been made in our understanding of pathobiology of asthma, its phenotypes and endotypes. Airway Considerable morbidity is anticipated from influenza driven inflammation is presently categorized into type 2 (T2) and non-T2 asthma exacerbations in both children and adults. In order to avoid inflammation. Important biomarkers of T2 inflammation have been ‘twindemic’ influenza vaccination should be completed by the end determined and used for practical purposes of asthma treatment of October ideally, clearly November flu vaccination is also apwith a new and revolutionary class of BIOLOGICS which have dras- propriate and utterly important. Hopefully social distancing, mask tically changed the landscape of asthma care in this country and wearing, home education and hybrid modes for school children will beyond. Fractional exhaled nitric oxide (FeNO), blood eosinophils, and serve not only COVID-19 spread mitigation, but also other respiratotal as well as antigen-specific IgE are widely used biomarkers of tory viruses dissemination. T2 inflammation allowing to select most appropriate of FIVE available In summary, be prepared for a viral season in earnest, making biologic agents approved as an add-on treatment for different endo- sure your children are well equipped with inhaled therapeutics, types of asthma. Two of them are FDA approved for children 6 years follow the guidelines and action plans. and older - OMALIZUMAB (XOLAIR), a monoclonal antibody against AHN Pediatric Institute Allergy, Asthma. Immunology Clinic is IgE and MEPOLIZUMAB (NUCALA), an anti-IL-5 monoclonal antibody. there for you for both in person and telemedicine consultations - call Xolair is designed to address allergic asthma phenotype, whereas at 412-348-6868. Nucala is most appropriate for eosinophilic asthma. These biologics Stay healthy and stay safe.