Personalized medicine approach now available for patients with moderate to severe disease
Innovations in Pulmonology & Sleep Medicine - Fall 2018
RODNEY J. FOLZ, MD, PHD
Division Chief, Pulmonary, Critical Care and Sleep Medicine, UH Cleveland Medical Center; Medical Director, Adult Pulmonary Functioning Laboratory, UH Cleveland Medical Center; Professor, Medicine, Case Western Reserve University School of Medicine
For the 5 to 10 percent of asthma patients with moderate to severe persistent asthma, the disease can negatively impact work, family life and an overall sense of wellbeing, says Rodney J. Folz, MD, PhD, Chief of Pulmonary, Critical Care and Sleep Medicine at University Hospitals Cleveland Medical Center. Fortunately, novel new tests and biologic therapies are starting to make a difference for these hard-to-treat patients.
PERSONALIZED MEDICINE APPROACH
Until recently, physicians treated all patients as if they had the same type of asthma, Dr. Folz says. “We just treated the symptoms. Now, we are learning more about the different phenotypes of asthma and we’re measuring patients’ biomarkers. We actually understand that different patients have different types of asthma. Some may respond to certain medications better than others.”
FENO testing. In addition to standard lung function testing with spirometry, Dr. Folz says UH physicians order a Fractional Exhaled Nitric Oxide (FENO) test. Nitric oxide is a gaseous biological signaling molecule with important physiologic functions. It is implicated in asthma and other cardiopulmonary lung diseases.
“FENO helps identify patients who have eosinophilic airway inflammation,” he says. “Knowing patients have high eosinophil levels in their airways helps guide how aggressive we need to be, and how closely we should monitor these patients when they’re on an inhaled corticosteroid spray. Every patient now gets this test.”
IGE Testing. UH also tests patients’ immunoglobulin (IGE) levels, Dr. Folz says. “IGE tends to be elevated in patients with a strong allergic reaction. If we know they have high IGE levels, we can look for what might be causing it, for example pollen, dust or food allergies, and then address it.”
Patients with high IGE are eligible for a novel infusion therapy with omalizumab (Xolair), one of the first infusion therapies for refractory, moderate to severe persistent asthma. “Reducing IGE levels in the blood can have a significant impact on improving patients’ asthma control, reducing asthma exacerbations and reducing the amount of controller medications and steroids they need to be on,” Dr. Folz says.
New infusion medications. Recently, three new add-on infusion drugs — reslizumab (CINQAIR), mepolizumab (Nucala) and benralizumab (FASENRA) — have become available for asthma patients with high eosinophils. These drugs block the interleukin 5 (IL5) pathway, which, when stimulated, activates the development and activity of eosinophils.
“A number of studies demonstrate these new infusion therapies can actually reduce the number of eosinophils, resulting in markedly improved asthma control, reduced number of asthma attacks and, in many cases, can reduce the amount of daily chronic controller medications patients have to take,” Dr. Folz says.
The UH pulmonary clinic has partnered with the pharmacy department at UH Seidman Cancer Center to develop protocols that make it easy for asthma patients to receive infusion therapies.
“When patients come to see us, we run biomarkers on them and phenotype the type of asthma they have,” Dr. Folz says. “If they’re eligible because they have elevated biomarkers, we can enroll them in the infusion therapy program at the clinic.”
ALWAYS CONFIRM DIAGNOSIS
It is important to objectively document that patients actually do have asthma, Dr. Folz says. “Studies show that up to 25 to 30 percent of patients who’ve been on controller medications for one or more years, and are then thoroughly evaluated, do not have asthma at all. Asthma is a chronic disease that requires years of medications and adherence to medications. Once patients are labeled with asthma, that label stays with them.”
Dr. Folz encourages healthcare providers to order a spirometry with and without bronchodilator if they suspect asthma. “If lung function improves 12 percent or more following bronchodilation, and pulmonary function improves by 200 ml, that’s your confirmation the patient has asthma,” he says. If the spirometry is negative, and you still suspect asthma, a methacholine challenge test (bronchoprovocation test) can confirm the asthma diagnosis.
“If you have a patient with moderate to severe persistent asthma who continues to have poor asthma control despite treatment, refer them to the asthma center at University Hospitals Cleveland Medical Center for evaluation and enrollment into one of our infusion programs,” Dr. Folz adds.