By Dr. Paul Ehrlich
To keep our board certifications, doctors are required to accumulate Continuing Medical Education (CME) credits every year as well as periodically take board examinations again, although at much greater intervals. One way we get these credits is to listen to lectures by experts on the latest research, and last night at the New York Allergy and Asthma Society was one such occasion. The evening’s topic was severe asthma, which was addressed by two speakers, both pulmonologists.
The first of these was Linda Rogers, MD FCCP, a colleague from NYU School of Medicine, Medical Director of the Bellevue Hospital Chest Clinic, and Assistant Director of Bellevue’s Asthma Clinic. I can’t do her entire talk justice, but I will say that it exposed the cracks in our overall approach to asthma. To wit, there are many, many patients we cannot help or do not help, and these shortcomings reflect flaws in the way we study asthma, the way we medicate asthma, the way we understand it, the way we work with patients, and the way patients work with us.
Part of this story can be told using numbers, and Dr. Rogers’ slides were full of significant ones. For example, in a telephone survey published last year, 71% of patients reported that their asthma was controlled and only 29% uncontrolled. Yet, by National Asthma Education and Prevention Program standards for control, the figures were exactly the reverse.
In data from before the age of Xolair, 25% could not achieve well-controlled asthma despite high dose ICS, LABA, and oral steroids. Since that time, Xolair has helped, but the pertinent statistics for Xolair are that it costs $1000 a month and requires infusions every two to four weeks.
Then there’s the issue of how we study new treatments. The standards for random controlled trials are more exclusive than a Washington, DC country club. In one community-based survey, only 4% of 179 patients with asthma met the eligibility criteria for 17 major randomized controlled trials. How can we expect to treat the broad population of severe asthmatics by excluding so many of them from research? It reminds me of the old banking rule: only lend to people who don’t need the money. As Dr. Rogers said, “Asthma is a heterogeneous disease, but treatment guidelines are one-size fits all.”
Indeed. Allergists have one big advantage over pulmonologists like Dr. Rogers—our asthmatic patients have allergies, which we know how to treat, although not always successfully. Non-allergic asthmatics present pulmonologists with a profoundly different challenge. Consider that these patients include a significant proportion of obese people—it’s hard enough to treat obesity alone, let alone the asthma that often goes with it. In a shocking statistic, 20% of them are current smokers or long-time smokers. What can doctors do for those who have failed to help themselves? Then, too, pulmonologists treat COPD, which has symptoms that overlap with asthma, but does not meet the most important criterion for asthma–reversibility.
The other speaker was Arthur Sung, MD Director, Bronchoscopy and Interventional Pulmonology at Beth Israel Medical Center in New York and on the faculty at Albert Einstein School of Medicine. An interventional pulmonologist mainly deals with conditions like lung cancer when you have to go into the lungs and do things. He spoke about a procedure called bronchial thermoplasty (BT), which Dr. Frank Adams, NYU pulmonologist, wrote about for us here.
Dr. Sung’s talk was quite explicit on how BT works, heat-zapping airway smooth muscles that have become permanently thickened by years of asthmatic bronchoconstriction, complete with video. The procedure is done in three separate sessions some weeks apart. One of the most intriguing things about the talk was that one study done involved a control group of sham-treated patients. That is, a third of patients went through all the motions of preparation, sedation, and having instruments shoved into their lungs, complete with sound effects, but not receiving the heat. The interesting thing was that all patients showed improved quality of life measures post-procedure, although the true BT patients did better for longer.
With Dr. Sung, too, a number told a significant story. He says that he only accepts 20% of patients who are referred to him. The rest are either COPD, whose lung damage can’t be reversed by heat any more than it can by medication, or asthmatics who are clearly not compliant with their medication regimens. BT is a last resort, not an easy way out. For now, BT is only being offered at certain medical centers around the country. I worry a bit that as it becomes more widely adopted, the lure of an $18,000 payday will become irresistible to other, less-careful practitioners.
Illustration by ivline.info