By Dr. Paul Ehrlich
In our book, we quote Dr. Anthony Gagliardi, a pulmonologist from St. Vincent’s Hospital in Greenwich Village, who said “the study of asthma is the study of one.” This is out of date only in the sense that St. Vincent’s is no longer there, which means there is no community hospital for a vast area in lower Manhattan. Otherwise, Dr. Gagliardi’s observation is just as valid today as it was a dozen years ago when I heard him say it.
I was reminded of it with a vengeance recently when the Journal of Allergy and Clinical Immunology (JACI), which is to allergists what Variety is to movie stars, published an article called “Asthma Across the Ages: Knowledge gaps in childhood asthma.” It was written by Dr. Stanley J. Szefler at National Jewish Health in Denver (where modern asthma treatment was invented) and his colleagues. As just one example of a “knowledge gap” you would think that we would be pretty good at recognizing exacerbations, yet the authors write that this, which you would think of as fundamental, is a gray area:
Although most clinicians are able to identify an asthma exacerbation, the definition of what constitutes an exacerbation, particularly as it relates to a clinical trial, remains elusive. Most definitions rely on a combination of symptoms and medication changes, such as the prescription of systemic corticosteroids and increased use of short-acting beta-agonists. However, the validity of such definitions is unknown because they can vary by study participant and investigator. Furthermore, the relative importance of an exacerbation in the natural history of the disease is unknown. Is there a cumulative effect of exacerbations such that a patient with more frequent exacerbations is more likely to experience increased morbidity later in life? Does the severity of the exacerbation matter? The answers to these questions are unknown.
If we can’t answer these questions about the signature symptom of a condition we have known about for thousands of years, what can we do?
I have repeatedly cited the observation of an old friend and colleague to the effect that there have been no game-changing breakthroughs in asthma treatment since the development of synthetic inhaled corticosteroids (ICS) 40-odd years ago. These remain the go-to treatment for asthma but they don’t work for everyone; as the new science of genomics has taught us, many patients are innately incapable of responding to ICS. Montelukast (Singulair) was just one drug that convinced many pediatricians and family practitioners they could treat asthma without inhalation. Chronic obstructive pulmonary disease (COPD) wheezes like asthma, but it isn’t, yet it is often treated with inappropriate asthma drugs. Inflammatory asthma sometimes was and still is treated only with drugs for bronchoconstriction, with tragic results.
The nature of exacerbation is not the only knowledge gap mention in the article. The authors write:
Primary unanswered questions related to the natural history and pathophysiology of asthma include the following:
•What inflammatory phenotypes are present in children, what is their long-term stability, and how do they relate to airway remodeling?
•What factors are responsible for triggering asthma onset?
•What factors are associated with progressive disease?
•What is the influence of sex on asthma in relation to inception, prevalence, persistence, remittance, and response to therapy?
•How do asthma exacerbations contribute to long-term outcomes?
We don’t have to answer all these questions to an academic standard to get better outcomes, however. We could do much more to cut the $56-billion annual US asthma bill by applying that which we do know more judiciously. ICS may not work for everyone, but lots of patients for whom it does work don’t use it as they should, and they end up in emergency rooms. Doctors who take a parent’s word for it that there are no symptoms and blithely renew a prescription for six more months—those are the ones whose patients end up in ERs. Of course, exacerbation isn’t the only measure of illness. As we say in our book, a child who is demoted from mid-field to goalie on the soccer team, or whose schoolwork is suffering because of interrupted sleep may also be suffering. Only 10% of patients with atopic diseases end up seeing a specialist; raising that percentage would help because you can’t cover the full range of issues in allergies or asthma in an 11-minutes-and-out general practice. For our part, allergists should return phone calls and emails about the little challenges that crop up in the everyday management of chronic disease. You don’t need a bedside to have bedside manner.
As a practicing allergist, I can’t fill in the big picture knowledge gaps, but I try to help my patients and other doctors by sharing the things that work for me. I am committed to giving a series of talks and grand rounds for pediatricians around New York and regular rotations for peds residents from NYU. I am very pleased to announce that Dr. Maureen Egan, who gave a wonderful talk to her fellow pediatric residents last year, has been accepted as an allergy fellow at Mount Sinai, where she will learn from the best.
Happy New Year.