Contributor: To Address Uncontrolled Asthma, Understand the Right Treatments for the Right Patients

As health care providers, it’s a scenario with which we are all too familiar–a patient, diagnosed with asthma long ago, visits for a routine appointment. They have been on, and adherent to, treatment since diagnosis, using an inhaled corticosteroid/long-acting beta₂-agonist (ICS/LABA) combination inhaler.

However, while they are sharing their current day-to-day activities, you notice they are experiencing symptoms more regularly and that these symptoms are impacting their daily routine. Many patients may not even realize that their symptoms aren’t a normal part of living with asthma and can be better controlled.

Not all asthma is created equal, nor will all therapies work for all patients. With continued innovations in asthma treatments offering new, improved options for patients, we are more prepared than ever to address uncontrolled asthma head-on.

What Is Uncontrolled Asthma?

Before we can talk treatment, it’s important to understand what “uncontrolled asthma” encompasses. Topline, uncontrolled asthma is defined as having frequent symptoms that interfere with everyday life, despite regularly taking medication. Symptoms may include:

• shortness of breath
• chest tightness
• wheezing
• coughing
• night waking due to asthma

According to the CDC, more than 60% of adults with asthma have uncontrolled asthma. Its effects can extend beyond the expected impacts–continued health care provider (HCP) appointments, worsening symptoms, and decreased quality of life. Given its unpredictable nature, uncontrolled asthma can lead to an increased risk of an emergency department visit or missed school and work, making the condition’s impact felt on an economic level as well.

As HCPs, we can tap into our training and toolbox of treatment options to help relieve symptoms, we are only as helpful as the information patients share with us, making diagnosing the condition and treatment a true team effort.

Involving Your Patient in Identifying Uncontrolled Asthma

Patients must know the role they play in managing their condition. It’s crucial that they know to diligently track their symptoms to ensure they can share an accurate representation of their asthma experience during their appointments. With months sometimes passing between appointments, it can be easy to forget about exacerbations or frequent rescue inhaler use or simply downplay the severity of the condition.

Patients should feel encouraged—even empowered—to take a critical eye to their own condition and treatment plan. Before making any pharmacological adjustments, however, HCPs need to ensure they understand the full extent of symptoms.

Objective strategies exist, including Baylor Scott & White Health’s Rules of Two or the QualityMetric Incorporated Asthma Control Test, both of which provide quantitative assessments to help determine how well a patient’s asthma is being managed.

For these uncontrolled patients in particular, self-management skills are key, including optimal inhaler technique, treatment plan adherence and awareness of their own triggers and risk factors, which may include cigarette smoke, stress, mold, physical inactivity, and poor nutrition leading to obesity.

Beyond tracking symptoms and triggers, and completing objective assessments, patients should also know to pay close attention to how frequently they use their rescue inhalers, as overuse can be an indicator that their asthma is not well-controlled. For these patients, HCPs need to assess what else can be done to help ensure treatment plans are as effective as possible.

Understanding When to Upgrade Patients’ Treatment Plans

While no treatment plan can be considered one-size-fits-all, it is not uncommon to prescribe a short-acting beta₂-agonist (SABA) for asthma attack relief, as well as a long-term control inhaler to supplement. Long-term control options include ICS, as well as LABAs, which are always paired with an ICS.

Despite taking their combination ICS/LABA as prescribed, even the most diligent, adherent patients can still experience asthma symptoms. With the typical combination treatment already at play, it becomes time to revisit the patient’s treatment plan and determine how to supplement.

It may be time to consider introducing an inhaled long-acting muscarinic antagonist (LAMA), which leverages a third mechanism of action to complement the existing ICS/LABA combination. ICS reduces inflammation, LABA activates bronchodilation, and LAMA inhibits bronchoconstriction, offering 3 distinct approaches to combating the underlying mechanisms of asthma.

As HCPs, we find ourselves practicing medicine that is constantly evolving and innovating, offering us even more options for poorly controlled, challenging asthma. While imperative to assess each patient’s lifestyle and condition on a case-by-case basis, tapping into these innovations–including LAMAs as a third mechanism of action–may be the tipping point to taking a patient from uncontrolled to controlled.