Dr J. Allen Meadows on Making the Decision to Put a Patient With Asthma on a Biologic

Patients with severe asthma are good candidates for biologics, but choosing which biologic requires a shared decision-making conversation, said J. Allen Meadows, MD, president of the American College of Allergy, Asthma & Immunology, a solo community-based practitioner at the Alabama Allergy & Asthma Clinic, and a clinical faculty member at the Alabama College of Osteopathic Medicine.

Transcript

What patients might be candidates for long-term treatment to prevent and control their asthma?

Well, you know, anybody that we're considering for a biologic therapy for asthma is somebody who has at least moderate to severe asthma and, in many cases, severe asthma. And asthma as a genetic illness, and we know that the children that have severe asthma often will go into remission, but once somebody kind of comes out of remission and has asthma as an adult, this is something they're going to have over their entire life. And typically, people who have severe asthma tend to continue to have severe asthma.

And in the absence of interventions from allergy and asthma specialists that change things, these people are going to need these medicines on a long-term basis. So, I don't ever view it when I'm starting somebody on a biologic that this is a short-term therapy, particularly in the domains of asthma. Certainly, for other indications for biologics, we use like hives, you might consider that for the short term. But this is something that's going to be long term.

And that's why it's really nice to have this long-term safety data, because I do shared decision making with my patients, and that's a question that frequently comes up.

There are several FDA-approved biologics in the United States to treat asthma. How do they improve care for patients over medications available before the first biologics?

The availability of biologics in the United States has really revolutionized how I treat people with asthma. I have always very aggressively managed asthma. I think everybody with asthma should live a normal lifestyle. I am not a person that's particularly afraid of the side effects of steroids—I'm more concerned about, you know, having fatal asthma attacks and not living a normal life.

And so, in my practice, I've had a number of oral steroid-dependent asthmatics, but since biologics have became available, I now have 1 oral steroid-dependent asthmatic and she's not on a biologic. Unfortunately, she got multiple myeloma as we are working her up for a biologic. The good news about that was that we were able to detect several eosinophil levels are very high being oral steroid-dependent, usually when I would check her eosinophil level, they'd be zero. And so, I got the records from the cancer center, and we're in the process right now. She's gonna have to be maintained on a biologic for the rest of her life for multiple myeloma and consulting with physicians at the university about using the combination of 2 biologics, which is not FDA approved and why I haven't done it up to now—not FDA approved and not researched research. So I want to do that [prescribe a biologic for her asthma] but you know, this person is the only person in my practice who still with asthma and oral steroid-dependent and because she was getting active treatment for multiple myeloma and remained on a biologic and even her I'm considering.

Now certainly, I have some patients with other conditions like sarcoidosis, and COPD that may be more oral steroid-dependent, and in terms of somebody that's got asthma would be a candidate for biologic none. And it's a blessing for these patients that just, you know, we see the research studies that they present on the biologics, and they say “I get your people who are dependent on oral steroids off of it”; well, just that they've all been taken care of. So, it's been a pleasure.

How do you identify the patients with asthma who will benefit the most from biologics?

We're looking at Th2 asthma and that's kind of a little bit of a nebulous term for some people severe asthma. I'm reminded of what former Attorney General Ed Meese said when he was asked how to define pornography. And he said that he couldn't define it, but he knew it when he recognized it.

And I know it's kind of an obtuse kind of reference, but I know Th2 asthma when I when I see it, and it's hard to lay specific things on it. They have elevated eosinophils, they have elevated exhaled nitric oxide, they typically have positive allergy tests, but there's even people with Th2 asthma that don't have that. They tend to be steroid responsive. One of the things that I think cues me off is the comorbid conditions. They've got sinusitis with polyps, and then atopic dermatitis. And certainly, when we're picking a biologic for a patient, I'm looking at the comorbid conditions. If they've got concomitant hives, it may lead me toward one decision or the other.

But, you know, when we're identifying the patients, it gets back for me with shared decision making. I mean, I point out the benefits, you know, “This particular drug will help these conditions,” and go through it. “This particular drug needs to be given this often. This particular drug is approved for this condition.” So, yeah, there are certain patients that are more likely to benefit—certainly the steroid-responsive ones, like I said before, the you know, people who are oral steroid-dependent. It's great to get them off of oral steroids.