Dr J. Allen Meadows on Using Shared Decision-Making to Choose Among Biologics for Asthma

There are clear differences between the biologics approved to treat asthma, and finding the right one for a patient requires shared decision-making conversations, 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

How does safety and efficacy compare among the different biologics for asthma? Are they largely similar? Do we see clear differences?

Well, I do see clear differences among the biologics, I want to be important to point out that, you know, safety comparisons don't, you know, imply similar FDA indications or efficacy. But, you know, the big thing with dupilumab and the safety is the red eyes. And, you know, based on the number of people that have the red eyes, and that's with your eczema and your [nasal] polyp patients, they tend to respond to treatment for dry eyes.

And the patients are concerned about the side effects, and when I'm doing shared decision making, I go over the side effect profile in detail. I had one patient, that I thought was an ideal candidate for dupilumab, who also had concomitant conjunctivitis and red eyes; when I told him about the red eyes, he said “I'm not interested my eyes are already red.” And I said, “Yeah, but your eyes are red now because of inflammation.” And if we, you know, reduce that inflammation, and in fact, after a couple years we did—he had eczema and polyps and asthma, we did convince him to go on it—in fact, his red eyes have improved on that.

But the side effects play a big difference in shared decision-making. From the beginning dupilumab you could use at home. All the other biologics, in the beginning, you had to use in the doctor's office. Several of them have been approved for home use now, but one of them is still [not] approved [for at-home use]. In terms of efficacy, I think you're looking at the patient profile, there may be some patient profiles that one drug may be more effective than, than other. Certainly, I'm looking at eosinophil levels when I'm coaching my patient about the decision that they make on that. And it's a shared decision. So, that I don't come in and say, “We're choosing this biologic,” I come in and say, “All right, according to your bloodwork, you're eligible for drug A and B. Here are the advantages of A. Here the disadvantage of A. Here's the advantages of B. Here's the disadvantages of B.”

But the efficacy is different. Certainly, you know, I've had patients that failed other biologics that improved when they began using dupilumab. Quite honestly, I can't think of a single patient that I've switched from dupilumab to another biologic, but I can certainly think there might be a time when that comes in the future.

How do shared decision-making conversations usually go? Do patients usually understand what is being talked about or is health literacy an issue?

Health literacy definitely is an issue. And that's why I do it over a period of time. Once I make the decision, in my mind, that a patient needs to go on a biologic, we have a process. And so, I begin at that visit, to discuss with them what the biologics are, why they're different than the medicines that they're taking, and, not in detail, but kind of briefly what maybe the pros are, and I’ll go over in the first visit over the cons. And then I give them some representative literature. So, you know, I may give them literature from an anti-IgE [immunoglobulin E] drug, I may give them literature from one of the anti–IL [interleukin]-5 drugs. And often, depending on the comorbid conditions, I give them literature on dupilumab.

So, they get the literature on all 3, and then we send them to the lab, preferably when they haven't been on all steroids recently. And then we get the bloodwork back. And then I would say that “you are eligible for these drugs, I want you to focus on reading the literature for these drugs before you come back,” something that the pharmaceutical company provides for me that I give to them. And then we're coming back, typically, I don't know, 3 to 5 weeks, we're going to come back for a follow up visit. And it's usually a long follow-up visit. That's when we have the big discussion.

So, you know, what do you understand about the medicines? What, what were your thoughts from reading the brochures I gave you that you might prefer one drug over the other? And then they tell me, I say, “Well, why? What aspect of that drug?”

Well, somebody might say that, you know, “drug X, I've got to come into your office to get it.” And, in fact, I had this conversation this week, a patient with Medicaid, a working mom, and we actually were even including immunotherapy, and she just isn't able to come in with her, her child to my office in the beginning. And she was really looking for something—that home administration would be something that she could do. And so that's kind of our shared decision-making conversation.

And you'd mentioned limited health literacy, this was somebody with limited health literacy. And we didn't come to a conclusion until after we've had a visit a phone call and then another visit, but that's the way [we do it] even with people with good health literacy. You know, they'll come in and say, you know, “I saw a commercial on TV and Dupixent is the drug for me.” And, and so I'll just look at them and say, “all right, well, that is certainly possible. Dupixent may be the right drug for you. But let's ask some questions. Let's get your blood work drawn. Let's see which ones that you're eligible for.”

And so, I kind let them take a little time out there, because they're all gung-ho and excited, and [they think] “this is the only drug for me.” And oftentimes the drug they ask for is the drug they get, but sometimes it's not. And so even people that I think have very good health literacy, I like this to be a process of over several weeks in making the decision. Because this is the medicine we're going to use over a long period of time, and some of these medicines can have adverse events. And so, if something like that comes, I really want, you know, the patient to have discussed it before we have the conversation, “well, you've had this side effect from this drug.” you know, for instance, with Dupixent, dupilumab, if they get red eyes, nobody's surprised. Because we've talked about it beforehand.