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Breathing Easier: The Past, Present and Future of Asthma Treatment · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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This is Pediatrics Now, brought to you by the Department of Pediatrics at UT Health San Antonio.
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Today, I'm bringing you Grand Rounds. Let's listen in. It's my pleasure this
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morning to introduce Dr. Jonathan Schroeder, who is a board-certified pediatric pulmonologist.
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He's a major in the United States Army and assistant professor at the Uniformed
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Services University of the Health Sciences.
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He serves at Brook Army Medical Center, where he is Division Chief of Pediatric
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Pulmonology, as well as Cystic Fibrosis Affiliate Director.
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He practices part-time with UT Health San Antonio. Dr. Schroeder completed medical
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school at the Uniformed Services University, pediatrics residency at Tripler
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Army Medical Center, and fellowship in pediatric pulmonology at Children's National Hospital.
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His academic and clinical work focuses on pediatric pulmonary disease,
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cystic fibrosis, asthma care, pulmonary function testing, medical education,
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and quality improvement.
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He has authored peer-reviewed publications and book chapters presented nationally,
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and he teaches medical students, residents, and faculty.
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So a warm welcome to Dr. Schroeder. Thanks, Dr. Schroeder.
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I will be talking today about asthma treatments, reading easier,
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past, present, and future of asthma treatment with very much emphasis on present.
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I have no disclosures as far as like, I don't work for a biotech company,
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but I do insert sometimes my own practice style with just, you know,
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we get asked a lot about these questions about like, you know,
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how do you interpret this and, you know, how do you interpret these guidelines
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and how should I treat my own patients?
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So at times I will say like, this is exactly what I do for my own patients.
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So I just want to be clear on that.
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That's not necessarily like truly from the guidelines. It's just how I've interpreted
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it myself and for my own patients.
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Learning objectives this morning, we will be talking about a little bit about
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asthma biology. I don't think I could do like an asthma talk without going a
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little bit into like, you know, some pathobiz.
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And then I guess the rationale for, you know, why we use inhaled corticosteroids
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so much in our practice, it's kind of the bedrock of asthma outpatient treatment care.
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I do want to add that, you know, this talk is intended for typically like a,
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you know, a generalist or a general pediatrician who is managing outpatient asthma therapy.
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I do go into GINA and NHLBI. There is a very heavy emphasis on GINA.
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And we will talk about air and smart therapy.
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We'll be applying like smart therapy as far as like dosing, counseling,
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a little bit about action plans.
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And then objective four is to talk and go over a bit about comorbidities of
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asthma, mimics, a little bit about biologics, and then potential new therapies out there.
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So asthma is, you know, it's becoming more complex.
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And it's kind of a good thing because like, you know, back when we had like
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a one-size-fits-fits-all model with asthma,
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it wasn't really, you know, we weren't really grasping the full extent that
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asthma is now like, you know, an umbrella term that does encompass multiple
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phenotypes, endotypes,
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and that we're having like more tailored therapies for our patients, which is a bit better.
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So it's common, it's complex, heterogeneous. It is an inflammatory disease,
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which I will get into a little bit.
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It's characterized by airflow obstruction, especially, you know,
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we can see that like when we have patients who wheeze and dry cough and have
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shortness of breath and things like that. But, you know, we can also measure
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it with pulmonary function testing.
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It is variable and reoccurring, which kind of goes into like the fact that like
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this is a chronic condition and it is at least like partially reversible.
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Like we do have some great, you know, medications, some staple medications and
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some new medications that can help
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reverse or suppress or downregulate all of the pathways that are leading to
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things like asthma attacks and recurrent symptoms and things like that.
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Asthma does combine variable airflow with airway disease. It is,
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again, a disease of inflammation, which is key to why we do things,
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like why we throw inhaled corticosteroids at these kids or our patients in general.
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So there's smooth muscle constriction, that mucus can narrow the airway and
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can cause a contraction over a smooth musculature.
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So you can get like a picture that looks a little bit on the left to the right
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where there's very obviously less airflow going through that, you know, that airway.
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It is a very, very common disease. So we're all, you know, as a general pediatrician,
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we see it a lot, a heck of a lot.
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And it tends to, you know, increase in the amount of patients,
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you know, that get diagnosed with that as we get older, or as patients get older, excuse me, where,
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you know, our prevalence increases, you know, as we get to adolescence,
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our prevalence is about like 9.5%.
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And this is from CDC data from 2021.
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And then as like overall, our prevalence is about 7.7%. So again, a very common disease.
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In the united states about 6.3 percent of u.s children have asthma and then
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there's like 1.4 million ed visits a year,
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so there is a incredible or a very very significant health costs and utilization
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burden to asthma people still die from asthma which is which is why i still you know,
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very kindly i do tell patients that like this is not a benign thing like we
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we do actually want you to use your medications because, you know,
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people still die from asthma.
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So in 2024, a total of 3,722.
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That is all ages. That's not just children. Very few are children,
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but it's still not benign. It is a disease that's still characterized by,
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you know, health disparity.
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Ethnicity. There's a higher prevalence in Black individuals versus other races.
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And then there's also a correlation potentially with income.
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And that, you know, it's certainly a great topic to talk about when we go into
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like things like social determinants of health, because there's a lot of disparity
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and certainly a lot of room for improvement in how we manage the disease.
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We do characterize phenotypes now with asthma. Like we do have like a set of
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symptoms that falls under a certain term or a category that we can use to better
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characterize asthma and break it down a bit more.
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Most of the asthma that you will ever see is allergic asthma,
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and that's like 50 to 80% of cases. But we also have a set that's non-allergic asthma.
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We're trying to measure these pathways and markers, and they're not necessarily coming up positive.
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We thought that this is maybe more neutrophilic. That is very,
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I think, in my own opinion, very difficult to measure even if we're doing like
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bronchoscopies on these kids.
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Cough variant asthma, it's like, you know, we're coughing all the time.
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It would get better with albuterol, but otherwise, you know,
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not necessarily a conglomerate of other symptoms that we're seeing to related to asthma.
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And then certainly asthma can pop up later on, which is, you know,
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what I do remind patients when like you have a teenager coming in and she's,
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you know, wheezing and having shortness of breath with exercise that improves
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with bronchodilators. Like how did this happen? You know, I hadn't think as a.
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Persistent airflow limitation, asthma with obesity, which is its own category.
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And then something I deal with, I've actually ever seen in my pediatric population,
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maybe others have, but aspirin exacerbated,
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asthma, which has its own trifecta of symptoms, including nasal polyps and NSAID
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sensitivity, as well as asthma symptoms.
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We can break that down further because we now have a better understanding of
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the molecular pathways included with asthma, you'll see in the literature a
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lot, like type 2 high asthma, type 2 low.
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I assume that also as like type 1 asthma, although lately in the literature,
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I think type 2 low is a more accepted endotype label for these pathways.
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So we have type 2 high, which is a TH2 cell mediated,
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which are triggering interleukin cell 2, which are small population cells that
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are powerhouses and driving forward cytokine release to eventually release IgE
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and increase emosinophils.
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This is defined more as an eosinophilic endotype versus type 2 lobe when you're
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not seeing those markers and is better characterized as a T2017 mediated pathway,
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and thought to be a bit more neutrophilic.
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It's a bit less defined. I almost feel like it's almost like we get these labs
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and sometimes we measure them over and over again. It's like,
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well, it's type two high because I can prove it. And if I can't prove it,
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like I'm going to label it as type two low.
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It does make a huge difference as we get into like management,
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especially when we talk about biologics on like what we can actually use and
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prescribe and what we can't.
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There are markers of type 2 inflammation that we can go, we can measure.
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You know, some of us have good access to these, others don't.
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And I'm not, you know, I don't have access to everything, including pheno,
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but we can measure things like bloody eosinophils to better define these endotypes.
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Pheno itself is, I didn't really use it very much in fellowship,
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and I don't have a machine now, but our allergy clinic does,
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so I send them a lot of patients too.
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So there are distinct cutoffs as far as with children and adults.
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I try to make these slides useful because I know you all get printouts,
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so it might be useful just, you know, keeping around if this is something you
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readily do, because I don't expect anyone to just memorize this.
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But it is, you know, important to use as far as when you're actually utilizing
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these markers and trying to figure out if this is high or not.
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Sputaminosinophils, I've only seen really in research purposes,
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or I don't regularly do it, but it's something you could do or something that's out there at least.
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And then, you know, we do, we can measure IgE, we get like allergy panels and
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things like that, or we can really show if someone is like allergic or not.
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And oftentimes we'll see like when there's like comorbidities of allergic rhinitis
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and someone is like coming up positive, it is not unheard of for them also to have asthma.
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And it's not also unheard of that. That asthma is probably triggered by many
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of the similar pathways that's causing someone to also have uncontrolled allergies.
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In total IgE, we can certainly measure as well.
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What this all boils down to is what we're trying to prevent,
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which is, you know, obviously several things like, you know,
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quality of life, keeping these kids happy and healthy and playing and doing
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normal kid things, keeping them out of the hospital.
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But over time, there could be the consequence of air remodeling,
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which is often triggered by ongoing inflammation, recurrent bronchoconstriction,
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recurrent exacerbations leading to, you know, increased fibrosis,
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smooth muscle and mucus cell changes that eventually thicken and narrow the airway.
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So you have normal on the left and then we have this remodeling going on on
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the right. And you can kind of easily tell like which one airflow probably moves in better or worse.
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So it's a long-term consequence for untreated asthma.
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So there's a reason for everything that we do. And I try to tell patients like
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I can't necessarily say that your condition will get better.
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And oftentimes we do see that in childhood, but there is also a chance that
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things could get worse if we live with relief. we leave things untreated so
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it's important to adhere to your your medications.
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ICS is the cornerstone of asthma. It kind of is integrating with most of our outpatient therapies.
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And then we're usually adding on things to ICS instead of adding on ICS to other medications.
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So it suppresses airway inflammation, it reduces swelling, improves airway sensitivity,
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and it does improve symptoms.
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You know, we've probably all seen like like plenty of patients that improve
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on these therapies and do a good job as far as, you know, maintaining their
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control and staying out of the hospital and then their lung function.
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Also, when we're able to measure, it does look better or tends to look better.
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And it has been very much proven to reduce severe asthma attacks.
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So we use it in our preschool children and I've used it in plenty of potential
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babies too, as far as like, you know, sometimes we're dealing with recurrent
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bronchiolitis, which is, you know, I will say that for a total different topic,
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but it does get into our cell and triggers transcription factors and ultimately
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helps suppress inflammation to better control the disease,
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which is very important in the overall control and symptom relief for these patients.
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So I'm going to get into the guidelines a bit, and this is going to become more,
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I guess, treatment-focused as of now. So the two, I think, biggest guidelines
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that we use in this country are GINA and NHLBI.
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So GINA is the Global Initiative for Asthma. It started in 1993.
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It's evidence-based. They do PICO scoring, and they do grade their evidence.
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And overall, it's used to improve care and reduce mortality worldwide.
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It is used for clinicians and policymakers.
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I do want to highlight that it's global. So you will see things in GINA that
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don't necessarily, or I wouldn't say does not apply to the United States,
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but it's a little more difficult to apply to the United States.
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I think the overall messages as far as what we do or what Gina recommends can
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still be very much applicable.
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It does come out every single year, which is great. So if you go on like Gina,
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you know, and try to download the copy, you'll get this like watermark on it.
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And if you pay more money, you'll get it without the watermark.
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But it is very, very much accessible, which I think is fantastic.
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Actually, both of them are. So you can readily look them up.
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NHLBI, National Heart and Lung Blood Institute under the NIH has been around for a while.
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So, but it is, are these our guidelines and actually true guidelines meant to
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improve diagnosis, management, and quality of life? And it's more centered around the United States.
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One thing I do like about NHLBI a lot is that like the dosing in it is more
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applicable to the medications that we readily give our patients,
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which makes things a little easier and less confusing, as well as things like,
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you know, asthma action plans and other material that the guidelines provide.
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Audiences, U.S. clinicians, is a U.S.-based organization. obviously,
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especially primary care.
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It is very comprehensive. The reports do, you know, there's certainly like number
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of years between when, you know, NHLBI puts out, you know, a report.
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And the last time there was any updates was 2020.
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And there was a total revamp in guidelines before that in 2011.
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So I'm sure they're working on future updates as we speak.
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So this was kind of where we've come from to where we're going to or where we are now, actually.
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So back in 2018 and even like earlier editions,
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we were using what, you know, most of us or many of us probably consider like
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traditional asthma therapy, like where we have a kid who's on,
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you know, some sort of ICS and that's like an ICS alone.
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And then the reliever is a Saba, like albuterol.
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And then as we increase that up and then finally, when we get to step three
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and five, we usually, We can use combination inhalers, but Saba use still remain
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very common as the reliever.
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We didn't have a lot of data as far as like ICS Fomoterol, which is what we use a lot more now.
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We didn't really think of that as a reliever, even though data was starting
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to come out on the uses of Fomoterol as far as what we could do with it in the
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introduction of, you know, our reliever.
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There is still mention of it, like, and this is the picture, the figure is from 2018.
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So as needed, Saba or low-dose ICS-Formeterol was a possible recommendation,
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as far as step three, step four, step five therapy,
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although it was nowhere near the push that it is now that there's a potential
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better way of giving relievers or like reliever therapy for our children,
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of our patients, which is very predominantly focused on Formeterol.
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And then that's where we get to now. So this is from GINA2026.
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Are, this is in particular, adults and adolescents 12 years and up,
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when we're seeing the preferred reliever, which is, you know,
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when we're talking about track wine, or as-needed low-dose ICS for midderall,
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and when we're talking about air inhalers, anti-inflammatory reliever inhalers,
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maintenance reliever therapy, mart therapy, aka smart therapy,
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and we're seeing now a big push to kind of use these inhalers,
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and I will go into potential evidence that supports why they're potentially
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better than just a Saba alone, you know, just albuterol alone.
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I do want to highlight, and I'll do this probably several times,
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not to beat a dead horse, but I will never consider a therapy if a child comes to my office, you know,
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on a Saba and on an ICS, I'll never consider that wrong. There's usually circumstances that led to that.
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You know, Gina still highlights that. That is still an approach as far as track two therapy.
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There's never a wrong approach necessarily with asthma, except to just not do
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anything at all and not to actually address the issue.
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So there's still kind of room for that and still, you know, the ability to use
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those therapies. There just might be better things out there for our patients.
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Asthma severity, NHLBI versus GINA, they do define it a little differently now.
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This slide is geared towards adults and adolescents greater than 12 years old.
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So NHLBI does, and this,
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is what I was taught, with mild, moderate, and severe persistent symptoms,
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and actually what I still code as far as ITD-10, or what's available to code for ITD-10 codes.
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But it's defined, like, based on how they are as far as their symptoms,
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whether they're, you know, waking up at night and, you know,
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with significant asthma symptoms, how often they're occurring a week,
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how often they use their albuterol,
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or their rescue, if they actually have it, what their pulmonary function tests look like.
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And we can break that down into categories. And that's, like,
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when we actually see the patient.
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Gina itself defines mild, moderate, severe more as what is actually keeping
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them controlled. Like, we've already started medication. We've already started a regimen.
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How are they actually responding to that? Where we can classify that as now
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they're on medication, they're well-controlled, they're using the medication,
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they're more mild, or they need more low to medium-dose ICS,
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LABA, such as Simicor, to actually control their symptoms.
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Maybe they're more moderate. And now we're on high dose, and we're either uncontrolled
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or requiring those to actually maintain control. So severe, that's how Gina
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defines severe asthma based on their actual dose needed to control their symptoms.
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The latest GINA and NHLBI updates, just to kind of gloss over this,
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is that with mild asthma in GINA 2026, we do have more school age,
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air, like anti-inflammatory or reliever recommendations.
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To do that at an earlier step than we've probably ever done that before,
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when we were using like SMART and MART therapy now in ages 6 to 11.
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And then severe asthma, there's more biologic options out there.
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So if there's anyone out there who does use biologics, such as,
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you know, allergy, immunology, or, you know, dermatology, we're finding more uses for them, too.
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But there's more guidance as far as asthma when it comes to biologics and GINA.
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And then there's better flow charts, too. So they do update this every year, as I mentioned.
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And the information, I think, is incredibly useful. And then for NHLBI,
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back in 2020, when the focus updates came out, there was certainly now more
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recommendations for smart therapy.
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But there wasn't any focus updates regarding air therapy so that's been more,
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I guess, genus-specific but certainly I'm sure some of us actually do incorporate
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air therapy in our practice as well when we're using Simicor as needed only,
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Smart therapy is actually recommended or advised down to age 4,
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which is different from NHLBI when it's down to age 6.
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There are new biologics out there, obviously, but because it's a focused update
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in 2020, there's certainly less mention of biologics in NHLBI itself.
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And there's more focused areas that NHLBI covers than GINA as well.
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So let's get into Fomitorol.
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So it's rapid relief. It does create long-acting, or it does last for a while, compared to albuterol.
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So it is a long-acting beta agonist, or considered a LABA.
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It works within minutes. It lasts for about 12 hours, compared to albuterol,
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which can only last for 4 to 6 hours.
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So the data is very comparable between the two, which actually does make,
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for motorol, a very good reliever itself. as it is comparable.
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And because it does last so long, it does make it generally a good option that
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we can combine with an ICS to lose potentially both as our maintenance inhaler
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in that formulation with an ICS, as well as our reliever therapy.
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And it certainly simplifies things.
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There have been several big studies that have come out to show that definitely
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in the combination of an ICS, there's potential improvement when we're looking
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at severe asthma attacks,
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or the comparison with other medications, and again, gene is global,
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so we're going to compare it to medications we might not readily use in the
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United States, like inhaled terbutyline.
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But there is certainly great evidence to say that it's working,
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and I'll go into the studies in a little bit in a bit more detail in some later slides.
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SMART and MART describe the same maintenance strategy. So SMART stands for single
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maintenance reliever therapy. MART stands for maintenance reliever therapy.
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It's the same thing. So you'll just see that on Gina, just not to confuse the
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two, that they are relatively interchangeable.
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So we're using as our daily controller scheduled ICS Fometorol with SMART.
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And as a reliever, now we actually get to use the same inhaler,
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which is fantastic and really does help our patients as far as better understanding their regimen.
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Just because of Fometorol's comparison to Albuterol.
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And not only like working very fast, but as better than Albuterol,
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it can work for much longer.
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And Gina, it's typically used in ages six to 11 and the preferred track one,
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although, which is what I mentioned.
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And there's such a thing now called air therapy, which is anti-inflammatory
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reliever therapy, which is what we can use.
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It's, there's no maintenance regimen or inhaler regimen with air therapy.
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We're basically using these inhalers as needed, which again is going to be an
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ICS for motorol inhaler.
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But now this is, now we're showing or we have evidence to say this is a bit
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more superior than using, you know, a Saba alone, such as albuterol.
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So there's, you know, usually this is typically for like mild patients or patients
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with like intermittent symptoms who are just trying to get them to use something
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at home or they're just having maybe exercise-induced symptoms.
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So definitely not for like severe patients who need to be on it every day.
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In the United States, we have several ICS for motor oil options.
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This is mostly dictated by, you know, insurance and what we have access to.
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And at least for one of the medications on this slide, I typically have to do
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a prior out to get it, which kind of discourages me to actually prescribe it for my patients.
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But in my hospital where I work at Burke Army, mostly can prescribe Budesonide
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for Moterol pretty readily, either a Simicord or Brina.
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Simicor, manufactured by AstraZeneca. We typically have two formulations available
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in the United States, including 84.5 and 164.5.
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Braina is the generic form of that, but manufactured by a different company,
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which is Mylan Pharmaceuticals under Viatris, conjunction with a company called Candiva, which,
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does more, it's like a pharmacy dispersing company.
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It's the same formulation and almost you can use the medications,
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I guess, interchangeably, as in like if a patient shows up with Brena 84.5 versus
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Simicor 84.5, there's no necessarily difference between the two.
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And that's what I've seen. And that's what I've also seen in the literature.
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But there's also Dulera, Mometazone, Formotorol, which is manufactured by Organon.
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This is what I usually need a prior auth to actually get.
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There's no superiority that I've ever seen between Dulera, Brina or Simicor clinically.
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And I think I have like one patient on Dolera that got it from.
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Another pulmonologist. Formulations are 105 and 205.
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The one big point I want to highlight from this slide though is like,
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you know, there's no such thing as a free lunch.
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So these inhalers are typically expensive.
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I've had great support from our pharmacy as well as from Tricare,
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which is what most of my patients use as far as coverage, that my patients typically
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do not have to pay out of pocket.
25:40
But if one were to pay out of pocket and just buy it without any sort of insurance
25:44
or discount, they do get pretty expensive.
25:47
And certainly more so, which I'll highlight on a later slide,
25:49
more expensive than albuterol, which is one disadvantage of this medication
25:53
if they do have to pay for that. But most patients hopefully don't.
25:58
ICS for motor oil inhalers in the United States, we use them a lot for as-needed
26:04
therapy or rescue therapy, including for anti-inflammatory reliever relief.
26:10
But in the United States, it is not FDA approved for that, which I think is very interesting.
26:15
So even though we have guidelines, including NHLBI, and we have strategies like
26:19
Gina actually saying that these medications actually do work and can or should
26:25
be used for this process, There's no necessarily FDA approval for that.
26:29
So I would just keep that in mind or just appreciate that kind of where we are.
26:33
It is a bit different than in other countries, such as New Zealand or United
26:38
Kingdom or Australia, when there are inhalers approved for that process,
26:42
such as the Simicor Turbuhaler or the TurboInhaler in the UK.
26:47
So it might be more readily available. It has not necessarily been a burden,
26:51
at least for me, as far as getting these medications for this use.
26:54
And we certainly have asthma action plans that label that it shouldn't be or
26:59
should be used for that purpose.
27:01
There's other combination inhalers out there. The purpose of this slide is to
27:05
show you that they exist, but not necessarily for SMART or not for SMART or MART.
27:10
There's Advair, I know Fluticozone, Salmeterol, and there's Wixella,
27:15
there's Brio, there's Trilogy, which is for adults. And typically I've seen more for COPD.
27:21
And they all contain a LABA. They all contain a long-acting beta agonist.
27:25
But none of these inhalers or none of the labas in these inhalers can be used
27:32
for a smart or MART therapy.
27:34
I have seen that used once overall when a patient was referred to me so just
27:40
not to get confused the only long-acting beta agonist approved for or a C like,
27:46
I guess eligible or dictated on guidelines such as GINA for the use of smart therapy is for motorol.
27:53
Again it works It's very fast. It's very effective.
27:56
Cymeterol takes much longer to work, as well as volanterol, as we find in Brio.
28:02
I guess if you had nothing else around, you could use these medications to try
28:05
to get someone under control in an acute exacerbation. But honestly,
28:09
I would always prescribe an ICS for motor oil inhaler, like we mentioned,
28:14
if we're going to do smart or more therapy on our patients.
28:17
There is one anti-inflammatory reliever out there that we have on the market
28:20
right now called Air Supra, which is albuterol budesonide.
28:25
Unfortunately, it's only approved for kids 18 or sorry, kids adults 18 and up.
28:32
It's as-needed therapy only. It is a true air inhaler, an anti-inflammatory reliever inhaler.
28:39
That's its purpose. It is not used for maintenance therapy. So it is something,
28:43
if you could prescribe it, if you have, if you're taking care of someone old
28:47
enough for, say, like step one, step two therapy, but,
28:51
you can't use it for smart and smart therapy because obviously albuterol will
28:54
only last a few hours anyway.
28:56
So we're going to get into kind of the nitty and gritty as far as like what
28:59
Gina actually looks like.
29:01
For each age group. So this is the latest and greatest from GINA,
29:05
2026 for adults and adolescents, 12 years and old, 12 years and up, excuse me.
29:11
So track one, we now have guidance that this is, we're using air only,
29:17
or what is recommended is for us to use air only or anti-inflammatory reliever
29:21
therapy with an ICS for motor oil inhaler like Simicory.
29:26
When we go into step one and step two therapy are combined to kind of separate
29:30
that from track two, which is a bit more traditional and what we used to use,
29:34
I guess, more predominantly in the past and what people still use.
29:36
If you want to highlight that, it's like what we have available.
29:40
Step three therapy, when we're doing, we're on now traditional mark with the
29:44
same inhaler when we're using every single day.
29:46
Step three therapy is still defined as low dose maintenance, ICS, Fomitorol.
29:51
And then step four, mark medium dose. And then step five, and we're adding on
29:55
therapies such as llamas, you know, like Spireva or leukotriene antagonists
30:00
like Singulair through our therapies, considering biologics.
30:03
And probably at that point, it wouldn't be a bad idea to send them to a pulmonologist
30:07
to make sure like this is truly asthma.
30:10
Track two is still more traditional.
30:13
You know, it's the alternative therapy. And Gina is very specific about this.
30:16
It's what you have available. It's what's actually working for the patient.
30:20
And this is not wrong. So the reliever as recommended is still like,
30:26
you know, an ICS Saba reliever, like Air Supra, if we have that available.
30:31
And again, that's only approved for individuals 18 and up.
30:35
But, you know, low-dose maintenance ICS, we're increasing that to like a medium
30:39
dose, like a BICEP-4, a combination inhaler.
30:42
And all adding on the same things as step five, track one, but an alternate
30:46
track that I'm sure many patients are still on and many of them are doing very well.
30:51
In fact, personally, if I have a patient on like a track two path and they're
30:56
doing very well, usually I don't try to rock the boat and to change that if
31:01
that is what exactly they're compliant on.
31:04
I do want to highlight the graph at the top that we're always reviewing our
31:07
medications, our treatment plans to make sure they work.
31:10
We're assessing to make sure they work.
31:13
And also make sure patients are using it appropriately and then adjusting as
31:17
accorded. So this is a very, like, you know, a dynamic treatment plan.
31:20
It changes. We step down, we step up.
31:23
But we're constantly assessing our patients to make sure we're trying to put
31:26
them on the lowest dose possible to still get, like, the same, you know, effect.
31:31
Getting into a children's 6 to 11, it's a little, it gets a little more confusing
31:35
when we get into like step two.
31:37
So there's one highlighted track here where step one is air only with an ICS for motor oil inhaler.
31:44
Step two, it's a little tricky. Daily low dose inhaled corticosteroid,
31:48
which is obviously not an ICS for motor oil.
31:53
It's not, it doesn't integrate the ICS for motor oil inhaler.
31:57
The reason for this is as we get into lower age groups, we just have less evidence.
32:00
So where we're dealing with like, you know, grade A and grade B,
32:04
as far as the quality of evidence that was used for the development of GINA
32:09
12 years and up, the quality of evidence is less in these categories.
32:14
So it's more difficult for GINA to actually justify using things like ICS for
32:20
motorol for every single step when there's no evidence to start to back it up
32:24
because we just don't have the studies out there to just prove it.
32:29
So step three we get into either a medium dose ics or low dose combo ics lava and then step four,
32:37
where you know we're still using low low dose ics for metrol or a medium dose
32:43
combination inhaler like the other ones that we saw
32:45
and finally in step five when we're on like higher doses but also considering
32:50
you know referral to someone like an allergist immunologist pulmonologist
32:54
to dive into whether, you know, this is truly asthma, what's their phenotype,
32:58
and what other therapies we could potentially add.
33:01
If, you know, we have, if you're a general pediatrician and you're not necessarily
33:04
used to prescribing therapies like Spireva, you know, we're always happy to take on these patients.
33:11
The one thing I do want to highlight with the daily lowest inhaled cardioposteroid,
33:17
and again, highlighting this as my own practice, and this is what I do.
33:20
This is not, you know, Gina never told me necessarily do this,
33:23
is I oftentimes do skip step one to step three.
33:27
When I'm, you know, giving out like SimiCore 84.5 and telling him to use that
33:30
as needed, and then I go into like maintenance therapy with like one puff twice a day.
33:35
That is my adopted practice, not to sorts them around on inhalers,
33:38
but try to make sure that they are both comfortable using an inhaler.
33:41
And if they are to continue using that inhaler, that they'll be most compliant
33:46
with, but also change their treatment plan. So they're using it a bit more if
33:50
they're not as controlled as I'd like them to be.
33:52
And then Gina ages five years and younger.
33:55
So we just do not have enough evidence to justify the use of ICS fomitorol like in this age group.
34:03
So you'll still see that the preferred controller is albuterol.
34:07
This is a bit different than other iterations in the past where I've seen like,
34:11
as their reliever, they should be taking their Flovent and their albuterol at
34:15
the same time, which I feel has been always very difficult to convince any patient to do.
34:20
So you'll still see like in this now, in the newest iteration,
34:24
the reliever of choice is added in short-acting beta agonists, which is albuterol.
34:29
So step one is insufficient evidence for potentially a daily controller.
34:33
But there is a plug for considering intermittent short course ICS, and it's considered
34:39
only because there's not great evidence for it, but it's something we can do
34:43
for our patients who are, you know, having very, very much intermittent symptoms
34:47
throughout the year, but we still want to do something for them to try to help
34:49
control their symptoms,
34:51
especially if they're happening when they're ill with like a viral respiratory infection.
34:55
That's step two, daily low dose inhaled corticosteroid. Step three,
34:59
when we double the dose in step four.
35:01
The recommendation is there's no true thing that you should put them on in step
35:05
four, but consider putting or referring them to some sort of,
35:08
I guess, expert assessment, such as with an allergy immunologist or a pulmonologist.
35:17
I put this table together, and I won't lie to you, I did have a little help with AI to do this.
35:23
But again, this is especially useful if you get the slides and you think,
35:27
hey, this might be a good guide as far as how I can best apply these therapies for my own patients.
35:34
The one, I think, tricky thing that took me, you know, it felt like it was reading
35:39
fine print. But when we're talking about like low, medium, high dose and how
35:43
Gina defines it, they put really good tables together.
35:46
But kind of, I guess, buried in there and maybe not so much for other people,
35:51
I'm sure I've read, you know, Gina very carefully, is the difference between
35:54
like meter doses and deliver dose.
35:58
So, GINA puts down metered doses as far as what those ranges are for 12 years
36:04
and older when it defines low, medium, and high dose.
36:07
Delivered dose is what's actually on the medication itself in this country because
36:11
it's different in other countries when you'll see like an inhaler with 106 on
36:15
it, which is the equivalent metered, sorry, delivered dose of 84.5.
36:20
A delivered dose is actually what is considered what gets in the actual patient.
36:23
And that's through like a spacer where some medication gets sick on the side
36:27
or through your mouth when you know medication can actually you know get stuck
36:31
in your mouth and not necessarily get to your airways your bronchioles where
36:35
it can actually like do its job,
36:37
so it's considered like a 10 to 20 percent decrease,
36:41
so you will see inhalers overseas that are labeled as the meter dose 106 206
36:47
or you know fluticasone 50 that is actually what the ranges are based off on
36:52
so just keep Keep aware when you're trying to like, is BDES9-164.5?
36:55
Should I do one puff or two puff?
36:57
I would just keep that fact that you may have to round up to,
37:00
I guess, be more accurate with Gina.
37:03
So the one other big point I wanted to highlight on this graph is that we are
37:09
using smaller and smaller doses when it comes to managing our patient.
37:13
There used to be sort of a push or an overall thing in pulmonology, at least.
37:19
We were trying to hit these kids really hard with really high doses and then
37:23
trying to tailor it down as we feel like they're more controlled.
37:27
Now we're doing much smaller doses, even in five years and younger,
37:31
which is also very different than what I was taught.
37:35
What is considered low dose by Gina is one single puff per day,
37:38
one single puff of Flovent 44.
37:41
Again, that's very small, more or less scaling it up. Like medium dose is one
37:46
puff twice a day, and then there's not even a definition for high dose,
37:50
So, do I have a lot of patients on OnePuff every single day? No.
37:56
But this is what Gina is saying.
38:00
So, it is something I think we should consider doing for our patients or considering
38:05
investigating for our patients, certainly, as we kind of navigate going forward
38:09
on how to best utilize these practices.
38:12
There are daily limits as recommended by GINA and NHLBI.
38:17
The age ranges for GINA and NHLBI are a bit different as NHLBI does advocate
38:23
particularly for smart therapy down to age 4 versus GINA, which is down to age 6.
38:27
The limit for ages 6 to 11 per GINA is 8 total puffs in a 24-hour period,
38:32
and ages 12 is 12 total puffs in a 24-hour period.
38:36
That includes the maintenance puffs that they do if they're on maintenance therapy.
38:40
That table was put together just to kind of, I guess, make it maybe a little
38:43
bit more easier to understand when they're doing like daily pause and simple,
38:48
addition to how to get to that total limit.
38:51
This is mainly dictated to like, well, what limit should we put on our patients
38:55
to say, I think you should go to the emergency room if you do reach that limit.
38:59
And so I feel that's a bit more, not set in stone, but a bit more universal
39:04
when it comes to both plans.
39:08
There is, I think, the risk of, certainly risk of side effects,
39:11
which I'll get into a little bit later, which I think, you know,
39:13
are still relatively safe when we get up to the higher limits.
39:16
But, you know, there is a limit to, you know, where we should actually,
39:20
like, you know, seek some sort of attention.
39:23
When we get to that as better guidance for our patients on our asthma action plans.
39:29
So when I was a resident, it's funny I can say that now, I guess I'm getting a little bit older.
39:35
When I can say that, you know, I was always taught that like two puffs is better than one puff.
39:38
And, you know, we need to do a second puff always with our inhalers because
39:42
the first puff might not have enough medication.
39:44
This is very old school thinking that I think there's enough evidence to say
39:49
that one puff is sufficient for our patients, which is why now I'll do residents
39:53
like one puff twice a day.
39:55
The strength per puff, you know, is a bit more outlined and different or a bit
40:01
stronger that that one puff might be just as sufficient for our patients too.
40:06
So we're still giving, you know, an appropriate medication that we actually
40:11
want to give with one puff.
40:12
I wouldn't necessarily estimate it
40:13
as less. So again, when we're doing or prescribing one puff, that is okay.
40:18
We don't just always have to do two puffs every single time,
40:21
especially when we're talking about like, how many puffs or one puff as needed
40:27
for rescue therapy for our patients.
40:29
I'm going to talk about anti-inflammatory reliever.
40:32
We're going to go into a bit more evidence to say why ICS fomitorol relievers
40:37
are so great or are potentially a bit better these days than using ASABA alone.
40:43
This was the CARE study, which was a study encompassing 360 children in ages
40:49
5 to 15, centered around New Zealand.
40:51
When we were looking at the comparison of ICS-4-Moderol and Saba,
40:56
I don't necessarily have a dose I can give you, although offline we could look
41:00
at the paper a bit more in detail if we needed to.
41:04
But the overall attack rate was very good, or a lower attack rate with ICS-4-Moderol.
41:09
45% lower attack rate compared to, say, albuterol.
41:14
And then 45% lower severe asthma rate when we're using oral corticosteroids.
41:19
So the results have been very good to advocate for one versus another.
41:23
And this form of therapy is helpful and potentially does lead to a lower attack
41:29
rate when used on our patients.
41:31
But also to highlight that the age range of this study was 5 to 15.
41:36
So, this is why it's very difficult to justify without great evidence the use
41:41
of ICS-Vomitorol in the younger populations.
41:43
Although, personally, I still give it out depending on the case or depending
41:48
on how the patient is doing and what they've actually done in the past.
41:53
Sigma-1 was an adolescent study. But we do have evidence now to say,
41:57
you know, when we're doing or when we're using, you know, Saba compared to ICS-Fometorol,
42:04
potentially one is potentially better than the other.
42:08
So, Sigma-1 was looking at adolescents 12 to 17,
42:13
when we were showing a potential 70% lower severe asthma risk in adolescents,
42:20
who were just on ICS fomitorol, potentially, versus terbutaline.
42:26
And then a lower OCS-treated asthma attack risk that was decreased by 55%.
42:31
So an overall improvement versus just an actual reliever alone in this population,
42:37
which further justified how we could potentially use this in ages 12 years and up.
42:43
But now we also have evidence to say that Saba reliance or just using Saba alone
42:50
is potentially harmful.
42:52
So there's evidence now for patients who are just prescribed Saba's alone or
42:59
just albuterol alone, potentially that this could lead to an increased exacerbation rate.
43:05
And the thought behind this is that as we're using this or as patients are using
43:09
their albuterol inhaler more, They're developing potential tolerance.
43:13
They're down-regulating beta-2 agonist receptors and thus becoming more susceptible
43:18
to asthma exacerbations or less efficacious or just, you know.
43:24
The inhaler will not potentially work as well when they actually need it,
43:27
when they actually need escalated doses.
43:28
So it's something to be very wary on.
43:31
Sabina Jr., there was a study that came out in 2023, ages 1 to 17,
43:36
looking at just patients who were prescribed more Saba inhalers typically than
43:41
maybe the average asthmatic,
43:43
and that they had a higher exacerbation rate compared to how many inhalers or
43:51
how many Saba inhalers they were actually being prescribed in a given year.
43:55
So there is the potential that that's not necessarily a good strategy anymore.
44:00
In fact, Gina outlines pretty readily that it is not recommended that patients
44:04
should be on any sort of Saba alone.
44:07
There should be some sort of ICS involved either as an anti-inflammatory reliever
44:12
or as a combination inhaler or on some sort of maintenance strategy,
44:16
even if the decision is made to maintain your StartTrack 2 therapy.
44:21
In our younger age groups, you know, SMART therapy has been shown potentially
44:26
to cut exacerbations versus usual care.
44:29
So when we're looking at SMART therapy, single maintenance reliever therapy,
44:33
in children in this age group versus fixed combinations or even higher doses
44:37
of ICS, there is a 70 to 79 percent lower exacerbation rate using SMART.
44:43
And then only 8 percent of SMART children or children on SMART had greater than
44:47
one exacerbation in that year compared to others.
44:50
So, again, there's better supporting evidence now that smart therapy is a better
44:57
strategy than in other inhalers that are on the market, potentially,
45:01
that we could still prescribe.
45:03
So, I think it's something to be mindful and why there's such a push to use
45:06
smart or smart therapy now than in other strategies or other tracks.
45:11
One thing that has come up and something I've wondered too is like,
45:13
you know, if we're giving all this like ICS from Metrol out and patients are
45:16
using it frequently has really thrush, you know, one of the,
45:20
you know, most, I guess, notorious,
45:22
if not, you know, it's still more or less benign side effect coming out of,
45:27
you know, frequent ICS use.
45:29
There has been no great evidence to say that there is increased thrush rates with SMART.
45:36
This is one particular piece of evidence that came out,
45:40
I believe, very recently, a few years ago in 2021, including 341 children,
45:47
that did not show conclusive evidence that increased ICS for mineral use versus
45:52
more traditional therapy showed increased rates of thrush.
45:55
What I've adopted with my own patients in dealing with this is that I still
45:59
have patients rinse their mouth out with mouthwash if they're older or water,
46:05
or just something to try to rinse any sort of lingering ICS in their mouth.
46:10
But I feel it's okay to use your rescue therapy if you're out and about and
46:16
you have nothing to rinse your mouth with.
46:19
Sorry, that there's no great evidence to say that you will have increased risk
46:25
of thrush if you're actually doing that.
46:27
So I would rinse if there's something available for you to rinse.
46:32
But I wouldn't worry about it if you did not or did not have access to readily
46:36
like an available source of water at the time.
46:39
But it is something, I guess, you know, it's not a bad idea to clean your spacer,
46:43
when it gets dirty, which is typically every two to four weeks or,
46:46
you know, they start noticing visible stuff in their inhaler that should not be there.
46:50
It's a good idea to actually clean it and then replace it typically is six to 12 months.
46:56
If they need a new one air and smart adoption in your practice i put this together
47:01
sort of like you know a very basic eye to say there certainly might be providers
47:05
out there who's still hesitant to use smart therapy in their practice.
47:09
But a you know there has to be some sort of mutual decision with your patient,
47:14
as far as you know being able to use it and being able to comfortable use it,
47:18
to advocate that like we are now using one inhaler alone and not using like
47:23
two inhalers or like you know, an ICS for mineral inhaler or a Saba alone with it.
47:27
They can use their ICS for mineral just by itself.
47:31
We're replacing Saba. So, you know, it's not like they have to just like chuck
47:36
it in the trash can immediately when they go home after a brief sky blitz in the court.
47:39
But we now have one inhaler that they should be using instead of multiple to
47:45
make sure they're, you know, using it appropriately.
47:47
Technique is everything. The technique will always be everything as far as like,
47:51
Like, you know, it doesn't matter what I say in clinic as they're not using
47:53
it correctly. How effective is, you know, my actual treatment plan at all? Not very.
47:59
And reviewing that constantly with them to make sure they're comfortable using it.
48:02
There has been a lot of confusion. And I do have plenty of patients who show
48:06
up and they're like, well, I'm on advert to puffs twice a day and I'm on like
48:09
a Saba and this works out for me.
48:12
Personally, myself, I keep them typically on their regimen if that's working out for them.
48:17
But, you know, I'll sometimes throw in that, you know, we do potentially have better inhalers
48:22
on the market that if we are having actual symptoms and we are,
48:26
you know, having emergency room visits, I don't necessarily have to scale you
48:29
up on a therapy that you're on that I could switch you to something that may
48:32
decrease that rate a little bit better at the same dosage,
48:35
of inhaled corticosteroid.
48:37
And oftentimes I'll get good buy-in with my patients for that.
48:40
So SMART more steps three and four. Oftentimes, you know, we might reserve this
48:45
more for like an allergist or a pulmonologist. We're using higher and higher medications.
48:50
But I do have a lot of general pediatricians that I work with that are in like
48:53
austere environments or overseas that do not really have available specialty care.
48:58
So it's so important to try to feel comfortable doing this while being mindful
49:01
of other things that could be going on.
49:03
But it's also more imperative than other that we're like checking technique
49:06
in these patients because oftentimes
49:08
we'll have patients that are scaled up, but we find out like they just never
49:10
had a spacer prescribed, or they're not really taking a big deep breath in,
49:14
or they're just using it incorrectly, or they're just holding it away from their mouth.
49:18
So I think that's super important in this age group to use that,
49:22
you know, when we're trying to improve these regimens, that might be,
49:25
that might be such a simple thing as just getting them to use it correctly.
49:28
That might make a world of difference for them.
49:30
And then always reviewing control attacks technique, making sure,
49:35
you know, there's, there's side effects such as growth that we should be reviewing,
49:39
Even though I think it's a bit,
49:41
personally, I think it's a bit overblown as far as growth, but I'm still mindful
49:45
of looking at their growth curves and making sure that they're still growing,
49:49
well, especially if they're using very high doses.
49:51
I very much want to be mindful of that.
49:54
But we should be trying to step them down to the lowest effective daily dose.
49:59
Just to try to minimize the amount of daily inhaled corticosteria that is still
50:02
providing them adequate control and good quality of life.
50:06
Is Fometeral safe? So I think the effects are very much dose dependent.
50:09
So these are three independent studies that came out in 2004,
50:13
1998, and 2016. Fometeral has been around for a while.
50:17
In children 6 to 11, these were children, and this is a very tiny study,
50:21
but they were given a lot of Fometeral. That's 10 cumulative inhalations over
50:26
2.5-hour and 2.5-hour period.
50:29
This was done using terbutaline as a comparison where they were actually,
50:34
and funny enough, noticing more like prolonged QT prolongation.
50:39
It was terbutaline compared to fomitorol and then potential greater potassium drop as well.
50:45
But no arrhythmias were observed in this study and no effective clinical significant
50:51
side effects were seen either.
50:54
The older dose response study in the middle, this came out in 1998,
50:57
again, a very small study, where they were given tons of Fometorol,
51:01
that's 96 micrograms compared to the 4.5 we'll see in like one puff of Simicor,
51:07
where the rates or the changes were very, I feel, mild, which only like,
51:11
you know, a 9% or sorry, 9 beat increase in heart rate and a very,
51:17
even like a more tiny increase in their QTC.
51:21
So it's just to say that, like, you know, we do see changes,
51:23
but whether they're truly significant and like a cause of clinical concern,
51:27
for my big takeaway from the literature has been like, no, but we also have
51:33
caps as far as how much we're actually dosing our patients on a given day.
51:37
And I strongly feel that if we are keeping under those daily limits that these medications are safe.
51:43
The safety trial, Peter's 2016, I guess, looked at more, you know,
51:46
severe asthma risks with intubation or even death.
51:50
And it was very comparable to just be does it alone. Again, my further takeaway
51:54
is that ICS-Farmeterol is generally safe for our patients and can be used as
52:00
long as we are setting some sort of limit with its use.
52:03
SMART, I'm sure around the country we're running into various issues.
52:09
This was a survey survey.
52:11
Particularly in the St. Louis network that looked at what are clinicians dealing
52:15
with when trying to get these inhalers out. And the biggest one was insurance
52:19
problems and cost burdens. These are expensive inhalers.
52:23
It was an issue I had in fellowship. I don't really have much problem getting
52:27
it now. We just got it on formulary at Brooke Army in 2024, which was huge and great.
52:34
But I can imagine that's not the same in other places in the country.
52:37
Again, this is why we have other tracks available in Gina, including track two,
52:42
that there's the potential option. If we don't have that, what can we use?
52:46
It is not wrong, again, to put patients on an ICS and Saba if that's all you have available.
52:52
Other things, clinician confidence, we have studies out there,
52:57
but in our younger age groups, do we really have a lot of evidence?
53:00
Not yet. And so that's why even
53:01
Gina outlines that the grading as far as evidence is not very good yet.
53:07
Lack of smart specific asthma action plans. This is improving,
53:10
but a couple of years ago, even our South Texas consortium asthma action plan
53:15
was lacking as far as smart options.
53:17
I'm not sure what UH uses, but I would imagine maybe we're in the same boat.
53:22
And then you know caregiver resistance like if it's working for me why am i
53:25
going to switch i personally try not to switch them if they're doing incredibly well in their therapy,
53:30
but even if someone is not doing well uh there can be confusion as far as like
53:34
oh why am i going to switch this inhaler to something new i'm not really sure
53:38
about it can you tell me more,
53:40
that's why i guess it's super important for us to you know get comfortability
53:43
with these uh inhalers so we can better educate our patients to put them on.
53:48
A potentially better a better treatment plan and more adherent to to guidelines
53:52
and strategies like GINA and NHLBI.
53:55
So NHL, our asthma action plan, excuse me, is very important.
53:59
This is exactly like, you know, this is the plan we put together.
54:02
This is the plan that will keep kids out of trouble and also,
54:05
you know, maintain a good quality of life so they can go out and play and,
54:08
you know, do sports and things like that and not have to deal with symptoms.
54:11
We're outlining daily and worsening symptoms. We're outlining,
54:14
you know, emergency instructions and what to do, you know, when they get sick
54:18
or they're developing symptoms.
54:19
And hopefully, you know, we're probably very good at, you know.
54:25
Being crystal clear on, you know, what their maintenance dose is,
54:29
what the reliever dose is, and, you know, how many puffs to count before,
54:32
like, what is too much before they should be seeking urgent or emerging care, who to contact.
54:38
All these things are incredibly important in your basic asthma action plan,
54:42
which I feel like are getting better. So this is the one I would typically give
54:45
to my patients when I first started at Brooke Army, what my nurses were giving
54:49
out from the South Texas Asthma Coalition.
54:53
When I first started, there were newest more options on this asthma action plan.
54:57
And so downloading it recently, now there are options, which is fantastic.
55:02
I apologize, it is getting a little later. So I'm just going to breeze through
55:06
the rest of this in case there's time for questions.
55:09
Albuterol still has a role in outpatient care.
55:12
Is still cost-effective. And again, we can still use that for other tracks.
55:16
And I personally do not give it out unless there are, or I personally do not
55:21
change someone to a SMART regimen
55:24
unless they're not doing well or unless they want improved control.
55:29
We do have other medications or add-on therapies with steroids,
55:32
including teotropium, biologics, leukotriene antagonists, and maintenance.
55:37
Maintenance OCS is like the last line of strategy these days in pediatrics,
55:42
but we have so much better medications out there, including biologics, that we can use.
55:46
I'm just going to skip this. But it's really just to highlight that we should
55:49
always be cognizant that there's other things potentially going on where there
55:52
are patients that are less controlled, including comorbidities and differential diagnoses.
55:56
Out there, and there's a number of them.
55:59
So, have a low threshold potentially to send them to someone like a pulmonologist.
56:03
I'm always happy to see your patients, even if they're mild,
56:06
in case there's any sort of suspicion that there's something else going on.
56:09
And there's plenty of mimickers out there for asthma, including things like
56:13
cystic fibrosis or like, you know, vascular or an arrowy malformation.
56:16
We're always happy to take a look.
56:18
Asthma biologics, we have several on the market right now, including all sorts
56:22
of targets like interleukin-5, which will stimulate eosinophils, interleukin-4, IgE.
56:28
TSLP is more upstream to target alarms that actually come from the respiratory epithelia themselves.
56:33
Now we can use that for like low type 2 or type 1 disease, which is fantastic.
56:38
They all have different targets, as I mentioned, but they all have different cutoffs too.
56:42
So hopefully this slide is useful just to outline what we have out there and what we have down to.
56:47
But, you know, just especially for a general pediatrician, And if you are,
56:51
you know, I think someone should be on a biologic, I'm going to send them to
56:54
a pulmonologist or an allergist immunologist to get that prescribed,
56:58
that there are cutoffs for ages.
56:59
So unless they have another comorbidity like, you know, eczema.
57:04
We can't readily necessarily put them on a biologics until they at least reach ages six.
57:10
We can put infants on, say, Dupixent because it's down to three months,
57:15
three to six months for eczema.
57:18
But they have to have eczema. And I've stretched that truth a little bit to
57:21
try to get them on a biologic.
57:23
But ultimately, you know, I am adherent or try to be adherent to the age cutoffs
57:28
to make sure that we are using these medications appropriately because they're.
57:31
Sometimes very expensive, but also sometimes very hard to get and does require a commitment.
57:37
And there are injections one does at home, which usually kids are not thrilled
57:40
about. I want to make sure they are the right fit and they're able to use it when I can prescribe it.
57:46
This is the newest one on the market. I'm just going to gloss over this,
57:49
that we do have one latest biologic that is now every six months in dosage.
57:53
I think it's fantastic. That came out in December. It was FDA approved December 2025.
57:58
Biologic therapy and asthma will get certainly more complicated in the next
58:02
five to 10 years, there's a lot more on the market with different targets.
58:05
The slides I've seen at conferences just get very confusing.
58:08
And so I feel like there is going to be certainly a push for more guidance on how to use these.
58:14
Surveillance is important, but we're using potentially better tools to surveil
58:19
our patients, including inhalers that we can better track. Home spirometry may
58:23
become a thing in the future, but I don't readily use it.
58:26
But certainly in certain centers, I think there's a push to do what can we do
58:29
at home to make sure They're well monitored rather than having them always come
58:32
in, especially they live very far away.
58:35
Combing each our registries, there's an awesome push, especially in San Antonio,
58:38
or at least like better transparency between centers, which I think is very
58:42
awesome to find out how actually, you know, our patients controlled,
58:45
especially if they're being seen somewhere else, which is what a lot of my patients end up doing.
58:49
A lot of them go to UH. So it's nice to actually have transparency on that.
58:54
And then what is going on as far as exposure? There's better access ever before
58:58
as far as no air quality index, pollution, and things like that.
59:01
Allergy indexes as far as what's going to trigger my patients or what they can
59:06
avoid or maybe stay indoors a little bit. These like today, if there's some
59:10
wildfires going on that we know about.
59:13
Digital inhalers are now a thing it's not something i readily like prescribe
59:18
but there are there are out there,
59:20
and they have different age cutoffs to you there's some for albuterol they can
59:24
actually some of these can measure the flow of what's coming out to make sure
59:27
patients are taking big enough breaths or even,
59:31
slow breaths so they're not doing it too much and air is just going into their
59:34
stomach but we have now one for like flutigazone that we can use.
59:39
I've never tried to prescribe these.
59:40
Maybe someone else has. And so I imagine there's some variable success on trying
59:44
to get these approved and paid for.
59:46
Future therapies, there will be other biologics coming out.
59:49
TSLP is an alarming that comes out from your release from your arrestory epithelia
59:54
when it gets triggered by, say, allergies potentially or a viral illness.
59:58
And we're going to, there are better strategies out there to try to target those
1:00:02
with different biologics that might be coming out in the future.
1:00:05
Longer acting biologics like the depimocumab. that I talked about.
1:00:09
It's certainly biomarker guided selection. And then the ultimate goal of,
1:00:13
how to define things like remission and treatment reduction are also huge pushes
1:00:18
now in the literature that if we're having all this great control now with greater
1:00:22
therapies, how do we scale them down on either their inhaled corticosteroid or on their biologic?
1:00:28
There's not great guidance on that, but certainly there's better guidance that
1:00:31
will come out in the coming years. These are my...
1:00:36
And, you know, thank you for.