Airway Disease, Allergy, Asthma, Respiratory Tract Disorders CE/CME ACCREDITED Watch Time: 40 mins

touchPANEL DISCUSSION Unravelling endotypes for treatment selection in severe type 2 asthma

Experts discuss how endotyping and biomarkers can help to guide optimal treatment selection in patients severe type 2 asthma

Dr Katharine Woessner

Scripps Clinic Medical Group, San Diego, CA, USA

CHAIR

Panelists:
Prof. Louis-Philippe Boulet, Prof. Arnaud Bourdin
 
Video Chapters
Introduction

Chair, Dr Katharine Woessner, introduces the expert panel and agenda for this discussion on unravelling endotypes for treatment selection in severe type 2 asthma.

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1/4 Next Chapter
 
What are the serious consequences of severe type 2 asthma?

The panel considers the burden of disease in patients with severe type 2 asthma and the practical advice that they give to patients to help them cope with their symptoms and the daily challenges they face

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2/4 Next Chapter
 
How do endotyping and biomarkers guide treatment selection in severe type 2 asthma?

The panel discusses the role of biomarkers in guiding treatment selection for patients with severe T2 asthma and appropriate treatments for each biomarker profile or endotype. This discussion includes a patient case study

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3/4 Next Chapter
 
How do recent data and clinical guidelines inform the long-term management of patients with severe type 2 asthma?

The panel considers recent data with biologics in patients with severe asthma; how the use of biologics impacts the long-term management of patients with severe type 2 asthma, both now and in the future; and key updates in the GINA 2021 guidelines that will inform best-practice for the long-term management of such patients

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Learning Objectives & Overview
Overview

In this activity, the expert panel will discuss three clinical themes covering the serious consequences of severe type 2 asthma, how endotyping and biomarkers can help guide treatment selection in such patients, and how recent data and clinical guidelines can inform the long-term management of patients with severe type 2 asthma

This activity is jointly provided by USF Health and touchIME. read more

Target Audience

This activity has been designed to meet the educational needs of allergists and immunologists, pulmonologists, as well as primary care physicians involved in treating patients with severe type 2 asthma.

Disclosures

USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education.
All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity. The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

Faculty

Dr Katharine Woessner discloses: Advisory Board or Panel fees from AstraZeneca and GlaxoSmithKline. Consultancy fees from AstraZeneca, GlaxoSmithKline and Regeneron. Speaker’s Bureau fees from AstraZeneca and GlaxoSmithKline.

Prof. Louis-Philippe Boulet discloses: Advisory Board or Panel fees from AstraZeneca, GlaxoSmithKline, Merck, Novartis and Sanofi-Regeneron. Consultancy fees from AstraZeneca, GlaxoSmithKline, Novartis and Sanofi-Regeneron. Grants/research support from Amgen, AstraZeneca, Biohaven, GlaxoSmithKline, Merck, Novartis and Sanofi-Regeneron. Speaker’s Bureau fees from AstraZeneca, Cipla, Covis, GlaxoSmithKline, Merck, Novartis and Sanofi. Nonprofit grants for production of educational materials by university Chair from AstraZeneca, Covis, GlaxoSmithKline, Merck and Novartis.

Prof. Arnaud Bourdin has no interests/relationships or affiliations to disclose in relation to this activity.

Content reviewer

Karim H Hanna, MD, has no relevant financial relationships to disclose.

Touch Medical Director

Sola Neunie has no financial interests/relationships or affiliations in relation to this activity.

USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

If you have questions regarding credit please contact cpdsupport@usf.edu

Accreditations

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

USF Health designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 Credit™ into European CME credit (ECMEC) should contact the UEMS (www.uems.eu)

Advanced Practice Providers

Physician Assistants may claim a maximum of 0.75 Category 1 credit for completing this activity. NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society.

The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 Credit™ by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

Date of original release: 16 December 2021. Date credits expire: 16 December 2023.

If you have any questions regarding credit please contact cpdsupport@usf.edu

Learning Objectives

After watching this activity, participants should be better able to:

  • Recall key data on the serious consequences of severe type 2 asthma
  • Summarize severe asthma endotypes and the corresponding selection of biological therapies
  • Evaluate the most recent evidence on key aspects of long-term management of patients with severe type 2 asthma
Faculty & Disclosures
Dr Katharine Woessner

Scripps Clinic Medical Group, San Diego, CA, USA

Dr Katharine Woessner, FAAAAI, is Head of the Division of Allergy, Asthma and Immunology at Scripps Clinic Medical Group in San Diego. read more

Dr Woessner has been an active member of the Pharmacy and Therapeutics Committee since 1998 and of the AAAAI since 1995, presenting at the annual meeting of the latter in most years. She is also past chairwoman of the Ethics Committee and past co-chair of the Leadership Academy. She served on the Aspirin Desensitization Joint Task Force, helping to produce a practice paper on aspirin-exacerbated respiratory disease (AERD). She was the Allergy and Immunology Fellowship Director from 2004–2016, and is a Past President of the San Diego Allergy Society and the Western Society of Allergy and Immunology.

Dr Woessner’s research interests have been focused on AERD and improving clinical outcomes with aspirin desensitization and the use of biologics. She has been involved in multiple publications and invited lectureships. Her other interests include hereditary angioedema, food allergy and mast cell disorders.

Dr Katharine Woessner discloses: Advisory Board or Panel fees from AstraZeneca and GlaxoSmithKline. Consultancy fees from AstraZeneca, GlaxoSmithKline and Regeneron. Speaker’s Bureau fees from AstraZeneca and GlaxoSmithKline.

Prof. Louis-Philippe Boulet

Laval University, Quebec City, Canada

Prof. Louis-Philippe Boulet is a Respirologist at the Institute of Cardiology and Respirology of Quebec. He is also a Professor of Medicine at the Department of Medicine, Laval University, Quebec City, Canada, and holds a Chair in knowledge translation education and prevention in respiratory and cardiorespiratory health at Laval University. read more

He is a past Chair of the Canadian Thoracic Society (CTS), past Chair (and current member) of the CTS Respiratory Guidelines Committee, and a member of many Canadian and International medical societies and guidelines committees, including the American Thoracic Society/European Respiratory Society (ATS/ERS) Committee on Diagnosis of Asthma and Severe Asthma, and the American College of Chest Physicians (ACCP) Cough Guideline Committee. Prof. Boulet is also a past member of the Board of Directors of ATS and ACCP, a founding member of the Quebec Respiratory Health Education Network, and Chair of the Board of Directors of the Global Initiative for Asthma (GINA).

Prof. Boulet leads a research programme focussing mainly on the themes of asthma phenotypes, airway responses, inflammation and remodeling, respiratory allergy, respiratory health of athletes, knowledge translation and health education.

He has been Associate Editor of CHEST, the European Respiratory Journal and the Canadian Respiratory Journal. He is the current Editor-in-Chief of the Canadian Respiratory, Critical Care and Sleep Medicine journal and Associate Editor of Clinical and Experimental Allergy. He has written more than 650 medical publications, 633 abstracts and 43 book chapters, and has edited/authored 17 books. He is frequently invited as a speaker at national and international meetings. Prof. Boulet has received many awards and performed many honorary lectures.

Prof. Louis-Philippe Boulet discloses: Advisory Board or Panel fees from AstraZeneca, GlaxoSmithKline, Merck, Novartis and Sanofi-Regeneron. Consultancy fees from AstraZeneca, GlaxoSmithKline, Novartis and Sanofi-Regeneron. Grants/research support from Amgen, AstraZeneca, Biohaven, GlaxoSmithKline, Merck, Novartis and Sanofi-Regeneron. Speaker’s Bureau fees from AstraZeneca, Cipla, Covis, GlaxoSmithKline, Merck, Novartis and Sanofi. Nonprofit grants for production of educational materials by university Chair from AstraZeneca, Covis, GlaxoSmithKline, Merck and Novartis.

Prof. Arnaud Bourdin

Arnaud de Villeneuve Hospital, Montpellier, France

Prof. Arnaud Bourdin is Head of Pulmonology, Consultant and Professor of Respiratory Medicine at Arnaud de Villeneuve Hospital in Montpellier, France. read more

Professor Bourdin gained both his MD and PhD from the University of Montpellier, and was subsequently a Fellow at Monash University in Melbourne, Australia.

His scientific research experience includes bronchiectasis, cystic fibrosis, severe asthma and sleep apnoea syndrome. He has therapeutic expertise in all of these conditions, plus chronic obstructive pulmonary fibrosis, idiopathic pulmonary fibrosis and pulmonary arterial hypertension.

Prof. Bourdin has co-authored more than 150 peer-reviewed articles, reviews and monographs.

Prof. Arnaud Bourdin has no interests/relationships or affiliations to disclose in relation to this activity.

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Question 1/4
Severe asthma places a substantial burden on the healthcare system. What are the approximate average numbers of ED visits and hospitalizations that a patient with severe asthma will experience annually?

ED, emergency department.
Correct

A systematic literature review of the clinical, humanistic and economic burden associated with severe asthma reported that, globally, patients with severe asthma had an average of 3.0–3.5 office visits, 0.6–2.0 ED visits and 0.5–0.6 hospitalizations annually.

Abbreviation

ED, emergency department.

Reference

Chen S, et al. Curr Med Res Opin. 2018;34:2075–88.

Question 2/4
Your patient, a 40-year-old female with a confirmed diagnosis of asthma and no contributing comorbidity, has experienced recurrent exacerbations and persistent symptoms while on high-dose ICS/LABA plus OCS (15 mg/day) for the past 6 months. For a few months she has also been taking an add-on LAMA, with only a modest benefit. The patient has shown good inhaler technique and adherence to treatment. Biomarker analysis reveals blood eosinophils of 142/µL and FeNO of 18 ppb. Based on this information and recommendations from the Global Initiative for Asthma, what would you do next?

FeNO, fractional exhaled nitric acid; ICS, inhaled corticosteroids; LABA, long-acting beta agonist; LAMA, long-acting muscarinic antagonist; OCS, oral corticosteroids; ppb, parts per billion; T2, type 2.
Correct

The patient’s biomarker analysis does not show evidence of T2-high inflammation, according to the GINA report (blood eosinophils ≥150/µL and FeNO ≥20 ppb). However, high-dose OCS can affect both eosinophil and FeNO results, and the GINA report recommends reducing OCS to the lowest possible dose to allow for repetition of biomarker analysis up to three times. Severe exacerbations are potentially life threatening and their treatment requires careful assessment and close monitoring. A patient such as the one in this case should be referred to a specialist, if available, for phenotypic assessment, consideration of add-on therapy and careful progressive OCS weaning.

Ideally, biomarker analysis should be performed before OCS add-on therapy is initiated.

Abbreviations

FeNO, fractional exhaled nitric acid; GINA, Global Initiative for Asthma; OCS, oral corticosteroids; ppb, parts per billion; T2, type 2.

Reference

GINA. 2021. Available at: https://ginasthma.org/wp-content/uploads
/2021/05/GINA-Main-Report-2021-V2-WMS.pdf
(accessed 11 November 2021).

Question 3/4
Your patient has severe T2-high eosinophilic asthma, is receiving OCS, and has started add-on treatment with mepolizumab. Based on recent data from an observational study, how would you advise your patient in terms of the expected clinical outcomes?

ED, emergency department; OCS, oral corticosteroids; T2, type 2.
Correct

The REALITI-A observational cohort study recently reported results from an interim analysis of patients with severe asthma treated with mepolizumab who had completed 1 year of follow-up. The analysis showed that rates of clinically significant exacerbations were reduced by 69%, and hospitalizations or ED visits were reduced by 77%. Patients who were on OCS had a mean daily dose decrease of 5 mg/day at the end of the follow-up period.

Abbreviations

ED, emergency department; OCS, oral corticosteroids.

Reference

Harrison T, et al. Eur Respir J. 2020;56:2000151.

Question 4/4
Your patient has severe T2-high eosinophilic asthma that was uncontrolled on high-dose ICS-LABA, and has started add-on therapy with dupilumab. Based on recent long-term data from an open-label extension of parent clinical trials with dupilumab, how would you advise your patient in terms of the expected clinical outcomes over a ~3-year period?

AER, annualized exacerbation rate; ICS, inhaled corticosteroids; LABA, long-acting beta agonist; T2, type 2.
Correct

The TRAVERSE open-label extension assessed the long-term safety and efficacy of dupilumab in patients with moderate–severe or OCS-dependent asthma who were previously treated in parent studies (phase IIa EXPEDITION, phase IIb DRI, phase III QUEST, or VENTURE) for up to 1 year. 

In the subgroup of patients with a T2 inflammatory phenotype, the long-term follow-up (148 weeks) showed a progressive decrease in AER and the initial improvements in lung function were sustained over 148 weeks.

Abbreviations

AER, annualized exacerbation rate; OCS, oral corticosteroids; T2, type 2.

Reference

Wechsler ME, et al. Lancet Respir Med. 2021. doi: 10.1016/S2213-2600(21)00322-2. Online ahead of print.

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