Five trends will influence care for allergic asthma

Key takeaways:

• Remote monitoring will let physicians collect data without an office visit.
• Physicians will target disease at the cellular and molecular level.
• Treatment will be tailored for each individual patient.

PARK CITY, Utah — Five trends will shape treatment for allergic airway diseases in the years ahead, according to a keynote speaker.

“There is a lot of progress. But there is also a lot of unpredictability,” Andrew Liu, MD, FAAAAI, director of the Airway Inflammation, Resilience & the Environment (AIRE) Program at Children’s Hospital Colorado, said during his presentation at the Association of PAs in Allergy, Asthma and Immunology (APA-AAI) Annual Allergy, Asthma & Immunology CME Conference.

Remote monitoring, wearable sensors

First, Liu said that remote monitoring and wearable sensors will play a larger role.

“These are tools, in some ways, [that] may be something that patients with conditions can use themselves,” Liu said. “They help us work with patients to provide better care.”

For example, Liu cited inhalers that identify when patients use their reliever and controller medication and share that data with physicians and with the patients themselves via the cloud and a mobile app.

Liu also discussed sensors that patients can wear like an adhesive bandage strip that can remotely provide vital signs, flow volume and other measurements of lung function, which he said would be particularly useful for children following exacerbations.

Physicians additionally are now using devices “that are better or easier than spirometry at assessing lung function,” Liu said.

Oscillometers are portable and can be used in brief applications that do not stimulate the airways, he said, which makes them useful for assessing airways and response to treatment for children and other patients with special needs, even during exacerbations.

The COVID-19 pandemic accelerated the use of telehealth and virtual home inspections as well, with different methods for assessing the environment, Liu said.

“We’re collecting dust and then sending it for allergy panels, or we have wearable monitors that we’ve studied that basically turn the patient into their own personal exposure monitor for ambient pollutants, and we put in a GPS tracker as well,” he said.

“It sits up in their respirable zone, so we can map out where the exposure is occurring, and when,” Liu added.

The omics revolution

Next, Liu said that we are on the cusp of the molecular “omics” revolution.

“There have been advances,” Liu said. “We’ve learned a lot about what you can learn about sampling the nose.”

The nose can tell physicians noninvasively about what is happening in the lungs, Liu explained, because approximately two-thirds of the nasal lining is similar to the airway epithelium with similar immune responses. The nasal swabbing that accompanied COVID-19 testing has provided a lot of insight as well, Liu said.

“We learned ... you can learn a lot from a swab,” he said. “We also found that you can see these molecular pathways that are underlying disease, and you can track them.”

Liu cited 69 genes related to eosinophil activation and mucus hypersecretion that can be linked together in a type 2 pathway. He also noted pathways that are activated among patients with exacerbations compared with patients who pick up viruses but do not experience exacerbations.

“There’s some that come on right in the first 2 days, and some that come on a couple days later that are inflammatory pathways,” Liu said. “There are mucus hypersecretion pathways. There are resolution pathways.”

Some pathways are resolved with systemic steroids, Liu continued, while some are not helped at all.

“That helps us understand when, for example, people or kids exacerbate,” Liu said. “We treat them. Some of them respond great, and some don’t respond at all, and they end up in the hospital for a couple of days. That’s the kind of insights we’re getting.”

Physicians can even look at every single cell in the nose, Liu said, to see which cells are telling other cells how to act, via single-cell RNA sequencing.

“The onus is getting down to the single-cell level as the technology improves,” he said.

Physicians also can culture and grow cells from the nose to replicate the airway and expose them to immune cells or mediators to see how they react, Liu said. Genetic manipulation via tools such as CRISPR are available as well.

“You can then take these cells, and you can change them just at a single gene locus,” Liu said. “Is this polymorphism causing someone’s airways to behave abnormally? You can actually do that in the cells. Proliferate and test them. See the results.”

Big data analytics

These treatments at the cellular and molecular level will require new technologies due to the volume and complexity of the data.

“Part of the way we march forward is with big data analytics,” Liu said.

There is a lot going on in big data analytics, Liu said, especially as the use of artificial intelligence (AI) programs such as ChatGPT grows.

Prior to his presentation, Liu said he asked ChatGPT to tell him about the past, present and future of allergic asthma. Within 10 seconds, Liu said, the AI provided historical data and information about improving diagnoses, avoiding allergens and treatments such as steroids, beta-agonists and biologics. It also predicted trends in future care.

“It actually listed the five trends that I had seen,” Liu said. “So, in a way, this is reassuring.”

Liu said he was particularly reassured by ChatGPT’s final piece of advice, which was to always consult with health care professionals for the most up-to-date and personalized information about managing allergic asthma.

But Liu also specified that ChatGPT depends on its data sources for success.

“It really has to do with how ChatGPT is educated. What is it using? How is it learning?” Liu said.

Adaptive design clinical trials

The next developments in care for allergic asthma will come from research that has been designed to be adaptive. Liu and his team are participating in one such study, Precision Interventions for Severe and/or Exacerbation-Prone (PrecISE) Asthma Network.

The multicenter clinical trial will involve adolescents and adults with severe asthma, targeting non-type 2 mechanisms of disease with five different drugs over 16 weeks of care and an 8-week washout period.

Bioanalysts will assess each patient at enrollment to determine which one of the five drugs will provide the most benefits.

“They have the statistical power to tell whether it’s futile to go on, in which case you drop that one and you move on to another, or whether you have proven that it is beneficial, in which case, then you already know to take that into FDA clinical trials for severe asthma,” Liu said.

Liu called it less like a randomized control trial and more like a crossover study, as the analysts will use predictive and monitoring biomarkers to determine which treatments patients will receive and predict how they will respond.

“That’s all getting us to that better place of personalized care,” Liu said.

Personalized precision medicine

The final trend will involve personalized precision medicine, Liu said, where care is tailored to each individual patient.

“This is part and parcel to what we do. Not only are there clinical pictures, and there’s symptoms, but they’re different in different patients,” Liu said.

“What’s actually driving them, it varies. It’s different. It can be a different mix of things. We’re always trying to understand that, to get to that difficult part of treatment, which is addressing the exposures that may be driving the reaction,” Liu said.

Overall, the goal is to leave patients satisfied with their care, Liu said.

“Maybe we’re not quite there yet,” he said. “In some ways, it can be great for some of our patients, and others, we fall short. But I think we’re getting to a better place.”

Key to success

Success in these trends will depend on collaboration, Liu said.

“You can see the march forward in innovation and science,” Liu said. “You see the themes moving forward because it’s many people who are working on it and identifying what are the themes that make up the difference.”

Liu thanked his team in the Children’s Hospital Colorado AIRE Program, as well as the laboratories in other specialties that he has partnered with.

“We’re really fortunate to be able to do this together,” Liu said. “I think the team science is really helpful where people work together, people collaborate to collectively leave it greater than the sum of the parts.”