Documentation of asthma remission endpoints varies
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Key takeaways:
- The workgroup’s definition of asthma remission includes seven endpoints.
- 94.2% of the patients had at least one endpoint documented.
- None of the patients had all seven endpoints documented.
SAN DIEGO — Few patients are evaluated based on all seven endpoints of guidelines indicating complete asthma remission, according to a poster presented at the American Thoracic Society International Meeting.
Standardized protocols that include all these domains are needed for accurate assessment of asthma remission, Thomas C. Corbridge, MD, FCCP, U.S. senior medical lead, respiratory biologics, GSK, and colleagues wrote.
“Foundational to this poster was a really important paper,” Corbridge told Healio.
Last year, a joint workgroup of the American Academy of Asthma, Allergy & Immunology, the American College of Asthma, Allergy & Immunology and the American Thoracic Society published a consensus definition of clinical remission in asthma on treatment.
“It was a paper that was meant for research, not clinical purposes,” Corbridge said.
The definition includes seven criteria that indicate remission: asthma exacerbations, systemic corticosteroid use, controller usage, rescue medication usage, the implementation of two or more asthma control tests, the implementation of two or more pulmonary function tests, and missed work or school due to asthma.
“If you achieve those, you can be considered potentially in remission,” Corbridge said.
“What we were interested in is, well, gosh, of those seven, how many do we have data on in clinical practice?” Corbridge said. “So, we went to a really good asthma center.”
The retrospective cohort study comprised 707 adults (mean age, 52.07 years; 60.96% women) with asthma in the Mayo Clinic’s electronic health record database who began biologic treatment between Jan. 1, 2015, and March 31, 2022.
“We tried to look in their record about how many of these endpoints were actually documented,” Corbridge said.
At baseline, 534 (75.5%) reported systemic corticosteroid use. Patients had a mean FEV1 65.2% predicted and a mean Asthma Control Test score of 16.8. Also, 351 (72.4%) had blood eosinophil counts greater than 150 cells/µL.
Prescriptions included mepolizumab (Nucala, GSK), dupilumab (Dupixent; Regeneron, Sanofi), benralizumab (Fasenra, AstraZeneca), omalizumab (Xolair; Genentech, Novartis), reslizumab (Cinqair, Teva Pharmaceutical) and tezepelumab (Tezspire; Amgen, AstraZeneca).
These patients had a year or more of follow-up at the Mayo Clinic including two or more refills of their treatment. Also, these patients had at least one encounter during the first year of their biologic therapy as well as one encounter after that first year.
Records included documentation of at least one of the criteria for complete remission for 94.2% (n = 666) of the patients. Also, 83.9% had documentation for two criteria, 65.4% had three and 36.1% had four. However, only 0.85% (n = 6) had documentation for at least six of the criteria. No patients had all seven criteria.
“It’s a documented patient abstract. It doesn’t mean they didn’t do them. They could have done them and not documented, because it’s an excellent clinic,” Corbridge said.
“What we found was that, really, nobody had all of the criteria documented in their record to even kind of consider making a judgment by way of documentation about remission as a definition,” he continued.
Specifically, percentages of patients with documentation per criterion included:
- systemic corticosteroid use: 55.45% (n = 392);
- exacerbations: 32.96% (n = 233);
- asthma control tests: 14% (n = 102);
- pulmonary function tests: 14% (n = 100);
- controller usage: 90.24% (n = 638);
- rescue medication usage: 83.16% (n = 588); and
- missed school or work: 0.42% (n = 3).
These findings indicate that routine practice infrequently captures these different components of asthma remission and that standardized assessment protocols including all these domains are needed for accurate assessment of remission.
“If you think these are seven important endpoints, it calls us to do better in clinic to ask the right questions of our patients, to do our diligence, to try to be more aspirational as we treat them to try to achieve as many of those as possible,” Corbridge said.
First, he said, clinicians need to be aware of this definition, which may require reaching out to them and helping them approach their patients with this kind of documentation in mind.
Corbridge also noted that the members of the joint workgroup intended their paper to be a living document and that they wanted feedback.
“The definition of remission continues to evolve,” he said. “As a community, we need to continue to discuss what a definition should look like.”
Corbridge said the definition will improve once the community decides which of these endpoints are most important in remission, but getting there will require better patient assessments and by matching appropriate therapy with how patients are assessed.
“Ask better questions, document and strive for a higher bar, because biologics in particular here have been very effective in being able to improve patient outcomes. That’s the bottom line,” Corbridge said.
This improvement may require a variety of strategies, he added.
“Recognize where they are in their journey, and if they aren’t meeting the endpoints, try to do better asthma care,” he said. “That could be education. It could be inhaler technique. It could be environment. It could be adding a biologic. It could be a lot of things to get you to a better place in clinical practice.”
For more information:
Thomas C. Corbridge, MD, FCCP, can be reached at thomas.x.corbridge@gsk.com.