Asthma remission is the next goal in asthma care, expert says

Key takeaways:

• More patients are achieving remission with biologic and inhaled therapies.
• Physicians need to shift to a “predict and prevent” treatment approach.

BOSTON — Targeting asthma remission as the next goal in asthma therapy should be prioritized, according to a presentation at the CHEST Annual Meeting.

“Asthma treatment is often inappropriate,” Njira L. Lugogo, MD, professor of medicine and director of the Michigan Asthma Program at the University of Michigan, said during the presentation.

“We often treat asthma inappropriately as a recurrent acute disease with no treatment in between, ignoring the fact that there’s ongoing inflammation and bronchoconstriction, even sometimes in the absence of symptoms,” she said.

Lugogo explained that this leads to a lot of burdens and a risk for mortality.

“We are unfortunately repeat offenders in giving patients oral corticosteroids,” she said. “There’s a lot of asthma morbidity and mortality, which are largely preventable.”

The clinical consequences of asthma can set up a “vicious cycle for recurrent exacerbations.” Lugogo explained that to break out of the cycle and preserve lung function, we can look at biomarkers that predict asthma outcomes.

She shared findings from the placebo arm of a phase 3 study that showed patients that had a FeNO of 50 ppb or more and eosinophils of at least 300 cells/µL lost 149 ml in lung function within 1 year compared with the normal rate of decline of 20 ml to 30 ml a year. In another study shared by Lugogo, eosinophils predicted exacerbation risk.

Shifting to a “predict and prevent” approach by preserving lung function, reducing airway remodeling and oral corticosteroid use can lead to remission, according to Lugogo. She cited GINA 2024 guidelines on long-term asthma outcomes as consistent with asthma remission.

“We need to embrace a new paradigm where we want every patient to have the best possible outcome,” she said. “Symptom control is not enough.”

Assuming that a lack of symptoms means there is no ongoing disease activity is incorrect, Lugogo said, noting that remission is a multi-component treatment goal. The components include exacerbation-free and OCS-free patients as well as symptom control and preserving lung function.

To better define what asthma remission is, Lugogo cited an expert framework conducted by Menzies-Gow et al. in 2020 that described it as an absence of asthma symptoms, lung function stabilization, patient-provider agreement on remission and no systemic corticosteroid use.

She also noted the need for standardized definitions of the different parameters and thresholds to accomplish complete remission. This includes things like symptom control, biomarkers and exacerbations among many others.

In terms of potential treatments to induce remission, Lugogo presented data on biologics and inhaled therapies. She highlighted that patients who achieved remission were more likely not to be on maintenance steroids and had similar numbers of exacerbations and higher eosinophils. They were also less likely to be female or have obesity, and they had shorter diseases duration, adult-onset asthma and nasal polyps.

In 2023, Lugogo published a review on the impact of biologics on asthma remission. The review shows that biologic use resulted in no exacerbations or OCS and a stable rate of remission. Specifically for patients using dupilumab, 30% met remission criteria within 1 year of use.

“I think patients are actually ahead of us,” Lugogo said. “They believe in remission, and if we give them a goal of remission, they’ll hold us accountable to helping them accomplish remission.”

Reference:

• Lugogo NL, et al. CHEST. 2023;doi:10.1016/j.chest.2023.04.028.
• Menzies-Gow A, et al. J Allergy Clin Immunol. 2020;doi:10.1016/j.jaci.2019.12.006