Asthma Clinical Case Review

I asked her to come back in 4 weeks to reassess. She comes back in 4 weeks and she has partial response. She's much better, but not completely better. And her FEV1 improved to 72% predicted, but she still has some symptoms and uses albuterol twice or three times a day, sometimes. And her asthma control test improved to 13.

In the case of severe asthma, you want to also look at comorbidities and to see if many of those or some of those comorbidities are contributing to disease being uncontrolled. And the first thing you could, you know, one of the questions we'll ask is whether she has reflux and heartburn, and she definitely has, and she reports taking some antacids for those symptoms. And you also want to ask people questions to see if there is any other contributing comorbidities.

There's lots of recent studies showing a correlation between diabetes and metabolic syndrome and asthma severity. And sure enough, in her case, she was diagnosed with kind of the pre-diabetes over her HbA1c is a little bit high. So far she doesn't take any medication just controlled by diet, but she also says that each time she takes a corticosteroid burst for her exacerbations with diabetes becomes uncontrolled, and go up.

And the other important information in her case was body mass index. And in her case, it was elevated to 4,100 kilogram per meters square. So this is important. Those are important comorbidities that needs to be addressed in this space to take care of this patient. One of the questioning you ask if the patient has like pets at home, which she doesn't have, whether she have rhinitis and nasal discharge, and she doesn't have that either. So the only other symptoms, you know, she was asked whether she has symptoms of sleep apnea and she doesn't have any, she didn't report any snoring or witnessed the apnea. So the most relevant comorbidities, so far, that needs to be addressed, is her obesity, her heartburn, and her diabetes.

So to treat this patient, many things should be done. The first one is she will obviously be started on proton pump inhibitors like omeprazole and lansoprazole, but also the biggest thing that needs to be addressed in this case is obesity. So in her case, obesity is- it has- it has two roles, treating her obesity has two benefits, the first one, it will benefit her diabetes and her you know, what was diagnosed with her pre-diabetes picture, and her HbA1c, but also it will control or help with her asthma. And the first thing that needs to be done in this patient is to send her to weight loss management program.

She's already on a very high dose of inhaled corticosteroids, but she doesn't have complete response. And also she's not eligible for any of the current biologic, at least those advanced T2 high asthma. So the first beneficial therapy will be weight loss, and many data have shown that when asthmatic's body weight index, body mass index become normal, their asthma will improve 50 to 70%. And some people that has got kind of become controlled and doesn't need any more therapy, not 50% of the patients. So that will be the most important strategy to treat her asthma and also, you know, she will need to be counseled about the importance of weight loss and how would this correlate to her symptoms. And that would be my final, last recommendation for her.

We'll send her to a weight loss management program where they have a multidisciplinary approach to her weight and obesity. In that case, she would be seen by an endocrinologist or specialist that deals with weight gain, and also she will be seen by a dietician that is specialized with this kind of comorbidity. And also she will be seeing a exercise physiologist that will come up with a targeted physical therapy or exercise plan that suits her lifestyle and her clinical and characteristics. And also she has a other contributing factor to her obesity, like depression or anxiety or other psychological problems.

The weight loss management program also will include a psychologist and maybe if the issue will be refocused. I can just address that important aspect as well. So having a multidisciplinary approach would be very important to her and they will also evaluate whether she will be a candidate for surgery, at least if she fails to improve with standard therapy for weight loss, and she will need to be followed every four weeks to see how this is progressing, and to make sure that additional therapy will not be needed, meanwhile, to treat her asthma. Something like long-acting antimuscarinic agent, like tiotropium and stuff like this. That would be the best. The most important thing that's keeping this patient is actually weight loss.

Unfortunately, this is an important issue in asthma management, and that is very commonly underappreciated and underrecognized by healthcare workers and providers.