Patients who aren’t responding to traditional asthma medication have more options than ever in terms of injectables and biologic therapies.
The introduction of Xolair has been a game changer for those with modern to persistent allergic asthma and clinical trials are increasingly targeting different pathways of inflammation.
Concurrently, new options for asthma management are emerging, including the expansion of heat treatment and a smart phone app to motivate teenage patients.
Pulmonologists at University of Rochester Medical Center in Rochester, NY, introduced bronchial thermoplasty – the first approved non-drug treatment – as an option to adults with severe, uncontrollable asthma last year. According to Sandhya Khurana, MD, FCCP, associate professor of medicine, the new therapy delivers low heat to the airway muscles and has, thus far, saved four patients a trip to the Cleveland Clinic for the same treatment.
The Alair Bronchial Thermoplasty System allows doctors to use a bronchoscope to insert a small catheter directly into the lungs and deliver controlled energy. This reduces the amount of smooth muscle in the airways and its ability to constrict the airways, thus quelling asthma symptoms.
The treatment is delivered over three visits, scheduled 3 weeks apart and each targeting a different area of the lungs. The procedure is performed using moderate to deep sedation. Patients are expected to experience fewer symptoms from asthma flares after completing all three procedures.
However, not everyone is a candidate for bronchial thermoplasty.
“As with any therapy, patient selection is key,” explained Khurana. “Patients referred to us or who approach us in the severe asthma clinic must have long-acting asthma that isn’t controlled on inhaled steroids. To be able to tolerate the procedure, we want their lung function to be at 60% spirometry of predicted. We’ve seen patients who are not quite there but we adjust their medications to help them reach that level.”
From there, the team begins the process of applying for insurance coverage. Although it has its own CPT code and is usually covered by Medicare, private insurers have yet to follow suit.
Because of the severity of their asthma, patients often experience symptoms immediately after the treatments sessions, but they’ve usually resolved within a week, said Khurana.
“The procedure itself isn’t very complicated and we can perform it in 30-40 minutes,” she said. “The data shows a long-term improvement in flare-up frequency, a reduction in missed work days and emergency department visits. Five years out, we know this procedure is safe and effective.”
Bronchial thermoplasty is permissible only in patients older than 18 but pediatric asthma rates are increasing. The problem is magnified in Chicago, where CDC data revealed 1.9 million asthma-related ED visits and 479,300 asthma-related hospitalizations in 2009. From 2001 through 2009, asthma rates rose the most among black children by nearly 50 percent. In 2007, asthma was linked to 3,447 deaths (approximately 9 per day).
Researchers at Rush University Medical Center in Chicago and The University of Illinois at Chicago initiated the first real-time study using the Internet and motivational multimedia coupled with positive reinforcement via a smart phone application to try to improve asthma outcomes among low-income, minority 11-17 year olds in Chicago.
Each participant in the study receives a smart phone preloaded with an application that uses a reward system to encourage them to proactively take their daily asthma controller medications. They also receive a free data plan (including unlimited talking, texting, email and Internet) for the duration of their participation in the study. The study is funded by the NIH.
“The kids are so excited to receive phones,” said Giselle Mosnaim, MD, asthma and immunology specialist at Rush University Medical Center and principal investigator. “When they’re 4 years old, parents can supervise them taking medications. It gets harder in adolescence as they want independence. This teaches adolescents to self-manage.”
The controller medication is fitted with a sensor that sends a signal to the smart phone application automatically when a dose is taken. Participants’ times and dates, locations in latitude and longitude, as well as ambient air pollution and pollen levels from the National Allergy Bureau and Environmental Protection are recorded every time they take a puff.
“We want to know where they are when they use their medicines – to see if they took it because asthma symptoms were induced by exercise, such as being on a basketball court, or if poor air quality and/or high pollen counts could be an influencing factor.”
Mosnaim monitors their real-time-medication-taking behavior via the data collected by the electronic dose counter, processed by the smart phone asthma application, and sent to the secure server. She and her colleagues may provide participants feedback by sending them messages via texting or email. Participants will also get immediate positive reinforcement when they take the dose within the correct time window.
Every time a participant takes the entire dose in the correct time window, they will score points in a virtual game (i.e., the participant scores a basket in a basketball game each time they take a dose), and they earn 50 cents that they can use at the Googleplay store to purchase music, apps, movies or television shows.
“We know their habits when left to their own devices,” she said. “This teaches baseline adherence,” she said. “We just started the study but hope to see a 25% improvement in adherence right away and then maintained throughout the 10-week study.”
Logically, Mosnaim and her colleagues believe that, once they start feeling better after following their medication regimen, intrinsic motivation will inspire them to continue the course of therapy. She cited research proving a 25% improvement in adherence reduced asthma exacerbation.
“Kids think they can’t play sports because of their asthma and it’s not true,” said Mosnaim. “It’s so rewarding to see them go from the sidelines to being MVP just by taking their medications.”
Robin Hocevar is on staff at ADVANCE. Contact: [email protected]