Severe Adult Asthmas: Integrating Clinical Features, Biology, and Therapeutics to Improve Outcomes

Evaluation and effective management of asthma, and in particular severe asthma, remains at the core of pulmonary practice. Over the last 20–30 years, there has been increasing appreciation that “severe asthma” encompasses multiple different subgroups or phenotypes, each with differing presentations. Using clinical phenotyping, in combination with rapidly advancing molecular tools and targeted monoclonal antibodies (human knockouts), the understanding of these phenotypes, and our ability to treat them, have greatly advanced. Type-2 (T2)-high and -low severe asthmas are now easily identified. Fractional exhaled nitric oxide and blood eosinophil counts can be routinely employed in clinical settings to identify these phenotypes and predict responses to specific therapies, meeting the initial goals of precision medicine.

Integration of molecular signals, biomarkers, and clinical responses to targeted therapies has enabled identification of critical molecular pathways and, in certain phenotypes, advanced them to near-endotype status. Despite these advances, little guidance is available to determine which class of biologic is appropriate for a given patient, and current “breakthrough” therapies remain expensive and even inaccessible to many patients. Many of the most severe asthmas, with and without T2-biomarker elevations, remain poorly understood and treated. Nevertheless, conceptual understanding of “the severe asthmas” has evolved dramatically in a mere 25 years, leading to dramatic improvements in the lives of many.

Target Audience

Pulmonologists, critical care specialists, translational researchers, and clinicians

Learning Objectives

At the conclusion of this activity, learners should be able to:

  • Develop a useful approach to identifying and characterizing patients with complex severe asthma.
  • Identify different clinical and molecular phenotypes of severe asthma and their various treatment approaches.
  • Use precision medicine approaches to better utilize biologic therapies to improve outcomes.
Course summary
Available credit: 
  • 1.00 AMA PRA Category 1 Credit(s)
    The American Thoracic Society designates this for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  • 1.00 Participation
Publication Date: 
04/01/2021
Credit Expires: 
04/01/2023
Rating: 
0

Accreditation Statement

The American Thoracic Society is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Disclosure Declaration

The current practice of the American Journal of Respiratory and Critical Care Medicine (AJRCCM) is to publish high quality, peer-reviewed and evidence-based original research, Concise Clinical Reviews, Guidelines and Consensus Statements. Articles published in AJRCCM include evidence-based summaries of optimal practice (Concise Clinical Reviews), evidence-based guidelines, workshop summaries and original contributions that will influence clinical practice. The publication of these articles by itself is only one piece of a multi-step process for the translation of evidence-based improvements in care to clinical practice. Articles selected for CME credit are designed to be the next step in the process of translating clinically relevant, evidence-based recommendations into clinical practice. This will be accomplished through a series of questions specifically designed by the author(s) to test that readers have the tools needed to translate recommendations for diagnostic and therapeutic clinical care into clinical practice. Members of the AJRCCM editorial board will review these questions and assess the quality of the questions based on:

  • Clarity,
  • Educational content, and
  • The quality of the evidence supporting the response to the question. Posttest questions will assess if practitioners have understood the most important recommendations available for the diagnosis and treatment of pulmonary diseases, critical illness, and sleep disorders and are able to implement them into clinical practice.

Article Authorship Disclosures (as submitted to the ATS prior to article publication date)

Sally E. Wenzel, M.D. (University of Pittsburgh, Pittsburgh, PA, USA) reported grants from GSK, AstraZeneca, Sanofi-Genzyme, Pieris, Novartis, Knopp, TEVA, and Boehringer Ingelheim; personal fees from GSK, Sanofi, Genzyme, and Novartis; and nonfinancial support from GSK; and served on an advisory board for asthma biomarkers for Sanofi-Genzyme.

Off-Label Usage Disclosure

Azathioprine, possible use in autoimmune severe asthma; mycophenolate, possible use in autoimmune severe asthma; methotrexate, possible use in autoimmune severe asthma.

Disclosures of AJRCCM CME Planners

The current practice of the American Journal of Respiratory and Critical Care Medicine (AJRCCM) is to publish high quality, peer-reviewed and evidence-based original research, Concise Clinical Reviews, Guidelines and Consensus Statements. Articles published in AJRCCM include evidence-based summaries of optimal practice (Concise Clinical Reviews), evidence-based guidelines, workshop summaries and original contributions that will influence clinical practice. The publication of these articles by itself is only one piece of a multi-step process for the translation of evidence-based improvements in care to clinical practice. Articles selected for CME credit are designed to be the next step in the process of translating clinically relevant, evidence-based recommendations into clinical practice. This will be accomplished through a series of questions specifically designed by the author(s) to test that readers have the tools needed to translate recommendations for diagnostic and therapeutic clinical care into clinical practice. Members of the AJRCCM editorial board will review these questions and assess the quality of the questions based on (1) clarity, (2) educational content, and (3) the quality of the evidence supporting the response to the question. Posttest questions will assess if practitioners have understood the most important recommendations available for the diagnosis and treatment of pulmonary diseases, critical illness, and sleep disorders and are able to implement them into clinical practice.

AJRCCM CME Planners

Harold Collard, M.D.
Associate Editor, AJRCCM

Dr. Collard reported that he is on the advisory committee of Bayer, Biogen, Boehringer Ingelheim, Fibrogen, Genentech, Gilead, Intermune, and Promedior; and is a consultant at Five Prime.

Gerard J. Criner, M.D.
Associate Editor, AJRCCM

Dr. Criner reported that he has research awards from Aeris Therapeutics, AstraZeneca, Boehringer Ingelheim, Forest Laboratories, GlaxoSmithKline, Ikaria, Medimmune, Novartis, Pearl, PneumRx, Pulmonx, Respironics, Spectral Diagnostics, and Theratechnologies Inc.; and has received lecture fees from Almirall, AstraZeneca, Boehringer Ingelheim, Celerion, CSA Medical Inc., Johnson & Johnson, and Respivert.

Jadwiga A. Wedzicha, M.D.
Editor-in-Chief, AJRCCM

Dr. Wedzicha reported that she is on the advisory committee of Napp, Pfizer, and Takeda; has research awards from Chiesi, Takeda, and Vifor Pharma; and has received lecture fees from Almirall, Bayer, Boehringer Ingelheim, Novartis, and Takeda.

Instructions to Receive Credit

To receive credit for this journal article:

  1. Read the journal article. Keep track of how long it takes you to read it.
  2. Once you open the article, the Post-Test becomes available. After reading the article, answer the post-test questions. You must answer all questions correctly to earn credit. You may take the test as many times as you like.
  3. Once you pass the Post-Test, the Evaluation becomes available. Answer all the evaluation questions.
  4. Once you complete the evaluation, select the amount of credit to receive based on the time it took you to read the article.
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  6. To review the credits you've earned in this system and reprint certificates, go to the My Learning drop-down list. Then select Transcript.

Available Credit

  • 1.00 AMA PRA Category 1 Credit(s)
    The American Thoracic Society designates this for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  • 1.00 Participation
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