may edition file
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
monotherapy for asthma or produce a<br />
cure, but then twenty years ago who<br />
could have known of the advances we<br />
have available today.<br />
Apart from monoclonals, what are<br />
the other approaches using biologics,<br />
currently being explored to address<br />
asthma?<br />
Despite the advances and benefits<br />
of currently available biologics, which<br />
are genetically engineered proteins,<br />
continued improvement is welcomed<br />
and there are definitely holes in our<br />
treatment choices. For the Th17 (non<br />
T2) type asthmatic, there are currently<br />
no highly effective biologics. Whereas<br />
currently 98% of all asthma treatment<br />
is small particle, the research pipeline<br />
contains 12% monoclonal and 17%<br />
non-monoclonal antibodies.<br />
The incidence of asthma is on<br />
the rise the world over despite<br />
wider availability of effective and<br />
comparatively less costly medicines<br />
to control the attacks. Why?<br />
It is estimated that asthma <strong>may</strong><br />
have increased as much as 12% over<br />
the past decade. There are a number<br />
of theories as to why the incidence<br />
of asthma is on the rise. In reality, it is<br />
probable that a number of these are<br />
contributing.<br />
First, it is suggested that asthma is<br />
more recognized and coded as such.<br />
Allergic disease, in general, has<br />
been increasing, not only asthma<br />
but also allergic rhinitis, food allergy,<br />
and atopic dermatitis. One theory is<br />
called the hygiene hypothesis, that our<br />
lymphocytes no longer have to fight<br />
infection as much as in the past, so<br />
they are becoming more Th2 cells and<br />
producing allergic disease.<br />
Air pollution has been linked to<br />
increased incidence of asthma in<br />
children, as has exposure to cigarette<br />
smoke, particularly if the mother<br />
smokes while pregnant. In addition, if<br />
a child’s diet is leading to obesity and<br />
overweight, it can be associated with<br />
an increased risk of asthma. Birth by<br />
It’s unlikely that biologics,<br />
as we currently know<br />
them, can function as<br />
monotherapy for asthma or<br />
produce a cure.<br />
Andy Nish MD<br />
Fellow of American Academy of<br />
Allergy, Asthma & Immunology, USA<br />
c-section changes the gut flora and<br />
increases the risk of asthma also.<br />
So, the rise in asthma is likely<br />
multifactorial, but the good news is<br />
that we do have more and better<br />
asthma medicines to use over time.<br />
Some of the experts in the field<br />
argue that the term “asthma”<br />
needs to be redefined, giving more<br />
emphasis on the heterogeneity of<br />
the disease. What is your comment?<br />
I definitely agree with this concept.<br />
As we have learned particularly<br />
in recent years, there is so much<br />
heterogeneity in the pathology of<br />
asthma and the inflammation thereof<br />
and response to treatment.<br />
The more medicines that have been<br />
developed, the more we learn about<br />
which patients do or don’t respond to<br />
particular of those medicines, and<br />
then research helps to delineate why<br />
that is.<br />
Some patients are primarily T2<br />
driven and some primarily Th17 driven.<br />
Some are primarily eosinophil driven<br />
and some primarily neutrophils. Some<br />
asthmatics respond dramatically to very<br />
small doses of inhaled corticosteroids<br />
and some respond minimally to<br />
very high doses of inhaled or even<br />
systemic steroids. It’s important that we<br />
recognize that asthma treatment is not<br />
“one size fits all”.<br />
Are corticosteroids being<br />
overprescribed for managing<br />
asthma?<br />
If the question is in regard to<br />
inhaled steroids, I would suggest<br />
that the answer is no. It <strong>may</strong> even be<br />
that inhaled steroids are not being<br />
prescribed often enough, partly<br />
because of steroid phobia, particularly<br />
on the part of parents. Other studies<br />
have suggested that asthma is<br />
underdiagnosed in general and the<br />
severity is underappreciated.<br />
It is recommended by experts<br />
that the drug of choice for the firstline<br />
treatment of mild, moderate<br />
and severe persistent asthma is<br />
inhaled steroids, of course with other<br />
medicines as needed as severity<br />
increases.<br />
We have good evidence from<br />
longitudinal studies that, if inhaled<br />
steroids affect children’s final adult<br />
height, it is a minimal effect and that<br />
other potential side effects, in general,<br />
present a favourable risk to benefit<br />
ratio. It is worth pointing out that<br />
inhaled steroids are in microgram<br />
doses and systemic steroids, if needed<br />
for an asthma flare, are in milligram<br />
doses, or 1000 times stronger.<br />
It is important to note that<br />
objective measures, such as<br />
pulmonary function tests, should be<br />
used to make sure that treatment is<br />
effective, and at the lowest possible<br />
dose for the fewest side effects.<br />
May 2019 / FUTURE MEDICINE / 23
Change language