Managing Chronic Asthma

According to the Centers for Disease Control (CDC), asthma affected 26.5 million Americans in 2016.¹ Despite advances in diagnosis and management, the disease is still associated with a substantial mortality and morbidity burden.² 

Asthma is a condition of hypersensitivity to common exposures associated with chronic airway inflammation, bronchial hyperreactivity with increased mucus and airway edema, obstruction, and narrowing.  

Symptom frequency and severity are variable, but the underlying inflammation and hyperreactivity of the airways are chronic and present even when a person “feels well.” For most people (about 80% of children and adolescents and >50% of adults) with asthma, inflammation is triggered or maintained by exposure to allergens to which they are sensitized. This exposure often results in unscheduled office visits or emergency care with a focus on dealing with acute symptoms or exacerbations.¹ In 2015, the CDC reported a total of 1.7 million emergency department visits citing asthma as the primary diagnosis.¹ Further evaluation to identify allergic triggers should happen when physicians see patients, but often do not due to limited time, costs, and/or patient burden.

Evaluation and Diagnosis

Much of the asthma burden is potentially preventable by evaluating not only pharmacotherapy but also triggers, medication adherence, and comorbid conditions.³ The 2007 National Asthma Education and Prevention Program (NAEPP) US guidelines highlight the importance of allergy testing and to delineate specific environmental control measures for sensitized patients experiencing symptoms.⁴ 

The Report of the Asthma and Allergy Taskforce highlight groups for which allergy evaluation is appropriate immediately, those with poorly controlled asthma, those on step 4 or 5 therapy, and those noting potential allergic triggers. Tools such as the Asthma APGAR Plus also help determine when allergen-specific testing should occur.⁵

Diagnosis varies and can include different tests but the most readily available include skin testing, typically performed by an allergist, the assessment of specific IgE sensitization, and in vitro diagnostic testing which can be ordered by a primary care clinician during a routine visit. Both methods are assessments of specific IgE sensitization. A key message is that a positive allergy test result (skin or blood) indicates only the presence of allergen specific IgE. It does not necessarily mean clinical allergy (ie, allergic symptoms with exposure).⁶ Both methods are comparable; however, in vitro testing can be considered a better option for patients who are unable to halt their medication during the testing process. 

Test results can be used to guide avoidance or exposure reduction, consideration of immunotherapy, and reassurance when testing is negative.

Managing Treatment

According to the US Environmental Protection Agency, in 2018, asthma cost over $56 billion in medical costs, and lost school and work days in the United States.⁷ The disease is a major driver of health care costs and the prevalence of asthma is on the rise. From 2001 to 2011, the number of Americans with asthma grew by 28%, increasing the costs of care year over year.⁸ 

Allergy trigger testing for people with asthma requires resources, but poorly controlled asthma is expensive in terms of emergency department visits, hospitalizations, and extended stays.  

A single case of uncontrolled asthma can cost $5964 a year—double the cost for a patient whose asthma symptoms are being controlled.⁹ Delivering excellence in value-based asthma care is a function of improving quality while containing cost—a continuous process fed by real-world data, which lends insight and helps to shape new, more successful approaches.

The more data that’s produced and shared, the better we can predict outcomes and devise care plans. For example, asthma ICD-10 codes and the prescription order system are allowing for the identification of high-risk groups who should be evaluated (Table). The ICD-10 system expanded the 14,000 original diagnoses codes available in ICD-9 to more than 60,000.¹⁰

Patients with at least two visits in the past 18 months should be flagged with an asthma code to help limit the group to people most likely to have asthma, and rule out those prescribed short-term inhaler use for a respiratory event or postviral cough. The prescription order system can then be used to pinpoint people with asthma who have been prescribed three or more months of daily maintenance therapy.

Relevance to Pharmacy Care

Pharmacists can identify individuals with asthma who are refilling quick reliever medications more often—once a month or even more often. These individuals should see their physician or clinician to discuss uncontrolled asthma and what further evaluation should be done.

 Pharmacists and pharmacy techs may note patients with asthma who are purchasing over-the-counter allergy therapy and suggest they may need to talk with their doctors about this.  Further allergen-specific testing may be appropriate. Pharmacists should discuss asthma care from a health care professional with any patient purchasing “primatene mist” over-the-counter.

The FDA removed the original over-the-counter primatene mist inhaler from the market in 2011 but a new version was approved in November 2018. The product utilizes the same active bronchodilator (epinephrine) but the device designed to administer doses has changed.¹¹ 

References:
1. Center for Disease Control and Prevention. Most Recent National Asthma Data. 2018. https://www.cdc.gov/asthma/most_recent_nationalasthma_data.htm. Accessed April 2, 2019.
2. Gruffydd-Jones K. Unmet needs in asthma. Ther Clin Risk Manag. 2019;15;409-421.
3. Papadopoulos NG, Arakawa H, Carlsen KH, et al. International consensus on (ICON) pediatric asthma. Allergy. 2012; 67(8):976-97.
4. Guidelines for the Diagnosis and Management of Asthma (EPR-3). National Heart Lung and Blood Institute. https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma. Accessed April 2, 2019.
5. ThermoFisher Scientific. The Allergy and Asthma Task Force Recommendations: The practical application of allergic trigger management to improve asthma outcomes. Allergy & Autoimmune Disease. 2018. https://www.thermofisher.com/diagnostic-education/hcp/us/en/resources/improve-asthma-outcomes.html. Accessed April 3, 2019
6. Cox L, Williams B, Sicherer S, et al. Pearls and pitfalls of allergy diagnostic testing. Ann Allergy Asthma Immunol. 2008;101(6):580-592.
7. 2018 Asthma Fact Sheet. EPA. https://www.epa.gov/asthma/2018-asthma-fact-sheet. Published May 8, 2018. Accessed April 3, 2019.
8. Center for Disease Control and Prevention. Asthma Facts CDC’s National Asthma Control Program Grantees. 2013. https://www.cdc.gov/asthma/pdfs/asthma_facts_program_grantees.pdf. Accessed April 3, 2019.
9. Sullivan SD, Rasouliyan L, Russo PA, et al. Extent, patterns, and burden of uncontrolled disease in severe or difficult-to-treat asthma. Allergy. 2007;62(2):126-33.
10. The American Academy of Allergy, Asthma & Immunology. CD-10 Coding. Asthma & Immunology. https://www.aaaai.org/practice-resources/running-your-practice/practice-management-resources/coding/icd-10-coding. Accessed April 5, 2019.
11. U S Food and Drug Administration. Center for Drug Evaluation and Research. Safely Using the Newly Available OTC Asthma Inhaler Primatene Mist. https://www.fda.gov/Drugs/NewsEvents/ucm624994.htm. Accessed April 5, 2019