Exploring Perceptions of Biologic Therapies: A Qualitative Study Among Canadians Living with Severe Asthma.

INTRODUCTION: Biologic therapies have demonstrated benefits for individuals with severe asthma, including reduced daily symptoms and severe exacerbations. However, data describing patient perspectives on these treatments are limited. This study sought to understand the preferences and priorities of Canadians with severe asthma in the context of novel biologic treatment options. METHODS: Semi-structured, qualitative interviews were conducted among Canadians with severe asthma from July to August 2022. Purposeful sampling included individuals with and without biologic therapy experience. All participants described daily life with severe asthma, experiences and priorities related to asthma treatment and their impressions of biologics. Reflexive thematic analysis was used to explore patterns in the data. RESULTS: Among 18 individuals included, 10 were currently taking or had prior experience with biologic treatment for asthma. Those who had never been treated with biologics were unfamiliar with them, considering treatment, or believed that they may not be eligible. Four themes were developed to convey the perspectives of participants on biologics: (1) life-changing benefits, but not for all; (2) navigating barriers to being prescribed and remaining adherent to biologic treatments; (3) treatment administration preferences are not only about convenience; (4) concerns about safety and the unknown as a source of treatment hesitancy. CONCLUSIONS: Findings suggest that the clinical benefits of biologics align with patient perceptions of achieving good asthma control. However, treatment gaps persist among individuals who do not experience a meaningful improvement in their asthma symptoms and those who face barriers accessing biologics. People with severe asthma attributed importance to greater availability of at-home treatment options, improved access to financial support to cover treatment costs and support to address safety concerns. This research provides insight into patient-based treatment priorities and preferences for biologics, which may help inform decision-making related to emerging therapies for severe asthma.

For people with severe asthma, biologics are a treatment option that can be taken in addition to their regular medication. In this study, we asked 18 Canadians with severe asthma about how having severe asthma affects their lives, their current and previous asthma treatments, and their views on biologics. Ten people in this study were currently taking or had previously taken biologics for severe asthma. We found that biologics can be life changing. Also, people with severe asthma can find it difficult to get on and stay on biologics. They would like financial and educational support when considering biologics and prefer to take biologics at home, if possible. This study helps us understand the priorities and preferences related to biologics of patients with severe asthma.

Asthma Exacerbations and Glucagon-Like Peptide-1 Receptor Agonists: a Review of the Current Evidence.

Asthma is a chronic inflammatory disease involving multiple mediators and cytokines. While our current treatments have shown significant therapeutic benefits, there still appear to be some patients who, despite aggressive therapy, good adherence, and inhaler technique, continue to have exacerbations. Exacerbations lead to loss of lung function, exposure to systemic corticosteroids, effects on quality of life, and even mortality. There is a large number of glucagon-like peptide-1 (GLP-1) receptors in the lung even compared with other organs, and studies have shown evidence of reduced exacerbations in asthmatics treated with GLP-1 receptor agonists (GLP-1 RA). While weight loss may affect lung mechanics, evidence of inflammatory changes has been revealed that could explain this relationship. This article will review the data behind these conjectures and outline potential clinical utility and the need for future studies to truly understand the role of GLP-1 receptors in the lung.

Obesity is a common issue and a comorbidity that negatively impacts asthma outcomes. Weight loss can improve asthma outcomes, and evidence shows that a particular type of therapy currently indicated for diabetes that assists in weight loss and targets receptors that are abundant in the lungs will outperform other therapies. GLP-1-receptor agonists may particularly help overweight patients who have asthma to control the disease as best as possible and prevent exacerbations. Video Abstract.

COPD Population in US Primary Care: Data From the Optimum Patient Care DARTNet Research Database and the Advancing the Patient Experience in COPD Registry.

PURPOSE: To describe demographic and clinical characteristics of chronic obstructive pulmonary disease patients managed in US primary care. METHODS: This was an observational registry study using data from the Chronic Obstructive Pulmonary Disease (COPD) Optimum Patient Care DARTNet Research Database from which the Advancing the Patient Experience COPD registry is derived. Registry patients were aged ≥35 years at diagnosis. Electronic health record data were collected from both registries, supplemented with patient-reported information/outcomes from the Advancing the Patient Experience registry from 5 primary care groups in Texas, Ohio, Colorado, New York, and North Carolina (June 2019 through November 2020). RESULTS: Of 17,192 patients included, 1,354 were also in the Advancing the Patient Experience registry. Patients were predominantly female (56%; 9,689/17,192), White (64%; 9,732/15,225), current/ex-smokers (80%; 13,784/17,192), and overweight/obese (69%; 11,628/16,849). The most commonly prescribed maintenance treatments were inhaled corticosteroid with a long-acting ß2-agonist (30%) and inhaled corticosteroid with a long-acting muscarinic antagonist (27%). Although 3% (565/17,192) of patitents were untreated, 9% (1,587/17,192) were on short-acting bronchodilator monotherapy, and 4% (756/17,192) were on inhaled corticosteroid monotherapy. Despite treatment, 38% (6,579/17,192) of patients experienced 1 or more exacerbations in the last 12 months. These findings were mirrored in the Advancing Patient Experience registry with many patients reporting high or very high impact of disease on their health (43%; 580/1,322), a breathlessness score 2 or more (45%; 588/1,315), and 1 or more exacerbation in the last 12 months (50%; 646/1,294). CONCLUSIONS: Our findings highlight the high exacerbation, symptom, and treatment burdens experienced by COPD patients managed in US primary care, and the need for more real-life effectiveness trials to support decision making at the primary care level.

Cannabis and Lung Health: Does the Bad Outweigh the Good?

Cannabis use is growing, with multiple medical 'indications' and approval for recreational use in many countries. This article will review some of the respiratory complications to cannabis use, which include lung function changes, lung destruction, increased risk of lung and head and neck cancer, and others. These are mostly related to smoking, and the co-administration of nicotine makes the risks a bit difficult to measure. However, with many reports of EVALI, electronic vaping-associated lung injury, being related to cannabis coadministration, it appears that the safest administration of cannabis, as far as lung health, is orally. Cannabis and Lung Health: Does the Bad Outweigh the Good? A video abstract (MP4 81,897 kb).

Global Quality Statements on Reliever Use in Asthma in Adults and Children Older than 5 Years of Age.

INTRODUCTION: Widespread misuse of short-acting beta-agonists (SABAs) may contribute to asthma-related morbidity and mortality. Recognizing this, the Global Initiative for Asthma neither recommends SABA monotherapy nor regards this formulation as a preferred reliever. Many health systems and healthcare professionals (HCPs) experience practical issues in implementing guidelines. Clear quality standards can drive improvements in asthma care and encourage implementation of global and national medical guidelines. METHODS: A steering group of global asthma experts came together between May and September 2019 to develop quality statements codifying the minimum elements of good quality asthma care. These statements were either evidence based (when robust evidence was available) or reflected a consensus based on clinical expertise and experience of the group. RESULTS: The quality statements (and associated essential criteria) developed emphasize key elements concerning (1) objective diagnosis specific to individual symptoms, (2) treatment appropriate to the long-term management of asthma as an inflammatory disease, consistent with evidence-based recommendations, (3) controlled dispensing of SABA canisters and monitoring to prevent overuse, (4) regular review of patients after treatment initiation or change, and (5) follow-up of patients in primary care after treatment for an exacerbation in a hospital or an emergency department. CONCLUSIONS: The steering group proposes quality statements that national and local clinical groups can implement as quantitative quality standards that are appropriate to their local circumstances, including during the coronavirus disease 2019 (Covid-19) pandemic. By translating these statements into locally relevant quality standards, primary care physicians and HCPs can encourage optimal management and reduce preventable healthcare interactions. The evidence-based evolution of care encapsulated in these statements will further engender high-quality, patient-centered holistic management that addresses asthma as an inflammatory disease. In particular, the statements empower self-management by patients and encourage health-promoting behaviors, which are essential to reduce exacerbations, the primary goal of asthma management.

Development of the Advancing the Patient Experience in COPD Registry: A Modified Delphi Study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is commonly managed by family physicians, but little is known about specifics of management and how this may be improved. The Advancing the Patient Experience in COPD (APEX COPD) registry will be the first U.S. primary care, health system-based registry following patients diagnosed with COPD longitudinally, using a standardized set of variables to investigate how patients are managed in real life and assess outcomes of various management strategies. OBJECTIVE: Gaining expert consensus on a standardized list of variables to capture in the APEX COPD registry. METHODS: A modified, Delphi process was used to reach consensus on which data to collect in the registry from electronic health records (EHRs), patient-reported information (PRI) and patient-reported outcomes (PRO), and by physicians during subsequent office visits. The Delphi panel comprised 14 primary care and specialty COPD experts from the United States and internationally. The process consisted of 3 iterative rounds. Responses were collected electronically. RESULTS: Of the initial 195 variables considered, consensus was reached to include up to 115 EHR variables, 34 PRI/PRO variables and 5 office-visit variables in the APEX COPD registry. These should include information on symptom burden, diagnosis, COPD exacerbations, lung function, quality of life, comorbidities, smoking status/history, treatment specifics (including side effects), inhaler management, and patient education/self-management. CONCLUSION: COPD experts agreed upon the core variables to collect from EHR data and from patients to populate the APEX COPD registry. Data will eventually be integrated, standardized and stored in the APEX COPD database and used for approved COPD-related research.

Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease (COPD): Boon or Bane?

Inhaled corticosteroid (ICS)-based therapy is often used for patients with chronic obstructive pulmonary disease (COPD). However, this approach is under scrutiny because of ICS overuse in patients for whom it is not recommended and because of concerns about adverse events, particularly pneumonia, with long-term ICS use. Evidence suggests ICS may be beneficial in specific patients, namely, those with high blood eosinophil counts (eg, ≥300 cells/µL) or who are at a high risk of exacerbations. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 ABCD assessment tool, these patients belong in group D. For these patients, recommended initial treatment includes ICS in combination with long-acting ß2-agonists (LABAs) when blood eosinophil counts are ≥300 cells/µL or LABA + long-acting muscarinic antagonist (LAMA) when patients are highly symptomatic, that is, with greater dyspnea and/or exercise limitation. Follow-up treatments for patients with persistent dyspnea and/or exacerbations may include LABA + ICS, LABA + LAMA, or LABA + LAMA + ICS, with use of ICS being guided by blood eosinophil counts. In this review, differences in the inflammatory mechanism underlying COPD and asthma and the role of ICS treatment in COPD are summarized. Furthermore, findings from recent clinical trials where use of ICS-based dual or triple therapy in COPD was compared with LABA + LAMA therapy and trials in which ICS withdrawal was evaluated in patients with COPD are reviewed. Finally, a step-by-step guide for ICS withdrawal in patients who are unlikely to benefit from this treatment is proposed. A video of the author discussing the overall takeaway of the review article could be downloaded from the link provided: https://www.youtube.com/watch?v=Uq7Sr5jqPDI.

The Electronic Asthma Management System (eAMS) improves primary care asthma management.

A high prevalence of suboptimal asthma control is attributable to known evidence-practice gaps. We developed a computerised clinical decision support system (the Electronic Asthma Management System (eAMS)) to address major care gaps and sought to measure its impact on care in adults with asthma.This was a 2-year interrupted time-series study of usual care (year 1) versus eAMS (year 2) at three Canadian primary care sites. We included asthma patients aged ≥16 years receiving an asthma medication within the last 12 months. The eAMS consisted of a touch tablet patient questionnaire completed in the waiting room, with real-time data processing producing electronic medical record-integrated clinician decision support.Action plan delivery (primary outcome) improved from zero out of 412 (0%) to 79 out of 443 (17.8%) eligible patients (absolute increase 0.18 (95% CI 0.14-0.22)). Time-series analysis indicated a 30.5% increase in physician visits with action plan delivery with the intervention (p<0.0001). Assessment of asthma control level increased from 173 out of 3497 (4.9%) to 849 out of 3062 (27.7%) eligible visits (adjusted OR 8.62 (95% CI 5.14-12.45)). Clinicians escalated controller therapy in 108 out of 3422 (3.2%) baseline visits versus 126 out of 3240 (3.9%) intervention visits (p=0.12). At baseline, a short-acting ß-agonist alone was added in 62 visits and a controller added in 54 visits; with the intervention, this occurred in 33 and 229 visits, respectively (p<0.001).The eAMS improved asthma quality of care in real-world primary care settings. Strategies to further increase clinician uptake and a randomised controlled trial to assess impact on patient outcomes are now required.

Large care gaps in primary care management of asthma: a longitudinal practice audit.

OBJECTIVES: Care gaps in asthma may be highly prevalent but are poorly characterised. We sought to prospectively measure adherence to key evidence-based adult asthma practices in primary care, and predictors of these behaviours. DESIGN: One-year prospective cohort study employing an electronic chart audit. SETTING: Three family health teams (two academic, one community-based) in Ontario, Canada. PARTICIPANTS: 884 patients (72.1% female; 46.0±17.5 years old) (4199 total visits; 4.8±4.8 visits/patient) assigned to 23 physicians (65% female; practising for 10.0±8.6 years). MAIN OUTCOME MEASURES: The primary outcome was the proportion of visits during which practitioners assessed asthma control according to symptom-based criteria. Secondary outcomes included the proportion of: patients who had asthma control assessed at least once; visits during which a controller medication was initiated or escalated; and patients who received a written asthma action plan. Behavioural predictors were established a priori and tested in a multivariable model. RESULTS: Primary outcome: Providers assessed asthma control in 4.9% of visits and 15.4% of patients. Factors influencing assessment included clinic site (p=0.019) and presenting symptom, with providers assessing control more often during visits for asthma symptoms (35.0%) or any respiratory symptoms (18.8%) relative to other visits (1.6%) (p<0.01). SECONDARY OUTCOMES: Providers escalated controller therapy in 3.3% of visits and 15.4% of patients. Factors influencing escalation included clinic site, presenting symptom and prior objective asthma diagnosis. Escalation occurred more frequently during visits for asthma symptoms (21.0%) or any respiratory symptoms (11.9%) relative to other visits (1.5%) (p<0.01) and in patients without a prior objective asthma diagnosis (3.5%) relative to those with (1.3%) (p=0.025). No asthma action plans were delivered. CONCLUSIONS: Major gaps in evidence-based asthma practice exist in primary care. Targeted knowledge translation interventions are required to address these gaps, and can be tailored by leveraging the identified behavioural predictors. TRIAL REGISTRATION NUMBER: NCT01070095; Pre-results.

Chronic Cough in Adults: Make the Diagnosis and Make a Difference.

Chronic cough is common and impactful, frustrating both patients and clinicians. An empirical trial of therapy is often done with inhaled corticosteroids, but this practice should be replaced with attempting to make an accurate diagnosis. The three most common causes are upper airway cough syndrome, asthma, and gastroesophageal reflux disease (GERD), but there are often multiple causes involved. Minimal investigations after history, physical exam, travel history, and drug history include a chest radiograph and spirometry. Empirical trial of therapy with inhaled corticosteroids is reasonable if there is evidence of eosinophilic inflammation. Empiric therapy for GERD may also be reasonable in those with symptoms. Red flags should especially be considered an urgency to make the correct diagnosis.

Hollywood raising awareness of smoking-related diseases: can it proactively counteract the impact of smoking in movies?-the final mission of Star Trek's Mr Spock.

This corrects the article DOI: 10.1038/npjpcrm.2016.52.

Why choose tiotropium for my patient? A comprehensive review of actions and outcomes versus other bronchodilators.

PURPOSE: Chronic obstructive pulmonary disease (COPD) and asthma are leading causes of morbidity and mortality. This narrative review provides an appraisal of the pharmacological and clinical characteristics of tiotropium in COPD and asthma, and examines how these compare with other long-acting bronchodilators. The evidence base is placed into context by relating it to factors affecting clinicians' choice of therapy. MAIN FINDINGS: Desirable attributes of a long-acting muscarinic antagonist (LAMA) maintenance therapy include effective pharmacological bronchodilation, improved lung function, exacerbation efficacy, and positive effects on symptom control, exercise capacity and quality of life across a broad patient population. Tolerability and convenience of use are also important for patient well-being and treatment adherence. Tiotropium shows higher affinity for muscarinic receptors than ipratropium, and prolonged binding to the M3 receptor compared with other LAMAs. In COPD, tiotropium has demonstrated improved lung function and exacerbation prevention compared with placebo or long-acting ß2-agonists, similar exacerbation efficacy to other LAMAs, and enhanced symptom control and health status versus placebo. UniTinA-asthma® showed the benefits of add-on tiotropium in patients with uncontrolled mild to moderate and severe asthma. Tiotropium is well tolerated, with an incidence of adverse events similar to placebo, except for known infrequent side effects of anticholinergics. Tiotropium HandiHaler® and Respimat® augment inhaler choice in COPD. PRINCIPAL CONCLUSIONS: With over 10 years' prescribing history and 50 million patient-years of use, tiotropium has the benefit of a more extensive clinical evidence base than other long-acting bronchodilators, with demonstrated efficacy and safety in COPD and symptomatic asthma.

Applying the wisdom of stepping down inhaled corticosteroids in patients with COPD: a proposed algorithm for clinical practice.

Current guidelines for the management of chronic obstructive pulmonary disease (COPD) recommend limiting the use of inhaled corticosteroids (ICS) to patients with more severe disease and/or increased exacerbation risk. However, there are discrepancies between guidelines and real-life practice, as ICS are being overprescribed. In light of the increasing concerns about the clinical benefit and long-term risks associated with ICS use, therapy needs to be carefully weighed on a case-by-case basis, including in patients already on ICS. Several studies sought out to determine the effects of withdrawing ICS in patients with COPD. Early studies have deterred clinicians from reducing ICS in patients with COPD as they reported that an abrupt withdrawal of ICS precipitates exacerbations, and results in a deterioration in lung function and symptoms. However, these studies were fraught with numerous methodological limitations. Recently, two randomized controlled trials and a real-life prospective study revealed that ICS can be safely withdrawn in certain patients. Of these, the WISDOM (Withdrawal of Inhaled Steroids During Optimized Bronchodilator Management) trial was the largest and first to examine stepwise withdrawal of ICS in patients with COPD receiving maintenance therapy of long-acting bronchodilators (ie, tiotropium and salmeterol). Even with therapy being in line with the current guidelines, the findings of the WISDOM trial indicate that not all patients benefit from including ICS in their treatment regimen. Indeed, only certain COPD phenotypes seem to benefit from ICS therapy, and validated markers that predict ICS response are urgently warranted in clinical practice. Furthermore, we are now better equipped with a larger armamentarium of novel and more effective long-acting ß2-agonist/long-acting muscarinic antagonist combinations that can be considered by clinicians to optimize bronchodilation and allow for safer ICS withdrawal. In addition to providing a review of the aforementioned, this perspective article proposes an algorithm for the stepwise withdrawal of ICS in real-life clinical practice.

Pulmonary Rehabilitation in Ontario: A Cross-Sectional Survey.

BACKGROUND: Pulmonary rehabilitation (PR) is a comprehensive intervention of exercise training, education, and behaviour change to improve the physical and psychological condition of people with chronic respiratory disorders, such as chronic obstructive pulmonary disease (COPD) and to promote long-term adherence to health-enhancing behaviours. Although PR is considered the standard of care for patients with COPD who remain symptomatic despite bronchodilator therapies, current evidence suggests that only 1.15% of COPD patients across Canada have access to PR facilities for care. OBJECTIVES: The objectives of this study were to identify the number of health care facilities across Ontario providing PR services for patients with COPD, describe the scope of those services, and determine the province's current capacity to provide PR services relative to need, for the province as a whole and by local health integration network (LHIN). METHODS: The Pulmonary Rehabilitation Programs in Ontario (PRO) Survey was a province-wide, descriptive, cross-sectional survey of health care facilities (hospitals, family health teams, and community health centres). It was distributed to 409 facilities to collect information on various aspects of PR services in the province. RESULTS: Between April 2013 and February 2014, 187 facilities responded to the survey (46% response rate). Most responding centres (144) did not offer PR services, and only 43 were full PR sites providing a comprehensive program. Hospital-based programs made up the majority of sites offering full PR services (67%), followed by programs based at family health teams (19%) and community health centres (14%). More than 90% of PR programs are outpatient-based. The average wait time for outpatient PR was 6.9 weeks, and 58% of programs provide services 5 days per week. More than 80% of patients attending PR complete the full program. Across all program types, the total estimated provincial capacity for PR outpatient care is 4,524 patients per year, or 0.66% to 1.78% of patients with COPD, depending on the estimated prevalence of disease. LIMITATIONS: These results are representative of 12 of the 14 LHINs in Ontario due to low response rates in facilities in 2 LHINs. CONCLUSIONS: Although some increase in capacity has occurred since a similar survey in 2005, PR resources in Ontario are insufficient to support the delivery of care to people with COPD in accordance with clinical practice guideline recommendations.