Finding the Right Approach to Treating Asthma

Sandra Zaeh, MD, is interested in improving clinical outcomes for patients with asthma. In recent research, she found that current guideline-based asthma treatment is implemented less than 15 percent of the time for moderate to severe asthma due to various factors, including a lack of knowledge about the proper treatment approach.

In the next few months, as a newly promoted assistant professor of medicine in the Yale Department of Internal Medicine Section of Pulmonary, Critical Care, and Sleep Medicine, Zaeh will lead the recruitment of subjects from the Yale Center for Asthma and Airways Disease for a study in collaboration with Brigham and Women’s Hospital. Funded by the Patient-Centered Outcomes Research Institute, the study aims to improve the quality of care for patients at risk of asthma attacks.

In an interview, Zaeh discusses the basics of asthma, different approaches to treating the inflammatory condition, and why controlling asthma is of the utmost importance to asthma physicians and pulmonologists.

Asthma is a chronic lung disease in which the bronchial airways in the lungs get narrowed and swollen, making it difficult to breathe. People with asthma can feel fine for some time, and then a trigger can cause an asthma attack, which can lead to significant health repercussions. Asthma disproportionately affects Black and Latinx people, low-income populations, and other groups.

Uncontrolled asthma with frequent exacerbations can cause adults to miss days of work and children to miss school. Asthma can impact your ability to breathe on a day-to-day basis. It can lead to hospitalizations, emergency room visits, and, in some cases, fatality.

For the past several decades, the treatment paradigm for asthma has involved control and relief medications. Controller therapy usually includes an inhaled corticosteroid that you take one to two times a day to control your symptoms. You take a reliever therapy between controller doses to minimize asthma symptoms such as cough, shortness of breath, and wheezing. The traditional reliever therapy has been albuterol, a short-acting bronchodilator that quickly opens the airways.

Interestingly, the data now supports a slightly different management strategy. The big update in asthma management is the introduction of anti-inflammatory reliever therapy for asthma. Current guidelines promote the use of the same inhaler for both control and relief for moderate to severe asthma, with a combination of an inhaled steroid and a quick-acting, long-acting beta agonist called formoterol. This approach is called SMART, or Single Maintenance and Reliever Therapy, because one inhaler does the job that two inhalers used to do.

Even though SMART is currently guideline-based care, we’re having difficulty implementing this approach in clinical practice. There are similar, alternative approaches that may be better for certain patients. One of those approaches, which will be tested in this study, is PARTICS, or Patient Activated Reliever-Triggered Inhaled CorticoSteroids. Every time PARTICS patients use their albuterol inhaler, they’re asked to use one puff of inhaled steroid. When they use their albuterol nebulizer as a reliever, they're asked to use five puffs of inhaled steroid. It’s different than SMART because the approach uses more than one inhaler and incorporates the use of nebulizers as relievers.

Many people in the U.S. use an albuterol nebulizer as a reliever because they feel it works more effectively. The PARTICS approach incorporates those individuals.

Studied in Black and Latinx patients with moderate to severe asthma a few years ago, PARTICS was shown to reduce severe asthma exacerbations and improve asthma control and quality of life. Our study compares PARTICS to SMART, the current standard of care. The idea of the study is to test to see if the two approaches are equally effective or if one is more effective than the other.

It’s important to have different asthma management approaches that can be used and tailored for each patient based on needs and preferences. For example, PARTICS is perhaps more appropriate than SMART for people who use nebulizers as their reliever. PARTICS may be more effective or better covered by insurance for some people.

Whether PARTICS or SMART, these approaches are the future of asthma management. By studying these different anti-inflammatory reliever approaches, we can improve implementation and use these therapies more efficaciously.

The more options we have to treat asthma, the better.

The Section of Pulmonary, Critical Care and Sleep Medicine is one of the eleven sections within Yale School of Medicine’s Department of Internal Medicine. To learn more about Yale-PCCSM, visit PCCSM's website, or follow them on Facebook and Twitter.