Community and hospital pharmacists can help identify patients with severe asthma

About 5% to 10% of people in Canada live with asthma have asthma that is classified as severe. Severe asthma is associated with frequent exacerbations, poor symptom control and significant morbidity from the disease itself, as well as from the high-dose inhaled corticosteroids and systemic corticosteroids used to treat it. Severe asthma is responsible for approximately 50% of all direct asthma-related costs. Patient access to severe asthma care varies across Canada, including access to biologic treatments. There appears to be over-reliance on short-acting beta-agonists (SABAs) and regular oral corticosteroid use; these two indicators of uncontrolled asthma can signal undiagnosed or sub-optimally treated severe asthma. A steering group of Canadian asthma experts has developed consensus standards of care for severe asthma in Canada. The steering group first identified 43 statements formed from eight key themes related to the care of patients with severe asthma. These statements were sent (via online questionnaire) to healthcare professionals working in asthma care across Canada to assess their agreement (consensus) with these statements (rated as high if ≥ 75% and very high if ≥ 90% of respondents agreed with a statement). Questionnaire responses were received from a total of 150 healthcare providers involved in severe asthma care, including certified respiratory educators, respirologists, allergists, general practitioners/family physicians, nurses, pharmacists and respiratory therapists. The responses to consensus statements were analyzed using Delphi methodology. Consensus among respondents was very high for 37 (86%) statements, high for four (9%) statements and was not achieved in two (5%) statements. Read: Tezspire now available for add-on maintenance treatment of severe asthma Consensus statements on when to refer to a specialist Consensus was reached on the following statements regarding when patients with asthma should be referred to a specialist: Patients who have used two or more courses of an oral corticosteroid and/or are using maintenance oral corticosteroid therapy over the past 12 months despite adherence to high-dose inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) therapy (99% agreement) Patients who have had one or more emergency attendances/unscheduled visits due to asthma over the past 12 months despite adherence to high-dose ICS/LABA therapy (98% agreement) Patients who have ever been intubated or admitted to an intensive care unit or high dependency unit due to their asthma despite adherence to high-dose ICS/LABA therapy (99% agreement) Patients who have used three or more SABA inhalers in the past 12 months despite adherence to ICS therapy (79% agreement). Patients with asthma who remain uncontrolled despite adherence to high-dose ICS/LABA (97% agreement) Healthcare professionals (including general practitioners, respiratory therapists and pharmacists) across Canada should proactively case-find patients who meet these criteria and flag them for referral to a specialist or severe asthma service (92% agreement). Consensus statements on initiation of advanced therapies Access to biologic therapies for patients (when indicated) is fundamental to improving outcomes of severe asthma in Canada (97% agreement). The choice of biologic therapy should be driven by phenotyping, which includes clinical history (e.g., triggers, age of onset), comorbidities, biomarkers and spirometry (100% agreement). Future Canadian severe asthma guidelines should include pragmatic and practical guidance on the initiation and choice of biologic therapies for severe asthma (97% agreement). Once a patient has been approved for an advanced therapy, initiation of treatment should not be delayed by more than two weeks (90% agreement) or more than four weeks (91% agreement). 10 key recommendations from the study Primary care clinicians should proactively identify suspected severe asthma patients for optimization (including appropriate referral). Community- and hospital-based pharmacists should be utilized to help identify potential patients with severe asthma. Asthma patients with a history of overuse of SABAs and/or repeat oral corticosteroid therapies should be assessed for severe asthma. Access to diagnostic tools (including spirometry, lung function tests) within four weeks of request should be an expected standard within Canada. A consistent pathway for referral of suspected severe asthma patients should be in place across Canada with clearly defined criteria and acceptable waiting time. All patients should receive education about their asthma from an asthma educator. The choice of biologic therapy should be driven by disease phenotype, which is determined by clinical history, comorbidities, biomarkers and spirometry. Initiation of a biologic therapy should be within two to four weeks of a patient being approved for biologic therapy. National pan-Canadian data collection about severe asthma should be established. Patients should be empowered to work together with their healthcare providers, through shared decision-making tools, to manage their symptoms and control their asthma. The authors believe that implementation of these 10 recommendations across the severe asthma care pathway in Canada has the potential to improve outcomes for patients through earlier detection of undiagnosed severe asthma, reduced time to diagnose severe asthma, and reduced time to initiate advanced phenotype-specific therapies. Reference 1. Godbout K, Bhutani M, Connors L, et al. Recommendations from a Canadian Delphi consensus study on best practice for optimal referral and appropriate management of severe asthma. Allergy Asthma Clin Immunol 2023;19:12. (accessed March 9, 2023).

Community and hospital pharmacists can help identify patients with severe asthma

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