What hinders individualized therapy plans for asthma patients?

KEYWORDS:

• ITPs: Asthma
• Pharmacotherapy
• Precision therapy

1. Introduction

Asthma is a chronic respiratory ailment that affects over 340 million people worldwide, making it one of the most common chronic diseases among children globally [1]. It leads to inflammation and narrowing of the small airways in the lungs, causing symptoms such as coughing, wheezing, shortness of breath, and chest tightness. Negative impacts of asthma range from diminished quality of life and decreased productivity at work or school, to increased healthcare utilization costs, and even death in severe cases [2]. Asthma has significant clinical and economic implications, impacting both an individual’s quality of life and healthcare costs, with severe cases potentially leading to death [3].

Current asthma pharmacotherapy involves inhaled corticosteroids and long-acting beta2-agonists, with the addition of long-acting muscarinic receptor antagonists or biologic agents as needed [4]. Treatment strategies are often outlined in a stepwise approach, adjusting the treatment based on the patient’s current symptom control and future risk of exacerbation [5]. However, managing uncontrolled asthma remains a challenge. While triple therapy, commonly comprising inhaled long-acting muscarinic antagonists (LAMA), long-acting beta-agonists (LABA), and inhaled corticosteroids (ICS), is effective, there is also a growing role for biologic drugs in treatment strategies [5].

Comprehensive, customized action plans comprising 2–4 action points, combined with both inhaled and oral corticosteroids, have proven to significantly improve asthma management outcomes [6]. A randomized controlled trial (RCT) demonstrated that these personalized asthma action plans can notably reduce emergency visits, acute attacks, and nighttime awakenings [7].

Despite the potential benefits of Individualized Therapy Plans (ITPs), several barriers hinder their improvement and adoption. Addressing these challenges is crucial to bridging the gap between current management guidelines and real-world practices, as well as addressing disparities that hamper implementation. This editorial aims to highlight these barriers, emphasizing innovative pharmacotherapy solutions as avenues to enhance asthma control and improve patient outcomes.

2. Challenges to individualized therapy plans (ITPs) in asthma

The concept of ITPs in asthma management embodies a patient-centric approach tailored to each individual’s unique clinical presentation, lifestyle, and preferences. The success of ITPs in managing asthma is contingent on overcoming a variety of challenges. This editorials focuses on clinical and socio-economic challenges.

2.1. Clinical challenges

Implementing ITPs for asthma introduces numerous clinical challenges, largely attributed to asthma’s heterogeneous nature, which manifests in distinct phenotypes and endotypes for each individual. Phenotypes, such as allergic and exercise-induced asthma, display varied symptoms among individuals, emphasizing the need for personalized treatment strategies over generic, one-size-fits-all solutions [8]. Pediatric asthma management, a critical subset of asthma care, often grapples with challenges due to the variability in asthma severity and control among patients. This variability complicates the formulation of a standardized treatment plan, thereby necessitating a more tailored approach. Further, the assessment of pulmonary function and airway inflammation, vital components for effective asthma treatment, brings about its own set of challenges in pediatric patients, particularly influenced by factors like age and cooperation level [9].

Studies on short-acting beta 2-agonists (SABAs) have revealed risks associated with their use in asthma management. A cohort study, utilizing Swedish national registries, investigated the impact of SABA usage on asthma exacerbations and mortality in patients aged 12–45 years [10]. This study found that 30% of patients misused SABAs in some form, leading to increased risks of exacerbation and mortality. Notably, collecting more than two SABA canisters annually correlated with heightened risks, with both exacerbation and mortality risks escalating with additional canister acquisition. Another study, examining data from over one million patients across North America and Europe, discovered that 40.2% were prescribed or possessed three or more SABA canisters annually. This analysis indicated an elevated risk of severe exacerbations with higher SABA exposure, regardless of maintenance therapy use [11].

On a molecular front, endotypes like Type 2-high and Type 2-low asthma elucidate the immunological pathways driving the disease. However, pinpointing these endotypes demands advanced diagnostic capabilities [8]. Owing to asthma’s multifaceted nature and its myriad subtypes, customizing treatment demands a profound understanding and expertise. The optimization of ITP medication regimes becomes intricate given the plethora of pharmacotherapeutic choices and the potential for adverse drug interactions. This complexity is especially evident in patients with comorbid conditions such as allergies, obesity, or GERD, which can further complicate asthma management. For instance, an asthma patient with GERD may encounter exacerbated respiratory symptoms, necessitating an integrated approach in the ITP to manage both conditions. The variability in treatment response, illustrated by disparate levels of symptom control in two patients on similar corticosteroid regimens due to genetic differences impacting drug metabolism, calls for individualized dosing adjustments. This challenge intensifies in cases of severe asthma coexisting with cardiovascular disease, where meticulous medication choices are vital to prevent potential drug interactions.

Inaccurate inhaler technique and non-adherence to treatment regimens can considerably undermine the effectiveness of ITPs, resulting in less than optimal asthma control for some individuals. A patient with flawed inhaler usage might not receive the full prescribed dose, leading to compromised asthma management. The expertise and resources of a healthcare provider can either facilitate or hinder the effective design, deployment, and modification of ITPs. For example, a less experienced healthcare provider might overlook a specific asthma endotype, leading to subpar ITP outcomes. Additionally, infrequent patient monitoring could miss essential changes in patient conditions or responses to treatment, bypassing vital chances to refine the treatment plan accordingly.

An innovative asthma management strategy to address these challenges is the integration of Maintenance And Reliever Therapy (MART) and Anti-Inflammatory Reliever (AIR). MART employs a single inhaler that contains a corticosteroid and a long-acting beta-agonist for both maintenance and symptom relief. This approach simplifies treatment regimens and has the potential to improve adherence and outcomes in over 90% of asthma patients. Conversely, AIR therapy combines fast-acting bronchodilators with anti-inflammatory properties, offering rapid relief from symptoms while simultaneously treating the underlying inflammation.

Biologic therapies have also become an invaluable asset to patients with severe or particular types of asthma, with monoclonal antibodies often serving as effective solutions to interfere with specific immune pathways involved in asthma pathogenesis and thus help patients who previously struggled to manage their symptoms with traditional treatments achieve greater control with tailored, personalized care. They may be especially useful in Type 2-high asthma cases.

2.2. Socio-economic challenges

Socio-economic factors can substantially influence the feasibility and efficacy of ITPs in asthma management. These are further compounded by challenges that call for strategic interventions. The cost of care emerges as a pivotal concern, especially since personalized healthcare necessitates advanced diagnostic tests, biologic therapies, and recurrent visits to healthcare providers for monitoring and plan adjustments. These factors culminate in a significant economic strain on patients. This burden could intensify without appropriate insurance coverage, specifically crafted to encompass personalized care components like medications and diagnostic tests, which are often pricey. In the absence of comprehensive coverage for biologic medicines and cutting-edge diagnostic tests, patients might gravitate toward less effective or generic alternatives.

A study conducted in New South Wales, Australia indicated that children from low- to middle-income families were considerably less likely to possess an ITP. Moreover, being an only child correlated with higher ITP compliance and improved asthma control. However, there was not a significant association between other socio-economic indicators and the rates of plan ownership or compliance, suggesting that economic considerations play a pivotal role in the access to and adherence of ITPs [12].

Furthermore, the availability of necessary healthcare resources, including access to specialized healthcare providers, advanced diagnostic tools, and state-of-the-art treatment facilities, is fundamental for effective personalized asthma care. Rural or underserved regions, characterized by limited access to asthma care centers or advanced diagnostic equipment, can hinder the effective deployment of ITPs. Income disparities exacerbate this challenge, as individuals with lower incomes may struggle more than anticipated with the costs linked to personalized treatment plans, potentially leading to a health equity gap in outcomes.

Moreover, the level of support from the healthcare system, in terms of policies promoting personalized care, and a deep understanding of health economics to analyze the long-term economic benefits of personalized care against the upfront costs, are crucial for fostering a conducive environment for the implementation of ITPs. Even nations with comprehensive healthcare coverage, such as Canada, confront socio-economic obstacles in delivering top-tier healthcare. One study highlighted this issue, revealing that individuals from lower socio-economic brackets did not receive guideline-based asthma care, consequently incurring higher costs [13].

3. Conclusion

Adoption of ITPs for asthma care is undeniably a game changer, yet their implementation faces both clinical and socio-economic challenges. While advancements in diagnostics, pharmacotherapy, and digital health tools promise a more tailored approach, economic barriers and disparities in access remain significant obstacles.

4. Expert opinion

The potential of ITPs for enhanced asthma management is certainly promising; however, the examination of clinical and socio-economic challenges inherent to their implementation remains underexplored in the existing literature. The current research landscape primarily underscores the clinical effectiveness of ITPs, often highlighting their impact on improved patient outcomes, reduced hospital visits, and enhanced symptom management. Nevertheless, a more nuanced exploration into the socio-economic challenges, which could potentially impede the realization of such benefits, is conspicuously lacking.

The dearth of focused inquiry into the clinical challenges of ITPs in asthma, despite its recognized heterogeneity, is noteworthy. Particularly absent are in-depth analyses on tailoring treatments according to phenotypes and endotypes, and evaluating pulmonary function across diverse patient populations. Socioeconomic impacts are especially pronounced. While the editorial touches upon some of the economic burdens of ITPs, such as costs associated with specialty medications, advanced diagnostic tests, and regular health assessments, a deeper exploration into their impact on patient accessibility and adherence is lacking. Socio-economic disparities, as illustrated by New South Wales, only scratch the surface of an issue which remains largely unexamined: financial barriers reducing access to personalized care have long had negative ramifications on health equity.

For effective asthma management, it’s essential to customize treatment plans based on each patient’s unique needs. Given the variety of asthma types and the presence of other related conditions like GERD or heart diseases, a detailed and thoughtful approach to treatment is crucial. Yet, much of the current research seems to be compartmentalized, mainly concentrating on specific elements of the disease or its treatment. This approach misses out on a comprehensive view that combines clinical, socio-economic, and educational facets of managing asthma. While distinctions at the molecular level, such as T2-high and T2-low asthma, are vital, they sometimes eclipse the equally important socio-economic issues. Additionally, an excessive emphasis on drug treatments might neglect the importance of education and self-care strategies, which are fundamental for effectively implementing ITPs.

The rise of targeted biological treatments, such as omalizumab and other monoclonal antibodies like mepolizumab, reslizumab, benralizumab, and dupilumab, offers a powerful way to manage severe asthma by targeting its molecular roots [4,14]. This aligns with the main principles of ITPs in asthma care. Especially those therapies aimed at type 2 (T2) inflammation have shown to effectively reduce asthma symptoms, as supported by multiple clinical studies. By embracing these biological treatments, medical professionals can better address the inherent challenges presented by asthma’s intricate nature, thus improving the effectiveness and customization of ITPs [15]. Moreover, the continuous efforts to identify asthma types using specific biomarkers and to create new treatments for non-eosinophilic or T2-low asthma highlight the move toward a more detailed, patient-cantered approach in asthma care.

In light of the foregoing, the burgeoning research in ITPs for asthma management heralds a transition from a generic to a more personalized, patient-centric model of care. The primary goal here is to enhance asthma management, reduce flare-ups, and improve the life quality of those grappling with this long-term condition. By promoting a harmonious integration of drug treatments, patient education, and self-care within the ITP structure, we’re inching toward a more comprehensive asthma care. For example, the emergence of Patient-Pharmacist Partnership Programs offers a promising method to boost adherence to treatments [16]. This not only potentially eases the financial strain on patients but also betters clinical results. This team-based model emphasizes the value of combining multiple disciplines, integrating drug treatments with educational efforts to ensure patients are both knowledgeable and empowered to manage their asthma effectively.

Recent studies underscore the importance of patient education in managing asthma. In one trial, 100 patients from 20 general practices throughout Bavaria, Germany, participated in an online asthma education program (eAEP). This program was part of an ongoing cluster randomized controlled trial. The aim of this trial is to evaluate the effectiveness of online asthma education programs (eAEP) compared to traditional face-to-face programs (fAEP). It focuses on assessing gains in asthma knowledge, improvements in asthma control, and the frequency of emergency treatments. The eAEP was designed to enhance accessibility and participation by allowing patients to access educational materials flexibly via PC, notebook, or smartphone. Prior evaluations have shown promising results, including significant increases in asthma knowledge and positive patient feedback in primary care settings [17].

To truly harness the benefits of ITPs, a collaborative approach spanning various disciplines is essential. It’s vital to undertake all-encompassing research that connects the dots between molecular biology, drug treatments, health economics, and patient education. One of the most significant hurdles is the financial challenges tied to personalized care. This calls for policy changes and adjustments in health insurance to counterbalance the elevated expenses. Furthermore, it’s pivotal to develop reliable diagnostic instruments and to equip healthcare professionals with the skills to use these tools for precise asthma type determination and treatment customization. The rise of innovative treatments and precision medicine is making its mark, especially with the introduction of therapies for severe persistent asthma, highlighting the potential of more individualized drug treatments. Moreover, models like the Physician-Pharmacist Collaborative Management have demonstrated their efficacy in decreasing emergency visits related to asthma and in bettering asthma management, further illustrating the importance of collaborative, multi-disciplinary efforts [18]. Outside the scope of asthma, some pharmacist-physician collaborative interventions have shown promising results in changing the behavior of patients by utilizing the power of social media [19].

In the forthcoming years, a concerted effort toward integrating advanced diagnostic tools, novel pharmacotherapeutic agents, and patient education programs within the ITP framework is anticipated. For example, the integration of artificial intelligence into asthma management plan [20]. The merging of these areas is set to make ITPs both more effective and widely available. Additionally, the shift in health policies toward supporting personalized care and tackling financial obstacles will likely be instrumental in creating a favorable setting for rolling out ITPs.

At present, the relationship between genetic differences, how drugs are metabolized, and the resulting treatment outcomes is a captivating field of study. Delving into the genetic factors that lead to varied drug reactions might reveal new avenues for drug treatments and fine-tune the accuracy of ITPs. Furthermore, the adoption of digital health tools, especially those offering real-time tracking and data analysis within ITPs, opens up thrilling possibilities. This could make asthma care more adaptable and attuned to the evolving needs of patients. The rise of tech start-ups offering solutions like on-the-spot monitoring and data analysis tools are encouraging strides. These innovations are set to make asthma care more adaptable and cantered on the patient, fitting perfectly with the tailored essence of ITPs.

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.