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Survey results show that clinicians largely disagree about choices for severe asthma treatment, due primarily to a lack of formal guidelines.

A survey of dozens of asthma specialists found low agreement about which treatments were appropriate for patients with severe asthma, according to findings published in the Journal of Allergy and Clinical Immunology In Practice.

“I wanted to look at novel biomarkers to try to identify which patients would benefit more from one treatment versus another in severe asthma,” Andréanne Côté, MD, tells Physician’s Weekly (PW). “I designed two studies to show that clinicians currently don’t know which medication to choose in severe asthma. We found that what we’re doing in the clinic is almost as good as flipping a coin.”

As Dr. Côté and colleagues noted, the number of monoclonal antibodies available for the treatment of severe asthma is increasing, but—due to their status as newer drugs—clinicians are selecting these therapies without clear guidelines. While knowledge of treatment response to monoclonal antibodies is improving, making the optimal choice for each patient remains a challenge. For their study, Dr. Côté and colleagues surveyed clinicians to better understand the factors impacting treatment selection.

The initial pilot survey included responses from 16 clinicians in Canada, which was followed by a larger international survey with responses from 70 physicians in 26 countries.

“We selected seven cases for clinicians to review,” Dr. Côté explains. “I chose some that I knew were ambiguous, patients with some specific characteristics where my colleagues and I struggled to choose the optimal treatment. I asked blindly which medication, and why, clinicians would use for each case.”

Moderate Agreement on Treatment Selection

Agreement on using a monoclonal antibody among respondents in the pilot survey was moderate (Gwet agreement coefficient [Gwet AC1], 0.48) and fair in the international survey (Gwet AC1, 0.33). This resulted in an overall level of poor to moderate agreement among respondents, according to the study results.

“Not every doctor agreed that the patient should be on a treatment option we offered, at a rate very much below what we had expected,” Dr. Côté says. “To ensure that it was not biased, we specified that there was no limitation to medication and no reimbursement issue. Clinicians could choose whatever they thought was best for the patient. The inter-observer agreement for starting a patient on treatment versus not was about 50%.”

When the researchers increased the number of choices available, from four options to five options, they observed a decrease in inter-observer agreement, although Dr. Côté notes that was not unexpected: “It showed that having more choices didn’t make treatment selection easier.”

Dr. Côté also highlighted that the results did not change with the number of patients a clinician was treating, years of experience, or training.

One consistent finding was the use of blood eosinophils to justify the use of a specific treatment.

A Call to Action for Treatment Algorithms

Findings from this investigation were supported by the results of the second part of this study that Dr. Côté designed.

“In the second part of this investigation, which we presented at the American Thoracic Society meeting, we followed algorithms currently published in the asthma literature,” she says. “Some algorithms show that if a patient has these characteristics, those biomarkers, and so on, you should choose that medication. We thought, perhaps, if we followed the algorithm, we’d get better results. However, that study showed that it was not better even using the algorithms.”

The takeaway from both studies “is that we need better tools to choose medication for severe asthma,” Dr. Côté continues.

“We need a way to quickly put together all the data and come up with a score that says: With this result, you get this treatment.”

She also pointed to the importance of clinical testing.

“I’m lucky,” Dr. Côté says. “I have access to all the phenotyping tools. Most clinics only have access to blood eosinophils. We need a system in which, for patients with severe asthma, clinicians need to order a full phenotype for patients to help choose the best treatment.”