Treatment of asthma, with particular emphasis on severe cases, should be continued during a pandemic, in accordance with GINA’s continuously updated recommendations. People with asthma should also be vaccinated against the SARS-CoV-2 virus.

Difficult asthma and severe asthma

According to GINA (World Initiative to Combat Asthma) statistics, as much as 24 percent. patients are classified in the 4th and 5th degree of the five-stage asthma classification, of which 17% are is the so-called difficult-to-treat asthma, including non-compliance patients.

However, the so-called severe asthma, including 3,7% all cases. It is characterized by poor symptom control with good access to treatment. It is a condition in which the patient wants to be treated, listens to the doctor, has access to medications, but the therapy does not bring the expected results. Almost half of patients with moderate to severe asthma struggle with the consequences of not fully controlling their symptoms despite the available treatments.

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Asthma. Promising three-drug therapy

The most severe stages of asthma constitute an indication for biological treatment, which – as specialists emphasize – becomes the present and future of therapy. However, there is a gap between traditional inhalation therapy and modern biological therapy in which there are patients suffering from uncontrolled disease symptoms.

New anticholinergic (LAMA) therapies known to treat other forms of obstructive disease have proven effective in asthma. Specialists doctors emphasize that the effectiveness of cholinolytic drugs is well proven. Previously, they were used in COPD, but in recent years they have also proved helpful in the so-called ternary therapy, which is effective in some forms of asthma and can significantly reduce the number of exacerbations.

One of the current directions of development of new drugs of this type is the aim of placing several active substances from different (2-3) therapeutic groups in one inhaler with the longest possible duration of action and the lowest possible dose, which reduces the risk of side effects. Thanks to this, it is possible to reduce the necessary number of inhalations of drugs per day, and thus significantly improve the effectiveness of the treatment. Specialists count on reimbursement of the triple-drug therapy, which will enable its wider use and will affect the so-called compliance.

Biological treatment – the future of severe asthma therapy

In Poland, drug programs introducing biological treatment in severe asthma have been available since 2012. Currently, it includes biological drugs: omalizumab, mepolizumab and benralizumab. From November 1, 2020, a significant change has been introduced: continuation of treatment at home. The latest modifications of drug programs also provide personalized therapy for the patient due to the availability of drugs with different mechanisms of action. The choice of a drug depends on the phenotype and endotype of the disease and should be preceded by an in-depth differential diagnosis. Biological medicines can be used in adults and even in children over 6 years of age, but treatment should be suspended in pregnant women and restarted after delivery.

However, specialists point to organizational and administrative problems. One of them is the requirement to suspend the patient once in the drug program 24 months after the first dose of one of the three biological drugs. According to allergists, this provision should be abolished. It is also postulated to increase the availability of biological treatment by, inter alia, removing or modifying contraindications to biological treatment, shortening the wash-out period (switching between different drugs) to 4 weeks, changing the schedule of monitoring visits, as well as changing the method of financing visits to patients during home therapy.

Currently 54 centers in Poland conduct drug programs in severe asthma, 7 of which are for children and 47 for adults. 1451 (as of 31.03.2021/XNUMX/XNUMX) patients are treated. However, the negative impact of the pandemic is visible in the form of a decrease in the number of new patients enrolled in the program. In addition, the need to strictly adhere to the provisions of the program, the lack of cooperation between specialist doctors and those who run the drug program, long distances to the centers, low awareness of the disease or, finally, the excessive burden on doctors with medical documentation related to the admission of new patients mean that too few people still use biological therapies. .

According to the recommendations of GINA, biological drugs should be used immediately and in all patients when the basic treatment regimen does not work, without resorting to oral glucocorticosteroids. In practice, the condition for qualifying for the drug program in Poland is still the earlier use of oral GCS and confirmation of their ineffectiveness.

The pandemic has accelerated the introduction of home treatment. Currently, it is possible to issue the drug to patients for 3 months of treatment and an increase in the number of patients receiving home medicines is expected. However, doctors emphasize that an asthma patient is difficult to manage and requires constant contact with the facility.

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Asthma and COVID-19

The Team of Experts, led by the National Consultant in the field of Allergology, issued recommendations regarding vaccination against COVID-19 with the mRNA vaccine, among others, for doctors referring to vaccinations and for allergology consultants. The document postulates the withdrawal from vaccination only in people with a history of a generalized allergic reaction after the first dose of the vaccine and with proven hypersensitivity to any component of the vaccine, in accordance with the Summary of Product Characteristics.

In the case of vaccinating patients, it is crucial that vaccinations take place under conditions that allow immediate specialist help and treatment of anaphylaxis in accordance with the applicable algorithm. Patients with known anaphylaxis or severe allergic reactions should be observed for 30 minutes after vaccination. In other patients, the observation should not be shorter than 15 minutes. The need for continuous monitoring of adverse effects following COVID-19 vaccination is emphasized.

For patients undergoing bio-therapy for asthma, it is proposed to maintain a 14-day interval between doses of COVID-19 vaccine and administration of a biological drug.

The team recommends vaccination against COVID-19 with a 2-week interval from other vaccinations in order to avoid possible overlapping of undesirable post-vaccination reactions. This interval is in line with COVID-19 vaccine clinical trial protocols.

In the context of the SARS-CoV-2 pandemic, the results of studies indicating that the reduction or discontinuation of inhaled corticosteroids are associated with loss of asthma control and a potential increase in susceptibility to SARS-CoV-2 infection have also been revealed. Experts emphasize that inhaled glucocorticosteroids used in patients with asthma reduce the expression of the gene for the ACE2 receptor, which is the main receptor enabling the penetration of the virus into the lung epithelium.

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Press material prepared by the Journalists for Health Association based, among others, on a lecture by prof. dr hab. Karina Jahnz-Różyk, med. Asthma and severe asthma and Covid-19 delivered as part of the online workshop How to treat asthma in the time of the Covid-19 pandemic? Organized by the Journalists for Health Association on the occasion of World Asthma Day 2021.

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