Bob Underwood, MD (Host): This is Expert Insights with the Carle Foundation Hospital. I'm your host, Dr. Bob Underwood, and today we are talking to Pulmonologist and Critical Care Specialist at Carle Health, Dr. Vishesh Paul. Dr. Paul, welcome to Expert Insights.

Vishesh Paul, MD: Good afternoon. I'm glad to be here.

Host: So today you're going to be sharing some important updates and recent changes in asthma treatment, and we're going to be focusing on adult-onset asthma. So let's start with that. What is adult-onset asthma? A lot of us associate asthma with kind of a kid's disease. So help us understand what makes that differentiation?

Vishesh Paul, MD: Very good topic to start with. When I also was in med school, our initial learning was that asthma is a childhood disease and kids either grow out of it or sometimes their symptoms persist. But over the last couple of decades, we have seen that asthma sometimes can be diagnosed as an adult also. Especially if you have a lot of allergies in your personal history, if you get exposed to agricultural grain dust or something at your work. Asthma as an adult is not an uncommon disease now. We see it regularly and sometimes the treatment can be challenging. It does not respond to treatment as it does in kids, so it can be difficult to treat often. And second thing is that because a lot of medical providers don't consider asthma as an adult disease yet, so diagnosis can be delayed.

So we have to keep that in mind that if a adult person also comes to us with shortness of breath, wheezing and coughing, or just any of these symptoms, adult-onset asthma is more common than we think.

Host: Yeah. That's very true. And the thing that I remember from med school is not all that wheezes is asthma, but we need to consider it in the differential. So let's talk about, you brought up, treatment. It's different in adults than it might be in kids. So how would that be different?What are some options that you would choose in an adult versus a child asthma?

Vishesh Paul, MD: The treatment can be challenging. Kids usually respond to first line inhaler therapy often. We see that response, a good response in kids, but in adults, often we see that one inhaler is insufficient. It may be in some cases, but in many people we see that they can be resistant to the first line of therapy.

So often we have to go to the second and third lines of therapy. And, another thing that we see in adults is other comorbidities that come. Often people have GERD, acid reflux symptoms. They may have sleep apnea, they may have obesity, they may have pharyngeal throat tissues. They also affect the breathing and can worsen the asthma.

So all these comorbidities worsen the asthma symptoms. So they also have to be tackled along with the asthma.

Host: So our initial thoughts when we take care of patients with asthma, are bronchodilators and steroids. But you said now that there are biological choices that might be an option.

Vishesh Paul, MD: That is true. That has been a paradigm shift in last 10 years I would say. Some of the patients that we see in our clinic, they are 70 years old and they have been on asthma treatment for decades. And all the medical doctors, including asthma specialists, for severe asthma, they would do the inhalers and often people will go on chronic steroid therapy, prednisone for months or even years.

Host: Right, which comes with its own issues.

Vishesh Paul, MD: Absolutely, and that was the drug to be used. We have had people who were on prednisone for decades, but it leads to weak bones, osteoporosis, blood pressure issues, mood issues, diabetes issues. So in last 15 years, we have had some monoclonal antibodies or what we call biological therapy that targets the inflammatory cells in asthma.

It started with omalizumab in 2007, 2008. It was anti immunoglobulin E antibody. But these days we have anti eosinophil injections, which are showing wonderful results in asthma patients, reducing the rate of exacerbations, reducing the need for prednisone, and we have been able to keep people off steroids for a long time.

We are seeing excellent results and these medicines are in use for a decade now, so we have a 10 year data at least, about their safety profile.

Host: And that's phenomenal that this is an option that's going to be available for these particular patients. Now, that's not good for rescue therapy. Would rescue therapy be different in an adult than in a child?

Vishesh Paul, MD: Rescue therapy is essentially the same, but that also has changed actually in last five years, there has been a big change and, if a person is on regular inhalers for asthma, then rescue therapy with albuterol or opium remains the same. But I do want to bring up an important point that some of these patients with mild asthma, who take albuterol as the only therapy, which we call albuterol monotherapy.

Even some of the athletes who have exercise induced asthma, they take albuterol just before their sporting activity. Leading asthma organizations are discouraging albuterol alone as the monotherapy, because it causes your airways to open up so people feel better. So you get symptom relief. But the underlying problem for asthma is the inflammation in the airways

that albuterol does not take care of. So all the leading organizations in the world which treat asthma, they recommend an inhaled steroid, even if it is as needed. Even if you need it every few weeks or every few month. That is becoming the rescue therapy, a combination of inhaled steroid and albuterol. This leads to lesser symptoms and less frequency of exacerbations.

Host: No, I was just going to say that is a big change from those of us who have been practicing medicine for a long time because steroids was never considered to be a one-time use or to be a rescue type therapy. And so for that to be added on is, really good information to have.

Vishesh Paul, MD: Yep. They were always discouraged. I've had family members, they would take their inhalers with steroids only as needed when they felt the need. And we would always get a little upset why you're doing it. But eventually it seems like they were correct.

Host: They were right after all. Now let's talk about a relation between obesity and asthma. What are some of the confounding issues when you have those two together?

Vishesh Paul, MD: Oh, very interesting. Again, yeah, this is, again, for last few years, we are finding more and more association with obesity and asthma getting worse and vice versa also. Obesity leads to inflammation in the body. So that includes the airways also. So people who are obese with BMI above 30, their asthma tends to be worse, does not respond to inhalers as well.

And the other comorbidities or illnesses that come with it, like sleep apnea and acid reflux, also worsen asthma symptoms. And if person has asthma, and if you keep giving steroids, that can lead to obesity so that you see the link there.

Host: Yes, absolutely. So what are options for treatment in this particular patient population? Are they different?

Vishesh Paul, MD: We are seeing that they require a little more inhaler, stronger inhaler regimen. Certain traditional medications like theophylline, they should be avoided in obese people. They can actually worsen the symptoms in long run and, pulmonary rehab is showing excellent benefits in people with obesity and asthma, treating the comorbidities, sleep apnea, acid reflux if you treat asthma, also gets better controlled. And of course, working on healthy dietary and habits and weight loss will help most of the people.

Host: Right. And that brings us really to our next question is lifestyle changes. What do you recommend if a patient's been recently diagnosed, for example, with adult-onset asthma? Then there's going to be recommendations for lifestyle changes that they may not anticipate. So what are those?

Vishesh Paul, MD: This, we see in clinic a lot. So some of these are, which I think most people know, most common is smoking cessation, which includes regular cigarettes, even e-cigarettes, and vaping, it can cause inflammation in the airways. Another thing is exposure to pets.

People usually know if they're allergic to pets. We see more often in people who have cats, birds, parakeets, horses, all the hair exposure, it can worsen the airway inflammation, and asthma. And, uh, especially people who have cats. We encourage them to avoid cleaning the litter if possible, or if they can wear a mask that can go a long way and prevent exacerbations.

Avoid strong perfumes. Identify the triggers that they have and be proactive to avoid them.

Host: Would you recommend they keep a journal?

Vishesh Paul, MD: One hundred percent.

Host: Yeah, because sometimes you don't even make that association until you start writing it down.

Vishesh Paul, MD: A hundred percent. We see that beneficial. Some people put it in their phone journal. We ask them to pay attention to where are their symptoms worse, in their house outside, if they go on a trip. So asthma can be regional. Also, people in Midwest, with all the exposure to agricultural dust that we have here.

When we hear they travel to Arizona or Florida, their asthma symptoms are absolutely gone. So journal about daytime, nighttime symptoms. Inside house, outside house, at work. Some people have occupational asthma when they get exposed to stuff at their work and then their weekend is fine at home. They don't need any rescue inhaler.

Host: That would be fascinating. And yes, it would come out. And if you're keeping a journal of your symptoms, I think everybody associates with cats. You mentioned pets, or other animals. I think everybody associates allergies with cats. But you said horses, parakeets, birds. That's fascinating.

So when does a patient know when it's time to seek a specialist's help? Um, a lot of this could be managed by a general practitioner, internal medicine doctor. When do they need to come see you as a Pulmonologist?

Vishesh Paul, MD: When diagnosis is in doubt, I would say so. Like, many times they have the symptoms, what the doctor's providing or, they're providing the inhalers, but they're not responding. Symptoms haven't changed. Then a specialist can look into confirming the diagnosis and also looking into other differentials, what other possibilities can be there. There can be sometimes larynx problems, other things that can be pseudo asthma.

And, of course I would say when the person needs more than one inhaler every day, or if they have two or more exacerbations in a year that requires them to take prednisone or go to convenient care, they should be seeing a specialist so that they can be evaluated for biological therapy or maybe fine tuning of what they're already taking.

Host: Anything else you'd like to add that might be of use to our audience?

Vishesh Paul, MD: I want to emphasize this again, that in the past, chronic steroid use it was the only therapy we had for difficult to treat asthma. And we still see people who want to stay on prednisone because they're used to it. But now we have better and safer options and for all people with milder asthma, including sport athletes, exercise induced asthma, again, albuterol monotherapy is not sufficient.

We recommend inhaled steroid based therapy. Talk to your doctor about this. And, it's a big change in asthma practice, which is slowly catching up and we are seeing excellent results.

Host: Oh, that's wonderful to hear. It really is. Dr. Paul, thank you for being on Expert Insights today.

Vishesh Paul, MD: Oh my pleasure. Thank you for having me.

Host: Sure, and for more information and to get connected with one of our providers, please visit carle.org or for a listing of Carle providers and to view Carle sponsored educational activities, head over to our website at carleconnect.com. I'm Dr. Bob Underwood. Thanks for joining us.