Treatable traits, combination inhaler therapy and the future of asthma management

Abstract

The landscape of asthma has considerably changed in the last decade. Effective medications and inhaler devices have been developed and integrated into the asthma pharmacopoeia, but unfortunately, the proportion of uncontrolled patients remains unacceptably high. This is now recognized to be mainly due to the inappropriate use of medications or inhaler devices, heterogeneity of the disease or other factors contributing to the disease. Currently, inhaled corticosteroids (ICS), with or without long‐acting beta agonists (LABA), are the cornerstone of asthma management, and recently international guidelines recognized the importance of combination inhaler therapy (ICS/LABA) even in mild asthma. In future, ultra‐long‐acting personalized medications and smart inhalers will complement combination inhaler therapy in order to effectively addresses issues such as adherence, inhaler technique and polypharmacy (both of drugs and devices). Asthma is now acknowledged as a multifaceted cluster of disorders and the treatment model has evolved from one‐size‐fits‐all to precision medicine approaches such as treatable traits (TTs, defined as measurable and treatable clinically important factors) which encourages the quality use of medications and identification and management of all underlying behavioural and biological treatable risk factors. TT requires research and validation in a clinical context and the implementation strategies and efficacy in various settings (primary/secondary/tertiary care, low‐middle income countries) and populations (mild/moderate/severe asthma) are currently evolving. Combination inhaler therapy and the TTs approach are complementary treatment approaches. This review examines the current status of personalized medicine and combination inhaler therapy, and describes futuristic views for these two strategies.

Treatable traits models of care

“…One approach that has been recommended is focusing on 'super traits' in primary care and referring to specialist care should patients continue to have poor control, exacerbations and more complex management needs. 17,53 Super traits for primary care include those that are common, treatable and are associated with future risk. Traits including T2 inflammation, airflow limitation, smoking, inhaler device technique, adherence, physical inactivity and some key comorbidities/ risk-factors, such obesity have been proposed as super traits for primary care.…”

“…Traits including T2 inflammation, airflow limitation, smoking, inhaler device technique, adherence, physical inactivity and some key comorbidities/ risk-factors, such obesity have been proposed as super traits for primary care. 17,34,53 These traits could be addressed by a multidisciplinary team involving the primary care practitioner, the practice nurse and referral to community allied health practitioners. A cluster randomized controlled trial evaluating the efficacy of a practice nurse-coordinated intervention targeting treatable traits in moderate-severe COPD in primary care, compared with usual care is currently underway (ACTRN12622000766718).…”

“…Irrespective of the setting, patient population, or traits targeted there are several key components that are inherent to the delivery of care using treatable trait approaches, and others that are likely to improve implementation, 17,53 and clinician 21 and patient acceptance. The essential components of treatable traits implementation have been previously reviewed.…”

“…The essential components of treatable traits implementation have been previously reviewed. 17,53 All treatable traits models of care involve the patient, clinician and the system in which the patient is being cared for. The components shown in Figure 1 synthesize the essentials of a model of care discussed by Davidson et al 23 in the context of treatable traits, and are worth considering no matter which model one chooses to apply.…”

A Roadmap for Using Causal Inference and Machine Learning to Personalize Asthma Medication Selection

“…So far, only a few biomarkers have been characterized for use in clinical practice. Despite a few successes using biomarkers for targeted therapy, ICS choice, especially in the primary care setting, is largely by trial and error and many patients remain uncontrolled [37][38][39][40][41][42].…”