Asthma biomarkers not yet fully adopted in daily practice


By Mardi Chapman

9 Jun 2020

Despite the growing body of research on the use of biomarkers to guide asthma treatment, clinicians are still resistant to their use in daily practice, research shows.

A survey of Australian members of the TSANZ Asthma Special Interest Group found only 53% of the 17 respondents were using or would like to use biomarkers to adjust corticosteroid treatment.

Slightly more of the respondents (58%) did not agree that biomarker based adjustment of corticosteroid dose is currently the optimal way to adjust corticosteroid treatment in patients with severe asthma compared to symptoms, lung function and exacerbation history.

Most respondents said use of biomarkers would be justified if ≥20% of patients requiring maintenance OCS could have a dose reduction.

The consensus was that a ≥5 mg daily oral prednisolone dose reduction would be clinically meaningful.

Regarding inhaled corticosteroids (ICS), the majority of survey respondents (59%) said biomarkers would be justified if ≥50% of patients could have a dose reduction.

The consensus was that ≥400 μg reduction in daily ICS would be regarded as clinically meaningful.

Similarly, biomarkers would be justified if they could achieve a ≥25% reduction in asthma exacerbations.

Respondents also indicated about 40% of their severe asthma patients had suboptimal adherence to ICS treatment and ≥30% of severe asthma patients in their clinic had persistent symptoms that were not corticosteroid responsive.

Senior investigator Professor Peter Wark of the University of Newcastle, NSW, told the limbic it would be helpful if clinicians were more open to the possibilities of incorporating the current biomarkers into day-to-day practice.

However he acknowledged that it takes time for clinical practice to change.

“I think there is still a bit of a struggle to know how to apply biomarkers and there is still quite a default on adding treatments as opposed to targeting treatments,” he said.

And the current biomarkers – FENO and blood eosinophils – were probably not all that responsive to change.

“We probably need to know more about the current biomarkers so there is the possibility there of some more utility.

“FENO is probably the point of care one that we have. It’s probably got a reasonably clear role in the setting of steroid naive people where there is a question over the diagnosis of asthma. Its role however in adjusting ICS dose still needs a little bit of work and needs to become more routine.”

“Blood eosinophils are neither a point of care test and probably not responsive enough for adjustment of treatment,” he added.

Professor Wark, from the Hunter Medical Research Institute, said the search for better biomarkers is ongoing.

“Something simple and reproducible would very rapidly find a lot of utility. It’s probably not FENO or blood eosinophils because if you have refractory type 2 inflammation you can be on buckets of steroids but they will still be high.”

“It would probably be valuable if we had a biomarker that would allow you to safely reduce oral steroids – but I’m not sure if there will ever be a single biomarker that would do that,” he said.

The survey was similar to an earlier one conducted in Europe including the UK.

“We probably found a little bit more uptake and we found the Australian answers were perhaps a little bit more open to biomarkers, but the Europeans were a much larger and more heterogeneous sample as well,” said Professor Wark.

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