What will be biggest challenges in respiratory medicine in 2018? We ask Australia’s respiratory physicians.
In 2018 Australia has found itself losing the battle for asthma control, says Professor Peter Gibson, respiratory physician and co-director of the University of Newcastle’s Priority Research Centre (PRC) for Asthma and Respiratory Diseases.
The country now faces the task of getting back on top of control, prevention and severe disease.
“We had a catastrophic epidemic [of thunderstorm asthma] in Melbourne in 2016, involving many people who never knew they had asthma,” Professor Gibson says. “This tells us that the at-risk asthma population in this country is large”.
We have lost our way on asthma control
Australia has effective tools for control, but can’t seem to implement them, Professor Gibson says.
“The risk factors for poor asthma control are outstripping our ability to manage asthma. Many of these risks relate to behaviour and lifestyle.
“How can we effectively engage people with asthma to control their disease? How can we effectively transfer knowledge and skills to clinicians to manage to complexities of people with more severe disease? How can we improve health policy so that it optimally benefits people with asthma?”
A radical rethink is needed to tackle prevention and severe disease
Current control strategies aren’t going to fix problems, he says. Prevention is a huge issue, “but not an impossible one”.
“Precision medicine offers a great hope here, but this will require cooperation, investment in research, and rethinking asthma.”
Removing barriers to accessing medicine should be a priority, he says.
“We already have life-changing precision medicine treatment for severe asthma, but people are missing out. In the next 12 months, we need to find ways for the right people to get the right treatment at the right time.”
Implementing optimal pharmacotherapy for patients with moderate to severe disease is shaping up as the biggest challenge for COPD management, with two soon-to-be-published studies set to challenge accepted wisdom around inhaled corticosteroids, says Professor Christine Jenkins, head of the respiratory group at the St George Institute and senior staff specialist at Concord Hospital.
Current thinking has been largely influenced by a couple of published trials about the benefit of dual bronchodilators, which questioned whether all patients who exacerbate also need to be given inhaled steroids.
But the two new prospective trials, expected within months, will add complexity to the decision-making regarding optimal management.
“It’s not going to be as straightforward,” she says.
“A lot of patients are already taking inhaled steroids, we’ve recently gone through thinking that some of them don’t need it. Now we will be asking ‘do they?’
“Some retrospective analyses of RCTs suggest that having peripheral eosinophilia is a predictor of benefit for steroids. The big question is: will these studies suggest benefit to a lesser extent if you don’t have eosinophilia?
“There is also the question of thresholds for eosinophilia. Is it 2%, 3% or 4% that identifies a patient from being able to benefit from inhaled steroids in relation to exacerbation? And what about other symptoms – are they responsive to steroids on this basis also?”
Professor Jenkins anticipates the studies will be a game-changer, possibly spelling a change to clinical guidelines.
“It’s quite possible there will also be some strong marketing push for inhaled steroids,” she predicts.
With the median age for survival with CF now approaching or even exceeding 50 years, there is no doubt people with the genetic condition are living longer. But major challenges remain for the clinicians charged with their care, explains Professor Scott Bell, executive director of research at Queensland Health’s Metro North Hospital and Health Service.
Balancing the changing infection epidemiology in the clinic
The changing landscape of infection in CF presents new challenges for doctors, says Professor Bell, with decreasing rates of Pseudomonas infection but growing rates of multi-resistant bacterial infections and non-tuberculous mycobacteria.
“Clinicians need to be thinking about how to best prevent and treat difficult infections and prevent cross-infection – particularly where we have fixed built infrastructure”.
More adults with CF putting strain on the hospital system
A 75% rise in the number of adults with CF is predicted within a decade. Professor Bell says it’s crucial to invest in a bigger workforce to future-proof the system.
“For an adequate workforce for our populations in the future it is vital we train CF physicians and multidisciplinary teams,” he says.
Finding patients to test out CFTR modulators – and the money to deliver them
There are a large number of candidate therapies that need to be tested on patients, but it will be a challenge to find enough patients and trial sites to ensure that CFTR modulators can be tested across the range of different CF genotypes in the population.
“Furthermore, delivery of CFTR modulators for the clinic has been a challenge given their cost,” Professor Bell says.
“In Australia, 8% of our patients have gating mutations (e.g. G551D) and now have access to Kalydeco (ivacaftor).
However, Orkambi (lumacaftor-ivacaftor) for patients who are homozygous to the most common CF mutation (F508del) (50%) is currently not funded.”
“Those patients accessing the drug currently include those with very advanced disease by special access programs, and those who have or who are currently participating in sponsored clinical trials.”
Professor Bell says despite these challenges, we are in an era of “unrivalled potential” where markedly improved clinical outcomes “have become a reality for many people with CF”.