Rachael Zimlich, RN, BSN

Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

As featured in Asthma Care ComplicationsÂ from our September issue. Swipe through the images for product descriptions and links to prescribing information.Â 

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At a Glance: Asthma Biologics 

Managing asthma is both complicated and costly for patients, so pharmacists play a unique role in helping them navigate how to use their treatments effectively and prevent exacerbations. Keeping up with ever-evolving treatment strategies, guidance, medications, and patient experiences is key.

Guidelines are continually updated to reflect new research, and Cleveland Clinic primary care clinical pharmacist 

, suggests making it a personal goal to review guidelines annually, and even regularly in between.

“I look for guideline changes,” Russo-Alvarez says. “We as pharmacists can be really helpful in reaching out to practices. We can provide small in-services to keep them informed, as well.”

Sometimes, changes are frequent and clinicians can’t keep up-even with major changes. Russo-Alvarez notes that some clinicians weren’t even aware of a major recent change that shifted decades of asthma treatment.

recommendation made in April 2019 by the Global Initiative for Asthma (GINA)

 to no longer treat teens and adults with asthma with short-acting bronchodilators alone. The recommendation has been hailed as a fundamental change to three decades of asthma management, but was made as a result of concerns over the effects of treating asthma with short-acting Ã2-agonists (SABA) alone. 

GINA was established in 1993 by the World Health Organization and the National Heart Lung and Blood Institute to improve global asthma prevention and management, and suggested in its latest annual report that teens and adults with asthma should receive symptom-driven or daily inhaled corticosteroid-containing (ICS) treatments as a way to reduce the risk of serious exacerbations. 

SABA risks were first identified in the 1980s and 1990s, according to GINA’s annual report, with evidence supporting an association between over-use of SABA and an increased risk of asthma-related deaths. Randomized controlled trials found no evidence to support the efficacy of regular, compared to as-needed, (PRN) use of SABA. Most guidelines were updated in the 1990s to support PRN rather than regular SABA use as a result of this research. 

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Trials have also shown that low-dose ICS treatment could reduce exacerbations by up to 50% and help control symptoms, but daily uptake of ICS has been slow-going over physicians concerns about the side effects of corticosteroids, according to the report. The concerns about Ã2-agonists were then shifted to long-acting varieties, and short-acting varieties remained widely used as initial therapy for mild asthma. GINA began looking into the issue more extensively in 2007 and found a host of data to support a link between regular use of SABAs alone, and higher rates of exacerbations and asthma-related deaths. 

The paper goes on to list specific treatment recommendations, and 

, assistant professor of pharmacy practice at the University of Connecticut, says the new guidelines could result in a shake-up at the pharmacy counter.

“These guidelines recommend against using a SABA as-needed alone, even in the most mild asthmatics. They recommend ICS be used in all asthmatics, even if on a symptom-driven, as-needed basis,” Sobieraj says. “Pharmacists are more likely to see as-needed dosing of ICS with this recommendation, and fewer patients treated with a SABA PRN only. This is very different than what we have traditionally seen for many decades of asthma management.”

As if changes to fundamental treatments aren’t enough to keep a pharmacist on their toes, immunotherapy and biologics are changing the game when it comes to treating a host of conditions, including asthma.

Immunology is a developing field in asthma care, with 

researchers recently identifying genetic variants for all types of asthma

 that could lead to new treatment modalities. Pharmacists may also see more asthmatic patients being prescribed biologics, particularly for specific types of asthma, Sobieraj says. 

“The field of biologics continues to evolve, specifically for patients with what would be considered eosinophilic asthma, which represents a small proportion of asthmatics that are extremely difficult to control,” Sobieraj says. “The most recent FDA-approved therapy is dupilumab, which is also approved for steroid-dependent asthma.”

 as an add-on maintenance treatment for patients age 12 and older with moderate- to severe-asthma with an eosimophilic phenotype or who are dependent on oral corticosteroids. The medication inhibits overactive signaling of interleukin-4 and interleukin-13-both of which are proteins that may contribute to the inflammation that causes moderate- to severe-asthma. Dupilumab comes in two doses-200 mg and 300 mg-in pre-loaded syringes, and is given every other week at rotating injection sites after an initial loading dose. Dupilumab has also been approved to treat eczema, and studies are underway for a number of other uses like various allergies and pediatric asthma. 

This newest biologic joins four others already approved for asthma-omalizumab, mepolizumab, reslizumab, and benralizumab-and several more are in development, according to the 

American Academy of Allergy, Asthma & Immunology (AAAAI)

. Omalizumab works on the immunoglobulin E (IgE) antibodies that play a role in allergic asthma; and mepolizumab, reslizumab, and benralizumab all target pathways that affect eosinophils-the cell involved in allergic inflammation. 

Patient Education, Exacerbation Prevention

Pharmacists are the front line to helping keep patients-particularly in the outpatient setting-compliant with their regimens, or signal to the clinician when a patient’s condition changes.

“I make sure I have a good understanding of what’s been happening recently with patients,” Russo-Alvarez says. She asks about recent changes like hospitalizations and exacerbations to guide her assessment and the questions she asks her patients. Ask about devices-patients may be using them at the wrong time or in the wrong way. Russo-Alvarez suggests asking both new and long-standing patients to demonstrate how to use inhalers, letting them lead the demonstration. It’s surprising what you can learn by watching a patient use a device, and asking the right questions, she says.

“At a minimum, pharmacists are really well-positioned to teach patients how to use these inhalers,” Russo-Alvarez says, adding that sometimes providers don’t have inhalers on hand to teach patients about their use, or patients become confused on how and when to use different types of inhalers.

She recommends using an inhaler technique training and assessment tool, which can mimic different types of inhalers.

“It can be set to mimic what breathing technique is used in soft mist versus dry powder and metered-dose inhalers,” she says. “You can use it to get feedback on how they are breathing, and the pharmacist can see what works best for the patient and reach out to the provider and maybe recommend an alternative, if needed.” 

Pharmacists are also crucial in signaling to clinicians when there may be a change in a patient’s condition. According to Russo-Alvarez, it is a red flag when patients are filling their rescue inhalers frequently, despite using them correctly.

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Asthma Care Complications

Patient visits with physicians are jam-packed with things to discuss and interventions to perform; adult vaccinations can be missed in this process. Pharmacies can fill the gap, but a new report highlights barriers that need to be addressed first.

The study, published in the July issue of Vaccine, reviewed the role of U.S. pharmacies in administering vaccines and what barriers exist to their administration in pharmacies. Nearly 2,000 community pharmacies were studied 2016, and 79.5% reported offering at least one type of vaccine.

Pharmacies most commonly offered influenza vaccine, followed by pneumococcal 13-valent conjugate vaccine, herpes zoster vaccine, and pneumococcal polysaccharide vaccine. Two-thirds of the pharmacies polled also provided vaccination to teens in addition to adults.


	The report revealed several reasons why patients often had to be referred outside the pharmacy for vaccination, including the patient’s insurance not covering pharmacy administration, and patient age not being approved for pharmacy administration.

Brandon J. Patterson, PharmD, PhD, manager of U.S. Health Outcomes and Epidemiology at GSK and coauthor of the study, says the findings highlight the progress that has been made in advancing pharmacy-based immunizations as an additional access point for patients.

Pharmacists play an important role in vaccine education and vaccine recommendations, providing access to immunization services, and administering vaccines, says Patterson and coauthor Philip Buck, PhD, MPH, head of U.S. Health Outcomes and Vaccines at GSK.

The scope of what pharmacies are able to offer varied by pharmacy and location, the report noted, particularly when it came to the maintenance of immunization registries. Insurance policies affecting coverage of vaccines and different rates of copay between pharmacies and physician offices continue to act as barriers, according to Patterson and Buck.

Related: States hope to improve vaccination rates in low-income familes using state registries

“Barriers to vaccination are often due to cost to patients or lack of insurance coverage. Additional strategies are needed to remind patients about the value and importance of vaccinations, especially for vaccines with multiple doses,” Patterson says. “Increasing the use of immunization registries within and accessible across states is also needed to improve the services.”


	Pharmacies can help increase vaccine rates by reinforcing vaccine recommendations to patients and by helping to complete immunization series, say Patterson and Buck. Physicians can help by communicating to pharmacists how they would like to receive documentation of vaccine administrations.

“Ideally, communication between pharmacists and other providers should be a two-way process with physicians providing a referral to the pharmacy and the pharmacy closing the loop documenting and sending confirmation back to the patient’s primary care provider,” Patterson says. “Both groups need to report vaccinations administered to the immunization registry and utilize the registry in assessing patient immunization status.”

Patterson and Buck say they hope the report will motivate additional efforts to address provider and patient barriers that hinder the optimization of the pharmacist’s role in immunization.

This article originally ran in Drug Topics’ sister publication Medical Economics.

New study reveals that immunization registries, communication, and the completion of immunization series can increase pharmacists' role in the immunization process. 

Author | Rachael Zimlich, RN, BSN

Articles

At a Glance: Asthma Biologics

Asthma Care Complications

Lack of Insurance and Age Restrictions Among Most Common Barriers to Vaccinations