Severe Asthma Exacerbations, Indirect Costs, and When to Escalate Therapy

"Severe Asthma Exacerbations, Indirect Costs, and When to Escalate Therapy" takes up the question of what frequent exacerbations cost patients and the health system, and how clinicians should define poor control.

Dr. Mosnaim opens by reviewing data on health care resource utilization in patients with frequent exacerbations. She agrees with Dr. Wechsler that much of the cost comes from hospitalizations, emergency department and urgent care visits, and unscheduled office visits. She describes a dose-dependent relationship, in which patients with more frequent exacerbations generate progressively higher costs.

She then highlights a hidden cost that she believes deserves more attention. Oral corticosteroid side effects accumulate over time and create substantial downstream expense that is rarely captured in the initial cost picture.

Dr. Chupp addresses the indirect economic burden, including missed work, missed school, caregiver strain, and reduced productivity. The personal toll is also significant. Students who miss school see their grades suffer, and adults who grew up with severe asthma may face lasting effects on earning potential.

He raises these issues directly with patients. Many do not realize they could live differently with more aggressive treatment. Some never see an asthma specialist until adulthood, so he argues for identifying severe disease as early as possible.

Dr. Wechsler then defines uncontrolled asthma. Warning signs include symptoms a few days a week, nighttime awakenings a few nights a month, activity limitation, and rescue inhaler use a few times weekly. Even one severe exacerbation a year can signal poor control.

He notes that more than 25 million people in the United States have asthma. Despite effective therapies, emergency visits still number in the hundreds of thousands each year. Across severities, about half of patients have at least one exacerbation annually.

For escalation, he describes moving from low-dose to higher-dose inhaled corticosteroids, which has limited added benefit. Triple therapy helps a subset. Patients who remain uncontrolled on combination therapy, have frequent exacerbations, or depend on oral steroids should be considered for biologics.

Our next episode, "Biologic Value in Asthma: Oral Steroid Toxicity and Prior Authorization," turns to how payers weigh the upfront price of biologics against exacerbations, cumulative steroid toxicity, and the administrative burden of getting patients approved.