A multi-disciplinary approach to complex asthma patients - when the village comes to you
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A/Prof Gregory Katsoulotos is a Respiratory & Sleep Physician at St Vincent’s Clinic with wide experience in the severe asthma space. A/Prof Katsoulotos is a member of the Guidelines Committee of the National Asthma Council. He chairs regular Severe Asthma multi-disciplinary team (MDT) meetings, consisting of different specialties and allied health professionals including respiratory physicians, allergists, ENT surgeons, speech pathologists, psychologists, respiratory nurses and respiratory scientists. He also now runs several multi-disciplinary clinics aimed at sorting out complex airways situations and has a substantial population of severe asthmatics that he continues to care for.
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In considering severe asthma, one must first understand “difficult-to-treat” asthma and appreciate the long-term dangers of repeated courses of oral steroids.
Difficult-to-treat asthma
This represents 17% of asthmatic patients. These asthmatics don't respond well to medium-high dose preventers and long-acting bronchodilators (such as Breo, Seretide, Fostair, Symbicort). This presents diagnostic and management challenges, often resulting in ongoing symptoms, asthma flares requiring oral steroids, and possibly poor lung function. This condition significantly impacts quality of life, creates limitations for patients, causes frustration, and leads to higher healthcare utilisation and costs. Contributing Factors to Difficult-to-treat asthma Multiple factors can contribute to difficult-to-treat asthma, including poor adherence to therapy, inadequate inhaler technique, and undiagnosed or untreated comorbidities. Conditions like gastroesophageal reflux disease (GORD), heart disease, lung clots, laryngeal disorders, and sinus/nasal problems can all mimic or worsen asthma symptoms and should be properly addressed as part of comprehensive asthma assessment and may also need input from ENT Surgeons and Speech Pathologists.
The long-term trap of oral steroids vs new treatments
Just 1g of oral steroids (eg Prednisone) in one’s lifetime is enough to set one up for long-term complications such as osteoporosis, weight gain, diabetes, frail skin, cataracts and adrenal failure. We now have new treatments (biologic agents) that are very effective and steroid-sparing, available on the PBS only via Specialist Prescription for severe asthma, but success depends on a thorough diagnostic approach and work-up that assesses the whole airway (lungs, nose, and throat). Severe Asthma Severe asthma is a subset of difficult-to-treat asthma affecting 3-10% of asthma patients. These asthmatics remain symptomatic despite being adherent to medium-high dose preventers and long-acting bronchodilators, and with their comorbidities treated or stabilised.
A multi-disciplinary approach
The gold standard for assessing complex asthma patients is multi-disciplinary care. This approach may involve multi-disciplinary meetings or clinics. Multi-disciplinary clinics allow patients to be assessed by multiple clinicians in a single visit, often resulting in high patient satisfaction. These clinics assess and educate patients using a patient-centred approach and establish a single onward plan of care. This multi-disciplinary approach allows for a more efficient and thorough diagnostic process compared to the traditional "pinball" approach of multiple referrals, helping to ensure you receive the most appropriate care for your specific condition.
In other words… Instead of chasing around the village seeing multiple people, why not have the village come to you?