Improving lives of people with severe asthma

Eastern AHSN is supporting the adoption of biologic treatments to reduce the number and severity of exacerbations, hospitalisations and deaths.
This innovation is being supported as part of the Rapid Uptake Products (RUP) programme.

Biologic therapy drugs (reslizumab, benralizumab, mepolizumab and omalizumab) can improve symptoms and reduce asthma attacks in people with severe asthma by helping to stop the body processes that cause lung inflammation.

Biological therapies can transform people’s lives by reducing long-term side effects of oral corticosteroids and can also reduce the number of exacerbations and life-threatening asthma attacks. The aim of this innovation will be to improve patient care and outcomes by providing a better treatment option for patients with severe asthma.

What is severe asthma?

Severe asthma is a subtype of asthma that is difficult to control and categorised by the fact that it does not respond well to typical asthma treatments1.  By conservative estimates, severe asthma affects approximately 5-10% of people with asthma worldwide2. People with severe asthma also have more frequent life-threatening asthma attacks, which can have a devastating impact on their lives3. The struggle to breathe can be a day-to-day challenge that overshadows daily activities, resulting in hospital admissions, intensive care and even death(3, 4). Severe asthma also accounts for the majority of health care expenditures associated with asthma; with the relatively small severe asthma patient population estimated to be 50% of all asthma-related costs5.

Compared with patients with milder controlled disease, patients with severe asthma also experience adverse effects from treatments that are used to manage asthma attacks. If oral corticosteroid treatments are used long term, the resulting adverse effects may include weight gain, diabetes, osteoporosis, glaucoma, anxiety, cardiovascular disease, and impaired immunity10. Asthma UK reports that patients “loathe” these treatments and that the substantial adverse effects are a significant reason they do not comply with their prescribed medications, which puts them at risk of experiencing a future asthma attacks(3, 8) .

Guidelines recommend that patients with severe asthma be referred to a specialist respiratory team for correct diagnosis and expert management. This is particularly important to ensure that they have access to newly available biologic treatments. However, many patients with severe asthma can suffer multiple asthma attacks, admission to emergency departments and a wait of up to seven years experimenting with different treatment options before they are diagnosed or referred for specialist care(3, 6, 7, 8).

What are asthma biologics?

Research has shown that not all asthma is the same and can have a number of underlying causes and different types of inflammation. For some people, their inflammation may be triggered by environmental allergens, such as dust mites, pollen and moulds. For others, their own body may be turning against them.

In around half of people with severe asthma, a raised level of eosinophils in their bloodstream causes inflammation and swelling in the airways that deliver vital oxygen to the lungs, making it difficult to breathe and increasing the risk of an asthma attack.

Biologic treatment options are now available based on our increased understanding of the causes of the underlying disease which work in a different way to conventional asthma treatments. They target the pathways that lead to lung inflammation help to stop the body’s processes that cause lung inflammation and mean people don’t need to be as reliant on the long-term use of OCS to prevent asthma attacks3.

Currently there are four NICE approved biologics for severe asthma (omalizumab, mepolizumab, reslizumab and benralizumab). Omalizumab is indicated for severe allergic asthma and the other three biologics (mepolizumab, reslizumab and benralizumab) are indicated for severe eosinophilic asthma. They are given as an injection or infusion (depending on which biologic is being taken) regularly in hospital or patients can self-inject at home.

Why is this important?

Severe asthma places a significant burden on the NHS and the lives of patients. According to the National Review of Asthma Deaths, a report produced by the Royal College of Physicians, asthma deaths in the UK are among the highest in Europe11. They investigated 195 UK asthma deaths that occurred in one year and found that two in three of the deaths could have been prevented. Amongst the reasons for the asthma attack deaths, 65% of cases were influenced by patient factors that could have been avoided. They also found that 45% died before they had sought medical assistance or before the emergency medical care could be given.

Despite existing treatment guidelines improvements in the quality of care for people with asthma falls behind that achieved for other diseases. For example, after experiencing a heart attack a patient would not be released from the hospital without a plan for follow up and treatment to prevent future attacks. Yet this is the experience of many people hospitalised for an asthma attack, even though they are very likely to experience another attack that could be fatal. Nearly a quarter of those who died from severe asthma had been to a hospital emergency department due to asthma at least once in the previous year11.

During the past 20 years, the introduction of biologics for the treatment of rheumatoid arthritis has transformed the experience of patients with this disease. Steroid therapy is no longer overused. The same revolution is occurring in the treatment of patients with severe asthma, with biologic treatments available that have demonstrated effectiveness in reducing future asthma attacks for patients with defined subtypes of severe asthma12. However, ensuring that patients with severe asthma who may potentially benefit from these new treatments are identified and seen by specialists is fundamental to achieving these improvements.

Asthma UK estimates that the eligible population for asthma biologics is around 60,000 in England but only one in four people eligible for biologic treatment are accessing it.

How is Eastern AHSN supporting this programme in our region?

Eastern AHSN is convening a range of stakeholders including commissioners, secondary care NHS trusts, pharmacists and the clinical community to deliver the following:

  1. Understand the current picture and potential barriers to adoption
  2. Provide training and support for primary care clinicians (including pharmacists) in this specialist area.
  3. Look at opportunities in the system to reduce variation and improve pathways.
  4. Capture great practice and look at how we disseminate.
  5. Develop evidence of financial impact while introducing a coding mechanism for severe asthma.

Eastern AHSN supported local NHS partners in their applications to the Pathway Transformation Fund (PTF), which provides financial support for integrating asthma biologics into everyday practice and addresses issues such as pathway redesign, training staff and establishing new data collection methods.

How to get involved

If you would be interested in working with us on this project, would like more information on the Pathway Transformation Fund (PTF) to help NHS organisations integrate the rapid uptake products into everyday practice, please contact Sarah Curry, Advisor, at [email protected].

What are Rapid Uptake Products?

The Rapid Uptake Products (RUP) programme has been designed to support stronger adoption and spread of proven innovations. It identifies and supports products with NICE approval that support the NHS Long Term Plan’s key clinical priorities, but have lower than expected uptake to-date.

References

  1. Menzies-Gow, A., Canonica, GW., Winders, T.A. et al. A Charter to Improve Patient Care in Severe Asthma. Adv Ther 35, 1485–1496 (2018). https://doi.org/10.1007/s12325-018-0777-y
  2. Chung KF, Wenzel SE, Brozek JL, Bush A, Castro M, Sterk PJ, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J. 2014;43(2):343–73.
  3. Asthma UK. Severe asthma: the unmet need and the global challenge. 2017. https://www.asthma.org.uk/get-involved/campaigns/publications/severe-asthma-report.
  4. European Federation of Allergy and Airways Diseases Patients Association (EFA). A European patient perspective on severe asthma: Fighting for breath 2012. http://www.efanet.org/images/2012/07/Fighting_For_Breath1.pdf.
  5. World Allergy Organisation. The management of severe asthma: economic analysis of the cost of treatments for severe asthma. 2005. http://www.worldallergy.org/educational_programs/world_allergy_forum/anaheim2005/blaiss.php. Accessed June 2018.
  6. Price D, Bjermer L, Bergin DA, Martinez R. Asthma referrals: a key component of asthma management that needs to be addressed. J Asthma Allergy. 2017;10:209–23.
  7. Royal College of Physicians. Why asthma still kills. The National Review of Asthma Deaths (NRAD). 2014. https://www.rcplondon.ac.uk/file/868/download?token=JQzyNWUs.
  8. Asthma Society Canada. Severe asthma: the Canadian patient journey. 2014. https://www.asthma.ca/wp-content/uploads/2017/06/Sastudy.pdf. Accessed June 2018.
  9. N/A
  10. Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol.
  11. Royal College of Physicians. Why Asthma Still Kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry Report. London, RCP, 2014. www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf
  12. Quirce S, Phillips-Angles E, Dominguez-Ortega J, Barranco P. Biologics in the treatment of severe asthma. Allergol Immunopathol (Madr). 2017;45(Suppl 1):45–9.

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