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Medscape
21-05-2025
- Health
- Medscape
Still Recommending Albuterol for Asthma? Time for an Update
This transcript has been edited for clarity. Matthew F. Watto, MD: Welcome back to The Curbsiders . I'm Dr Matthew Frank Watto, here with my great friend and America's primary care physician, Dr Paul Nelson Williams. Paul N. Williams, MD: Matt, how are you? Watto: I'm doing well. Paul, we recently discussed asthma management with Dr Cyrus Askin. He's a homegrown pulmonologist, I would say. Williams: Dr Askin is a longtime Curbsiders team member. I just had the occasion to listen to the episode. Typically, I try not to rewatch our episodes if I can help it because I hate listening to my own voice, but man, he did a good job with this topic. It's a really strong and comprehensive episode. Watto: And he has his own podcast, Critical Care Time. Now, Paul — I heard that albuterol is dead. Can you tell me about that? Because albuterol is what I give to all my patients as first line. I tell them not to mess with any other asthma medications. Williams: That's right: Albuterol is dead, at least in regards to asthma. I think we've all seen (and probably still have) a lot of patients with mild intermittent asthma who have an albuterol inhaler, that they may or may not use, that's been on their medication list for 20,000 years. We should have moved past that paradigm at this point, Matt. The 'new' guidelines— I say 'new' but they've been around for over 5 years now, at this point — Watto: Yeah, we covered this in 2019. Williams: Exactly. So that idea of using short-acting beta-agonist (SABA) monotherapy is verboten. We should not be doing that anymore. SABA monotherapy leaves the airways unprotected from inflammation and the outcomes of SABA monotherapy alone are not great. What you want is a little bit of inhaled corticosteroid (ICS) to reduce the inflammation in addition to the bronchodilation. ICS with formoterol (ICS/FORM) is the new albuterol, and we can talk about whether we're using this only as a rescue medication or as a controller or as both — all of which are okay, but you want to have the ICS there because patients just don't do as well on SABA monotherapy. They end up with worse exacerbations and more hospitalizations. Watto: Using ICS with formoterol, a long-acting beta-agonist (LABA), is prioritized because it has a quick onset of action. There is an ICS, budesonide, that is commonly paired with formoterol. The pairing of budesonide with albuterol, a SABA, has also been advertised recently and I've noticed that it's on some formularies. We asked Dr Askin about his opinion on pairing budesonide with a LABA vs a SABA, and he prefers the LABA formoterol. However, in some cases, patients may only have access to albuterol with inhaled steroids. So, I guess having some inhaled steroid is better than none. Williams: Dr Askin even gave us very hesitant permission to have an ICS plus albuterol as needed as a rescue inhaler in extreme circumstances. But again, you want that ICS in there as your base note. Watto: In my experience, the ICSs by themselves are not that cheap compared with the combination therapy, so it almost doesn't make sense to not go with the ICS/FORM option. But I know there are some patients that just can't afford the formoterol-containing formulation, so you may just be stuck there. Paul, I heard there's some nonpharmacologic measures we can take to improve asthma symptoms. Do you have any favorites? Williams: I loved a lot of points that Dr Askin made at the end of the episode when we started talking about nonpharmacologic measures. He talked specifically about how exercise is a potential trigger. He doesn't even use the term exercise-induced asthma because he feels like that gives a signal to patients that they should stop exercising, and it turns out that patients do better when they exercise — as is the case in almost every circumstance. Instead, he identifies exertion as a potential asthma trigger, as opposed to exercise-induced asthma. Then, as physicians, we just treat asthma appropriately and the patient should still be encouraged to exercise, as that will help them have better health outcomes overall. We also spent a fair amount of time talking about weight loss. Patients with obesity have poor asthma control and more frequent exacerbations. Even in his pulmonology clinic, he has conversations with patients about medications for weight loss and therapeutic lifestyle changes. And in the primary care setting, especially, we should do the thing we're supposed to be doing anyway: vaccinating against viruses. Make sure COVID, influenza, and pneumococcal vaccinations are all up to date so we can protect our patients against potential infectious triggers, as best as we're able to. I thought that was a nice reminder that we should be making sure our patients are vaccinated, especially for our patients living with asthma. It's really important to be diligent about protecting our patients in that way. Watto: In terms of asthma diagnosis, we had previous guests who weren't the biggest fans of spirometry. However, both the guidelines and Dr Askin support the use of spirometry as the gold standard for asthma diagnosis. Now, if you're in an extremely resource-limited setting and someone has a very classic presentation of asthma, treating them and then confirming diagnosis at later timepoint is probably alright to do. But if you're in a well-resourced setting, getting spirometry is the best course of action for most patients. If your patient has no symptoms at the time of spirometry, that may be normal. In those cases, Dr Askin said he might go right to spirometry with methacholine and administer escalating doses of methacholine to try to induce some obstruction that you can detect on the test. Then, you would do the bronchodilator challenge after that to see if you can reverse the airway obstruction in order to make the diagnosis of asthma. In some cases, Paul, you can even use peak expiratory flow to diagnose asthma in resource-limited settings. But that's not something I've done before. Williams: No, neither have I. Every place I've practiced, both rural and urban, has had fairly easy access to pulmonary function testing, although I have not seen it conducted as consistently as it probably should be for our patients with asthma or presumed asthma.
Medscape
19-05-2025
- Health
- Medscape
Managing Comorbid Chronic Lung Disease With Allergies
Michael A. Bernstein, MD, can't contain his curiosity when he hears the common claim: This is the worst allergy season ever . 'I feel like the current season is always said to be 'the worst' for allergies, but it's difficult to know how bad any season is until it's actually over,' said Bernstein, a pulmonologist at Stamford Health, Stamford, Connecticut. What's easier to acknowledge, however, is the number of patients requiring treatment for seasonal allergies, including those with chronic lung disease, continues to escalate. As more patients experience greater allergy symptom severity with each calendar year, Bernstein and other physicians are often establishing appropriate care planning for patients in real time. While there's a certain level of unpredictability to accept with allergies, there's also evidence that defines effective strategies based on each patient's symptom portfolio, age, chronic lung conditions, and the time of year. Many of the protocols used by today's specialists are born out of a better understanding of why seasonal allergies are on the rise and how environmental clues can assist patients. New Sense of Seasons Numerous factors are increasing the rate of allergy diagnoses. Among them is a heightened awareness about outdoor and indoor aeroallergens — airborne substances such as pollen from grass, weeds, trees, and plants; fungi and mold spores; dust mites; animal dander; and insect debris that can trigger a cascade of hay fever–related symptoms. But the lead cause of more allergies today is primarily the effect of global climate change, most notably changes in seasonal variation and increased production of pollen. According to the US National Oceanic and Atmospheric Administration (NOAA), the earth's average surface temperature has become consistently warmer since the late 19th century, with 2023 ranking as the warmest year (by a wide margin) since global temperature records began in 1850. The 10 individual warmest years have all occurred since 2014, per the NOAA. 'Because of climate change, the winter season is now shorter,' explained Bernstein. 'When you're robbing days from winter, you're adding days to spring. Whereas allergy season previously started toward the end of April or the beginning of May, we're now seeing it begin early in April or even March. The season now starts further back.' It is estimated that the typical allergy season is 13 days longer than it once was, said Purvi S. Parikh, MD, an allergist at New York University Langone Health, New York City. 'We have fewer 'frost-free' days today as well, and these are the types of days when pollen can form.' Compounding the issue is an increase in carbon dioxide levels, which allows for more efficient photosynthesis, leading to more pollen. 'The pollen itself is becoming more allergenic, meaning its structure is evolving to be more likely to cause allergies,' said Parikh, who also pointed to basic human genetics and other circumstances as associated allergy culprits. 'You only need one parent with allergies to increase your risk [of eventually developing allergies], along with lack of exposure to good bacteria and microorganisms that protect us from being allergic,' she said. 'An increase in urban living away from farmland has also done a disservice to our immune systems because urbanization exposes us more to carbon emissions and ozone that worsen with climate change. And the foods that we eat with pesticides or that are processed can also disrupt our internal microbiome and immune systems.' Consequences for Chronic Lung Disease Despite the potential for allergy symptoms to mimic various chronic lung conditions, allergy symptoms can likely be identified temporally. 'Ultimately, it's that their clinical symptoms worsen episodically during times when you know the pollen count is high,' said David Beuther, MD, PhD, professor of medicine at National Jewish Health, Denver. 'In addition to their chronic condition, we're also seeing rhinitis — it's itching, sneezing, watery eyes, nasal drainage, congestion — and sometimes, this puts them at risk for worsening lung problems or sinus infections. There's that clinical timing of symptoms that are big clues.' Beuther estimates that asthma is most likely to occur in conjunction with allergies, followed by chronic obstructive pulmonary disease (COPD), 'because asthma is typically more chronic year-round,' said Beuther. 'For a subset of patients, allergens in the environment are a trigger for their asthma to worsen. But independent of that, patients who have sinus issues caused by allergies can actually lead to their asthma becoming uncontrolled, or not well controlled, when those conditions are most active.' Inflammation within the nasal passages caused by allergies can lead to enhanced inflammation of the airways and worsen asthma. Additionally, persistent coughing can cause an irritation of the airway, and nerves that become irritated can cause bronchial spasms when they're triggered. 'But there are also asthma patients who say they have no response to allergens,' Beuther said. 'So there's variability. Inflammation caused by seasonal allergies can also disrupt the normal mucosal barrier that serves as the immune system's 'first line of defense,' leaving patients at increased risk of developing upper respiratory tract infections, which are a major driver of asthma and COPD exacerbations.' As a heterogeneous disease, COPD can mimic allergy symptoms or be exacerbated during allergy season, making it difficult to decipher the cause of symptoms. 'I see many COPD patients who experience worse symptoms when their nasal passages are congested, or they're sneezing or coughing,' said Beuther. 'You may see some patients who say their COPD is worse seasonally, similar to those with asthma. That's important to know.' Patients with cystic fibrosis, however, are less likely to experience seasonal allergy aggravation of the condition. 'I don't know that we spend a lot of time worrying about allergies with these patients,' said Beuther. 'But what we more often see is that cystic fibrosis affects the nasal passages and the sinuses so much from the disease alone that the allergy issue is not felt to be that much more.' According to Sobia Farooq, MD, a pulmonologist at Cleveland Clinic, Cleveland, mild to moderate warning signs of an allergy exacerbating a chronic lung condition include increased coughing, especially at night or early morning; chest tightness or discomfort; increased nasal congestion; sneezing; postnasal drip that triggers wheezing; noticeable drop in peak flow readings; and more frequent use of a rescue inhaler. Warning signs requiring immediate care include shortness of breath during minimal exertion or while at rest, wheezing that doesn't improve with standard medication, lack of relief when using a rescue inhaler, a persistent drop in peak flow below 50% of personal best, difficulty speaking in full sentences, blue lips or fingernails, and showing signs of fatigue or confusion. 'When seasonal allergies start to worsen chronic respiratory symptoms, early recognition is critical,' said Farooq. There are also patients who are diagnosed with perennial rhinitis defined by yearlong nasal congestion and drainage, which can be linked to external triggers or be experienced unrelated to environmental allergens. 'It depends on the patient,' said Bernstein. 'We know that some patients' chronic lung disease is made worse by allergy triggers. But for some, as their lung disease gets worse than it was earlier in their life, they're going to have more impact by the allergens in the air. We don't see as many people 'growing out' of their allergies anymore — which I'm not really sure if that was ever true.' Treatment Strategies and Suggestions Multiple options are available for treating seasonal allergies, as well as routes of administration that offer certain tradeoffs, including intranasal medications, pills or liquids, eye drops, and injections. 'I often recommend 24-hour, non-drowsy antihistamines — particularly those that don't cross the blood-brain barrier, so there's no drowsiness or 'brain fog,'' said Parikh. 'Also, steroid nasal sprays, antihistamine nasal sprays, and eye drops. Start your patients on their controller medications for allergies and asthma as early in the year as possible, as it's easier to target allergies proactively rather than retroactively. If they suffer every year, consider immunotherapy or allergy shots, which actually decrease allergies over time and are the closest thing to a 'cure.'' Farooq also suggests the use of sublingual tablets to help with potentially reducing long-term sensitivity. Physicians suggest allergy season is not the time to tinker with medications prescribed for chronic lung disease regardless of allergy severity. Instead, take stock of those with confirmed allergies and plan patient referrals to an allergist if they're not already seeing a specialist. 'The first question for patients who have chronic lung disease is to determine if they have seasonal allergies,' said Bernstein. 'Ask if they've previously had symptoms and, if so, what time of year do they happen and what triggers their allergies. If they have seasonal allergies and their breathing is worse during seasonal allergy times, that's not a great time to make major moves with their medications. For most of my patients with chronic lung conditions, April, May, and June tend to be the months when I won't take them off medications. Even if they're doing well, I'll suggest that we get to the end of June and then see how they do when stopping their medication. Because if we stop in the middle of allergy season and they get worse — you won't know if it's the allergy season or if they needed the medication.' Bernstein also suggests timing routine and follow-up appointments for patients with allergies. 'The worst thing that you can do is try to play catch-up during allergy season,' he said. 'But if you get patients started before the spring, you'll have time to help them prevent the symptoms that they have at their worst time of the year.' Mainstay treatments for Bernstein include corticosteroid nasal sprays. 'Oral antihistamines will also certainly help, but they have side effects such as drowsiness and dry mouth that can become issues for patients. And antihistamines, particularly in older patients who are on other medications, get more complicated to use. If you can avoid that it will help.' Beyond medications, avoiding exposure to allergens can also reduce symptom severity. 'Allergens tend to be the worst at dawn and dusk,' said Bernstein. 'On the highest allergy days, being inside air-conditioned environments is suggested. Don't have patients taking walks during early evenings unless they're walking inside.' These measures can potentially complicate typical self-care among chronic lung patients, however. 'For many of these patients, the best advice you give them is to exercise, so it's a problem when pollen is thick in the air during the spring or when there's wildfires during the summer because taking a walk outside is not going to be the most beneficial recommendation for their health,' said Bernstein. 'Some patients benefit from walking outside with a mask.' Parikh also advises that patients change their clothes when at home during high-pollen days and showering to wash off any pollen to decrease exposure. 'Keep windows closed early in the morning for the same reason,' she said. If such precautions aren't taken, allergy severity can peak. 'Two of the issues for patients with chronic lung disease is they'll get bronchial constriction or tightening or narrowing of the airways in their lungs,' said Bernstein. 'This can manifest in wheezing, and that's directly triggered by the allergens in the air. The other is increased mucus production, where mucus builds up in their airways, and they have to cough it up and clear it out. These are constant struggles for some of these patients, and if they have severe allergies, you're taking what's their normal baseline and making it worse.' Bernstein also warned that some prescribed medications, such as beta-blockers metoprolol and carvedilol, have been known to worsen allergy symptoms. Conversely, drugs prescribed for rheumatoid arthritis, lupus, and other inflammatory conditions can actually help with allergies. 'Some patients will experience lessened allergy symptoms when they're started on anti-inflammatory medications just as an added bonus to being treated for those conditions,' Bernstein said. 'With COPD, we are increasingly using the medication Dupixent. This can help with allergies regardless of how it treats COPD.' During allergy seasons, physicians can also add bronchodilators or leukotriene receptor antagonists, such as montelukast, suggests Farooq. Can't Sleep on Symptoms Poorly controlled allergies can also lead to another general health malady that has a tendency to be overlooked, said Beuther — poor sleep quality due to overnight coughing and congestion. 'It's very clear from the care of our patients that the impact on sleep and quality of life from allergies can make the experience of a chronic lung disease worse,' he said. 'Imagine that you're someone with any chronic lung disease. You're struggling to breathe, you're having cough and mucus from your lungs, you might be on oxygen. And now we're adding a nose that's plugged up and you're not sleeping.' Allergy symptoms during evening hours can be reduced with steam humidifiers, the use of high-efficiency particulate air filters, and peak flow monitoring with a digital app. Other digital tools or telehealth can also support patients in logging symptom cadence. Updating action plans with clear steps for managing worsening symptoms will also reduce potential for emergency department visits, said Farooq. 'This type of care coordination between pulmonologists, allergists, and primary care physicians, as well as patient education, all improve outcomes,' she said.
Associated Press
18-05-2025
- Business
- Associated Press
IMVARIA Reports Multi-Site Clinical Experience With FDA-Authorized AI Diagnostic Service for Idiopathic Pulmonary Fibrosis at ATS 2025
BERKELEY, Calif.--(BUSINESS WIRE)--May 18, 2025-- IMVARIA Inc., a health tech company pioneering AI-driven digital biomarker solutions, today reported results from multi-site clinical experiences with IMVARIA's diagnostic referral service, where pulmonologists send cases for AI-supported diagnostic evaluation of suspected Interstitial Lung Disease (ILD) and Idiopathic Pulmonary Fibrosis (IPF). Built by medical doctors with software engineering expertise, Fibresolve is the first ever FDA-authorized AI adjunctive diagnostic service of any type in lung fibrosis. Clinical data from use around the U.S. will be presented by pulmonary experts from Harvard's Mass General Hospital at ATS 2025 International Conference, focusing on respiratory diseases, held on May 16-21, 2025 in San Francisco. 'We're excited that our clinical users are sharing real-world experience with Fibresolve at the ATS Conference,' said Joshua Reicher, MD, Co-founder and CEO of IMVARIA. 'At IMVARIA, we've taken a different approach to AI – one that makes it far easier for pulmonologists to benefit from this new technology without changing workflows or installing complex systems. As practicing medical doctors, my co-founder Dr. Michael Muelly and I designed Fibresolve to meet the highest medical standards, deliver new insights, and make it easy for clinicians to use AI with confidence and minimal burden. We're proud to see that approach working in real clinical settings.' IMVARIA's Fibresolve received FDA authorization in early 2024 and has gone through a rigorous process to make it useful and reliable for pulmonologists. Fibresolve is available through IMVARIA's centralized service that uses AI to help guide safe, non-invasive diagnoses. Fibresolve also has the distinction as the first FDA Breakthrough-Designated AI diagnostic tool with simultaneously adopted CPT billing codes by the American Medical Association (AMA) in any disease. IMVARIA is additionally presenting data on ScreenDx and Bronchosolve, two more AI solutions in its pulmonary portfolio. ScreenDx, FDA-cleared in 2025, is the first AI technology authorized to assess interstitial lung findings compatible with ILD. Bronchosolve is an investigational tool designed to support more accurate assessment of indeterminate lung nodules and is currently under research investigation. Poster Presentations at ATS 2025 Conference Fibresolve Title: Clinical Experience with the First FDA-Authorized Artificial Intelligence Tool in Interstitial Lung Disease and Idiopathic Pulmonary Fibrosis Session: A46 - New Research in Biomarkers and Imaging for ILD Poster: P1547 Date and Time: Sunday, May 18, 2025: 9:15 AM - 4:15 PM ScreenDx Title: Automated Al Detection of Interstitial Lung Disease by Computed Tomography (CT) in the COPDGene Trial; Subanalysis and Characteristics of Accurately Detected Cases Session: A57 - Late Breaking Abstracts in Clinical Problems Poster: P1006 Date and Time: Sunday, May 18, 2025: 9:15 AM - 4:15 PM Bronchosolve Title: Closed Loop, Full Automation of Suspicious Lung Nodule Risk Assessment with AI in Screening Cases Session: B110 - The Road to Early Detection: Advancing Lung Cancer Screening Through AI, Risk Models, And Real-World Data Poster: 619 Date and Time: Monday, May 19, 2025: 2:15 PM - 4:15 PM Title: Age-Stratified Subanalysis of a Closed Loop, Fully Automated Lung Nodule Risk Assessment Al Software Session: B80-1 - From Bench to Bedside: Innovative Biomarkers, Screening Approaches, And Personalized Treatments In Lung Cancer Poster: P804 Date and Time: Monday, May 19, 2025: 9:15 AM - 4:15 PM Together, these presentations reflect IMVARIA's mission to empower clinicians to make the best decisions through clinically meaningful AI. For more information about IMVARIA, click here. About IMVARIA Inc. IMVARIA is a health tech company pioneering AI-driven solutions that empower clinicians to make accurate diagnoses and prognoses at earlier stages of disease. Founded in 2019 by physician-engineers from Google and Stanford University, the company operates its AI Lab with automated, machine-learning algorithm technology to transform clinical decision-making into data science. IMVARIA is based in Berkeley, CA. For more information, go to View source version on CONTACT: Media Contact Anthony Petrucci Bioscribe [email protected] KEYWORD: UNITED STATES NORTH AMERICA CALIFORNIA INDUSTRY KEYWORD: TECHNOLOGY RESEARCH HEALTH TECHNOLOGY CARDIOLOGY BIOTECHNOLOGY HEALTH GENERAL HEALTH SCIENCE ARTIFICIAL INTELLIGENCE SOURCE: IMVARIA Inc. Copyright Business Wire 2025. PUB: 05/18/2025 10:30 AM/DISC: 05/18/2025 10:29 AM
