CHEST Guidelines-Rebuttal-From-Dr-Barnes

Rebuttal-From-Dr-Barnes_chest

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Dr. Peter J. Barnes provides a rebuttal discussing challenges in managing severe or difficult-to-treat asthma, emphasizing both adherence issues and the rarity of severe refractory asthma, which affects less than 4% of asthma patients. He notes that poor inhaler technique, comorbidities, and exposure to exacerbating factors can contribute to difficulty in asthma control. Barnes acknowledges the limited benefit of anti-eosinophilic therapies that target eosinophilic inflammation, which help only a small fraction of patients due to variable inflammatory phenotypes. Induced sputum analysis, although informative, is impractical for regular clinical use due to its complexity and cost. Instead, Barnes suggests that simpler, less invasive tests such as measuring fractional exhaled nitric oxide, despite limitations like influence from smoking or corticosteroid use, could be beneficial yet costly.<br /><br />Barnes concurs that biologic agents like anti-IL-5 and the anti-IL-4a receptor may reduce exacerbations and oral corticosteroid use in selected patients. However, these options are expensive and rarely cost-effective. Oral drugs like prostaglandin D2 antagonists, such as fevipiprant, show promise in cost-effectiveness by reducing eosinophils in sputum in severe asthma patients, but their full clinical impact is undetermined.<br /><br />Barnes emphasizes that although the development of targeted biologics is a significant advancement, it serves only a limited patient population. Furthermore, he highlights the importance of improving asthma management through better adherence to existing therapies and correcting inhaler techniques to avoid the expense of new biologic therapies as alternatives. He acknowledges that the high cost and limited approval of treatments like mepolizumab make widespread use challenging, stressing cost-effective asthma management as paramount.

Keywords

severe asthma

asthma management

biologic therapies

inhaler technique

anti-eosinophilic

fractional exhaled nitric oxide

cost-effectiveness

oral corticosteroids

prostaglandin D2 antagonists

mepolizumab