A Multidisciplinary Approach to Controlling Severe Asthma

Senior woman on medical exam

About 24.7 million Americans live with asthma, according to the Centers for Disease Control and Prevention. Patients with severe asthma comprise 10 to 15 percent of this figure, said pulmonologist Elliot Israel, MD, co-director of the Severe Asthma Program at Brigham and Women’s Hospital. And yet, he added, caring for this segment of asthma patients accounts for over half the cost of asthma care.

Established in 2017, the Severe Asthma Program offers the latest diagnostic and therapeutic options to improve the respiratory health of patients with severe asthma. This form of the condition is resistant to conventional treatments, such as inhalers that contain corticosteroids and long-acting bronchodilators, or is otherwise hard to control.

The Severe Asthma Program takes a multidisciplinary approach to disease management, bringing together a team of pulmonologists and allergists who collaborate with otolaryngologists, voice therapists, gastroenterologists and psychiatrists. “All of our physicians have an asthma focus and work specifically with asthma patients,” said co-director Christopher Hardy Fanta, MD. “Together, we can address all of the different factors that can contribute to severe asthma.”

Those factors, Dr. Fanta noted, may include sinusitis, nasal polyps, aspirin allergy or sensitivity, vocal cord dysfunction and/or gastroesophageal reflux. New patients are screened for issues like these, and their care team is augmented with additional specialists if necessary. For example, if screening suggests gastroesophageal reflux may be a problem, a gastroenterologist will get involved.

“We also have a physician assistant who coordinates and sees patients, follows up with them and answers their questions in between visits when a doctor isn’t available,” Dr. Israel added.

Building such a robust, multidisciplinary program isn’t possible at every hospital. As Dr. Israel pointed out, it requires a certain volume of patients with severe asthma along with specialists outside of pulmonology and allergy who are interested in the condition and willing to make the commitment. The ability to provide patients with access to novel investigational therapies and therapies waiting for approval is also crucial. The Brigham meets all of these criteria.

“These cases can be really hard nuts to crack,” Dr. Israel said. “We see patients whose lives were destroyed by asthma — they couldn’t go outside, couldn’t be in social situations or had to be hospitalized every month — and we’ve managed to turn their lives around. The impact we have can be life-changing.”

One Patient’s Success Story

One such patient is Kenneth Apfelbaum, a 64-year-old resident of a Philadelphia suburb. Apfelbaum had struggled with severe asthma for 16 years, during which he saw three pulmonologists in an effort to stop the constant coughing and feeling of extreme pressure on his lungs and chest caused by the condition.

Throughout this period, Apfelbaum was on prednisone nearly nonstop but could never get to baseline for more than one day. His professional and social life suffered. Any type of physical activity put him at risk of an asthma attack. Furthermore, one of the side effects of prednisone is hunger, which led to a weight gain of about 60 lbs.

On the recommendation of a friend, Apfelbaum traveled to Boston in April 2018 for an appointment at the Severe Asthma Program. Following a thorough evaluation, Dr. Israel significantly adjusted Apfelbaum’s medication regimen.

Apfelbaum started feeling relief within about six weeks. By July 2018, his coughing and the pressure on his lungs and chest had decreased markedly and he had been weaned off of prednisone. Now that he can exercise, he has dropped nearly 50 lbs. and hopes to lose another 10 lbs. He currently returns to the Brigham every six months to see Dr. Israel.

“Going to the Severe Asthma Program was probably the best decision I’ve ever made,” Apfelbaum said. “It has improved my life substantially. I feel like a different person. There’s nothing I can’t do, and that hadn’t been the case for the longest time.”

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