{"id":19375912,"date":"2024-09-25T15:59:19","date_gmt":"2024-09-25T19:59:19","guid":{"rendered":"https:\/\/allergyasthmanetwork.org\/?p=19375912"},"modified":"2024-11-15T10:01:58","modified_gmt":"2024-11-15T15:01:58","slug":"remission-of-asthma-consensus-statement","status":"publish","type":"post","link":"https:\/\/allergyasthmanetwork.org\/webinars-updates\/remission-of-asthma-consensus-statement\/","title":{"rendered":"Remission of Asthma: Review of Consensus Statement (Recording)"},"content":{"rendered":"\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe title=\"Remission of Asthma: Review of Consensus Statement\" width=\"720\" height=\"405\" src=\"https:\/\/www.youtube.com\/embed\/VxNQHXdJs0U?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<p><span style=\"font-size: 18pt;\"><em>This webinar was recorded on November 12, 2024<\/em><\/span><\/p>\n\n\n\n<p>With the introduction of new therapies for asthma like biologics, achieving disease remission has become a new goal of treatment and classifying asthma control is in transition. In December 2023, the Annals of Allergy, Asthma &amp; Immunology published a consensus statement between the American College of Allergy, Asthma, and Immunology, American Academy of Allergy, Asthma, and Immunology, and American Thoracic Society to update the definition of clinical remission in asthma. In this webinar, learn more about the consensus statement and the outcomes of the working group.<\/p>\n\n\n\n<p><span style=\"font-size: 18pt;\">Speaker:<\/span><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Michael S. Blaiss, MD<br>Clinical Professor of Pediatrics<br>Medical College of Georgia at Augusta University<br>Augusta, Georgia<\/li>\n<\/ul>\n\n\n\n<p>Michael S. Blaiss, MD,&nbsp;is a clinical professor of pediatrics at Medical College of Georgia in Augusta, Georgia, and allergist at Good Samaritan Health Center of Gwinnett in Norcross, Georgia.&nbsp; He received his medical degree from the University of Tennessee Center for Health Sciences and did pediatrics at University of Tennessee\/Le Bonheur Children\u2019s Medical Center in Memphis and completed a fellowship in allergy\/immunology at Ochsner Medical Foundation in New Orleans, Louisiana.<\/p>\n\n\n\n<p>He is past president of the American College of Allergy, Asthma and Immunology. He served as treasurer of the American Board of Allergy and Clinical Immunology, a past member of the Board of Directors of the World Allergy Organization and past president of the Tennessee and Louisiana Societies of Allergy, Asthma and Immunology. He was Executive Medical Director of the American College of Allergy, Asthma, and Immunology. Dr. Blaiss has published about 200 scientific peer-reviewed articles and presented at more than 500 meetings and seminars throughout the world.<\/p>\n\n\n\n<p>This Advances webinar is in partnership with the American College of Allergy, Asthma &amp; Immunology. ACAAI offers CMEs for physicians for this webinar. If you are a member of ACAAI, you can obtain CME through the member portal for Advances webinars.<\/p>\n\n\n\n<p>All attendees will be offered a certificate of attendance. No other continuing education credit is provided.<\/p>\n\n\n\n<p><em><em><strong>CME is available through\u00a0<a href=\"https:\/\/education.acaai.org\/content\/remission-asthma-what-it-can-it-be-obtained-aan#group-tabs-node-course-default1\" target=\"_blank\" rel=\"noreferrer noopener nofollow\">ACAAI for this webinar.<\/a><\/strong><\/em><\/em><\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<p class=\"has-text-align-center\">Sponsored by the American College of Allergy, Asthma and Immunology<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><img decoding=\"async\" width=\"288\" height=\"79\" src=\"https:\/\/allergyasthmanetwork.org\/wp-content\/uploads\/2024\/10\/ACAAI_Allergist.jpg\" alt=\"Logo for the American College of Allergy, Asthma &amp; Immunology next to the word &quot;allergist,&quot; both with stylized circular designs.\" class=\"wp-image-19377962\" title=\"\"><\/figure><\/div>\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<p><strong>Transcript:&nbsp;<\/strong>While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.<\/p>\n\n\n\n<p><strong>Lynda:<\/strong>&nbsp;Hi, everyone.&nbsp;We will get started in a&nbsp;minute.&nbsp;Just waiting for more folks to&nbsp;log in.&nbsp;I appreciate all of you who&nbsp;joined us here today.&nbsp;If you want to tell us where&nbsp;you are from, that would be&nbsp;really great.&nbsp;If you don&#8217;t, that is OK, too.&nbsp;All right.&nbsp;We will go ahead and get&nbsp;started.&nbsp;Hello, everyone.&nbsp;Thank you for joining us today.&nbsp;I am Lynda Mitchell.&nbsp;Welcome to this afternoon&#8217;s&nbsp;webinar.&nbsp;We are going to hear a really&nbsp;interesting discussion on&nbsp;asthma with Dr. Michael Blaiss&nbsp;as today&#8217;s presenter.&nbsp;We have a few housekeeping&nbsp;items to go over before today&#8217;s&nbsp;webinar begins.&nbsp;All participants will be on&nbsp;mute for the webinar.&nbsp;We will be recording the&nbsp;webinar and posting it on our&nbsp;website within a few days after&nbsp;today&#8217;s session.&nbsp;You will be able to find the&nbsp;webinar on our website on the&nbsp;homepage if you just scroll&nbsp;down to where we keep all of&nbsp;our recorded webinars following&nbsp;their completion.&nbsp;You will also see upcoming&nbsp;webinars as well.&nbsp;This webinar will be one hour&nbsp;in length, and that will&nbsp;include time for questions at&nbsp;the end.&nbsp;But you can put your questions&nbsp;into the Q&amp;A pane at any time&nbsp;and we will go through and keep&nbsp;track of them so we can ask&nbsp;them later on.&nbsp;The Q&amp;A pane is at the bottom&nbsp;of your menu.&nbsp;There is a similar chat box to&nbsp;put your questions in the Q&amp;A.&nbsp;We will get to as many&nbsp;questions as we can before we&nbsp;conclude today&#8217;s webinar.&nbsp;This is a webinar in&nbsp;partnership with the American&nbsp;College of Allergy, Asthma, and&nbsp;Immunology.&nbsp;ACAAI offers CME&#8217;s for&nbsp;physicians in attendance.&nbsp;You can create a free account&nbsp;and receive a certificate&nbsp;through the portal or the&nbsp;webinars.&nbsp;All attendees can have a&nbsp;certificate of attendance.&nbsp;If you would like that, we will&nbsp;drop a link in the chat and&nbsp;follow-up with an email and&nbsp;give you a link to it as well&nbsp;there.&nbsp;A few days after the webinar,&nbsp;you will receive an email of&nbsp;supplemental information to&nbsp;download the certificate of&nbsp;attendance.&nbsp;And we will try to also like I&nbsp;said add the certificate of&nbsp;attendance link in the chat.&nbsp;So let&#8217;s get started.&nbsp;Today&#8217;s topic is remission of&nbsp;asthma.&nbsp;What is it?&nbsp;With the introduction of new&nbsp;therapies, achieving disease&nbsp;remission has become a new goal&nbsp;for treatment and classifying&nbsp;asthma control in its&nbsp;transition.&nbsp;In December of 2023, the Annals&nbsp;of Allergy, Asthma, and&nbsp;Immunology published a&nbsp;consensus statement between the&nbsp;American College of Allergy,&nbsp;Asthma, and Immunology, the&nbsp;American Academy of Allergy,&nbsp;Asthma, and Immunology, and the&nbsp;American Thoracic Society to&nbsp;update the definition of&nbsp;clinical remission of asthma.&nbsp;It is my pleasure to introduce&nbsp;our speaker, Dr. Michael&nbsp;Blaiss.&nbsp;Dr. Blaiss is a clinical&nbsp;professor of pediatrics at the&nbsp;medical College of Georgia and&nbsp;of the stock, Georgia &#8212; in&nbsp;Augusta, Georgia.&nbsp;He received his medical degree&nbsp;from the University of&nbsp;Tennessee Center for health&nbsp;sciences and it pediatrics at&nbsp;the University of Tennessee&nbsp;while there.&nbsp;children&#8217;s Medical Center in&nbsp;Memphis and completed a&nbsp;fellowship at a medical&nbsp;foundation in New Orleans.&nbsp;He is president of the American&nbsp;College of Allergy, Asthma, and&nbsp;Immunology and also served as&nbsp;treasurer of the American Board&nbsp;of allergy and clinical&nbsp;immunology, and member of the&nbsp;board of directors of the world&nbsp;allergy organization, and past&nbsp;president of the Tennessee and&nbsp;the Louisiana societies of&nbsp;Allergy, Asthma, and&nbsp;Immunology.&nbsp;He was the executive director&nbsp;of the American College of&nbsp;Allergy, Asthma, and Immunology&nbsp;until recently.&nbsp;Dr. Blaiss has published over&nbsp;200 peer-reviewed articles and&nbsp;presented with 500 meetings and&nbsp;seminars throughout the world&nbsp;so we are in for a real treat&nbsp;today.&nbsp;Thank you for being here, Dr.&nbsp;Blaiss.&nbsp;I will turn it over to you.<\/p>\n\n\n\n<p><strong>Dr. Blaiss:<\/strong>&nbsp;Thank you, Lynda.&nbsp;Thanks for that kind&nbsp;introduction.&nbsp;Welcome, everyone.&nbsp;Thanks for joining me on a&nbsp;subject I am very passionate&nbsp;about, and that in fact is&nbsp;remission and asthma.&nbsp;So these are my disclosures for&nbsp;this particular lecture.&nbsp;And I have three learning&nbsp;objectives that I want to try&nbsp;to cover today with you.&nbsp;In one, very importantly,&nbsp;understanding the differences&nbsp;between the term asthma&nbsp;control, which is what we have&nbsp;been using for numerous years,&nbsp;and now we are starting to see&nbsp;in the literature the term for&nbsp;asthma remission, and with that&nbsp;I think it is very important&nbsp;for all of us to understand&nbsp;there are in fact different&nbsp;definitions of remission in&nbsp;asthma and one of the key&nbsp;points I will be covering is&nbsp;there is no complete consensus&nbsp;at this time worldwide exactly&nbsp;what we mean by remission in&nbsp;asthma.&nbsp;And because of that, we have&nbsp;developed, at I was on the&nbsp;workgroup, joint consensus&nbsp;statement as you heard Lynda&nbsp;mention through the American&nbsp;College and the American&nbsp;Academy of Allergy, Asthma, and&nbsp;Immunology and the American&nbsp;Thoracic Society on what we&nbsp;felt should be included if in&nbsp;fact we talk about remission on&nbsp;treatment and asthma.&nbsp;I will cover that in detail for&nbsp;you.&nbsp;So let&#8217;s first start talking&nbsp;about asthma control.&nbsp;Because that is what we have&nbsp;been talking about with our&nbsp;patients basically since the&nbsp;1970&#8217;s.&nbsp;And with that, the reason we&nbsp;start to understand about&nbsp;asthma control is understanding&nbsp;that asthma is a chronic&nbsp;inflammatory condition of the&nbsp;airways.&nbsp;And if in fact we can control&nbsp;the underlying inflammation, we&nbsp;can decrease symptoms,&nbsp;exacerbations, and improve&nbsp;patients&#8217;s lung function.&nbsp;We started understanding this&nbsp;with the use of inherited&nbsp;corticosteroids &#8212; inhaled&nbsp;corticosteroids, and that is&nbsp;when we see the term asthma&nbsp;control.&nbsp;You may be familiar with the&nbsp;right on this slide, rules of&nbsp;two.&nbsp;I still in fact use this in my&nbsp;clinic situation.&nbsp;So they ask these three&nbsp;questions.&nbsp;Do you take a rescue inhaler&nbsp;for asthma symptoms more than&nbsp;two times per week?&nbsp;Do you wake up at night with&nbsp;your asthma symptoms more than&nbsp;two times per month?&nbsp;Do you refill your rescue&nbsp;inhaler more than two times per&nbsp;year?&nbsp;<\/p>\n\n\n\n<p>Again, if you answer yes to any&nbsp;of these, in fact your asthma&nbsp;is not under control.&nbsp;Now, we also have the GINA&nbsp;guidelines.&nbsp;GINA is the global initiative&nbsp;in asthma.&nbsp;This is a group of clinicians,&nbsp;others that are involved in&nbsp;asthma management throughout&nbsp;the world who put together a&nbsp;monogram on a yearly basis,&nbsp;including the most updated&nbsp;guidelines in the management of&nbsp;patients with asthma.&nbsp;For a long time, they in fact&nbsp;have talked about asthma&nbsp;control.&nbsp;And as you can see here, they&nbsp;mention that the level of&nbsp;asthma control, the extent to&nbsp;which the manifestations of&nbsp;asthma can be observed in the&nbsp;patient or have been reduced or&nbsp;removed by treatment.&nbsp;They talk about asthma control&nbsp;in fact in two major domains.&nbsp;One is what is going on&nbsp;presently, and that is symptom&nbsp;control.&nbsp;But very importantly, future&nbsp;risk of adverse outcomes.&nbsp;So if in fact we look at the&nbsp;GINA monograph, this comes from&nbsp;them.&nbsp;This is there &#8212; their&nbsp;assessment of asthma control.&nbsp;First we look at symptom&nbsp;control.&nbsp;It asks, what has happened over&nbsp;the past four weeks?&nbsp;There are four questions here.&nbsp;Do you have daytime symptoms&nbsp;more than twice a week?&nbsp;Nighttime awakenings due to&nbsp;asthma?&nbsp;Have you been using a reliever&nbsp;for symptoms more than twice a&nbsp;week?&nbsp;Any activity limitations due to&nbsp;asthma?&nbsp;If you answer no to all of&nbsp;these, you are well-controlled.&nbsp;If you answer yes to one or two&nbsp;of these my are partly&nbsp;controlled.&nbsp;If you answer yes to three or&nbsp;four of these, you are not&nbsp;controlled.&nbsp;For most of us, this is the&nbsp;definition we have been using.&nbsp;They also talk about risk&nbsp;factors for poor asthma&nbsp;control.&nbsp;In other words, future risk.&nbsp;One of the things they stress&nbsp;here is monitoring pulmonary&nbsp;functions after patients are&nbsp;placed on controller therapy,&nbsp;looking at the FEV1.&nbsp;And the reason they stress this&nbsp;is we know the lower the&nbsp;patient&#8217;s FEV1, the lower the&nbsp;risk for asthma exacerbation.&nbsp;With that, let&#8217;s move on and&nbsp;talk about the subject for&nbsp;today.&nbsp;That in fact is remission.&nbsp;So I am sure you are familiar&nbsp;that the term remission has&nbsp;been used in many different&nbsp;disease states that are&nbsp;commonly seen in our patient&nbsp;population.&nbsp;So probably the most common way&nbsp;we hear remission used in a&nbsp;diseased that is cancer.&nbsp;You see the finish and from the&nbsp;National Cancer Institute where&nbsp;remission is a decrease or&nbsp;disappearance of signs and&nbsp;symptoms of cancer.&nbsp;They talk about partial&nbsp;remission.&nbsp;They talk about complete&nbsp;remission.&nbsp;And in complete remission, all&nbsp;the signs and symptoms have&nbsp;disappeared but cancer may&nbsp;still be in the body.&nbsp;Also, we have edition of&nbsp;remission from the American&nbsp;diabetes Association related to&nbsp;type 2 diabetes.&nbsp;So they talk about remission as&nbsp;being defined as a return to&nbsp;the hemoglobin A1D to less than&nbsp;6.5% following intervention or&nbsp;six months in the absence of&nbsp;usual glucose&nbsp;lowering therapy.&nbsp;The one I want to talk about&nbsp;today is related to rheumatoid&nbsp;arthritis because it relates&nbsp;more to asthma.&nbsp;So this definition as you can&nbsp;see talks about one or fewer&nbsp;swelling joints or tender&nbsp;joints.&nbsp;Also, look and see if it is in&nbsp;the body.&nbsp;And disease modifying drugs and&nbsp;Biologics have led to a great&nbsp;increase in remission in this&nbsp;particular condition.&nbsp;So if we&nbsp;&#8212; the model and how to&nbsp;achieve remission asthma, let&#8217;s&nbsp;compare the two.&nbsp;Rheumatoid arthritis is an&nbsp;incurable inflammatory&nbsp;condition.&nbsp;We can say the same thing for&nbsp;severe asthma.&nbsp;We talk about rheumatoid&nbsp;arthritis.&nbsp;We have disease progression&nbsp;that occurs in the patients.&nbsp;There reversible joint damage&nbsp;and visible disability.&nbsp;And again, we know in severe&nbsp;asthma we get a disease&nbsp;progression that can lead to&nbsp;fixed obstructive lung disease,&nbsp;irreversible decline.&nbsp;This can lead to significant&nbsp;disability in our patient&nbsp;population.&nbsp;In rheumatoid arthritis, we&nbsp;mentioned they have multiple&nbsp;targeted therapies.&nbsp;They can lead to a realistic&nbsp;goal of clinical remission.&nbsp;We now have in asthma several&nbsp;targeted therapies out there.&nbsp;The question is, do these&nbsp;possibly lead to remission in&nbsp;our patient population&nbsp;suffering with asthma.&nbsp;Now, when one goes through the&nbsp;literature and sees different&nbsp;types of remission in asthma&nbsp;and the one we are going to ke&nbsp;ony &#8212; key today because it is&nbsp;the one most commonly seen in&nbsp;studies out there is clinical&nbsp;remission.&nbsp;This could be on or off therapy&nbsp;but it is in most cases on&nbsp;therapy.&nbsp;Generally, this definition&nbsp;talks about no symptoms, no&nbsp;exacerbations, normal lung&nbsp;function.&nbsp;Also, you may see&nbsp;&#8212; including normalization.&nbsp;Normalization of the different&nbsp;biomarkers in asthma, such as&nbsp;inhaled nitric oxide.&nbsp;Now, this is an important slide&nbsp;because this &#8212;&nbsp;.<\/p>\n\n\n\n<p><strong>Lynda:<\/strong>&nbsp;We lost you for just a minute.&nbsp;I don&#8217;t know if your Internet&nbsp;connectivity is a little off.&nbsp;And you are on mute.&nbsp;While Dr. Blaiss is working on&nbsp;his connectivity, just wanted&nbsp;to let you know there was a&nbsp;question about the slides.&nbsp;We don&#8217;t provide slides but&nbsp;will provide a recording and&nbsp;will be following up with that&nbsp;in a few days.&nbsp;Also, the consensus statement&nbsp;that Dr. Blaiss will be&nbsp;referring to, we will provide&nbsp;you with a link to that in the&nbsp;Journal so that you can take a&nbsp;look at the whole thing.&nbsp;With that, I will hand it back&nbsp;to Dr. Blaiss. Dr. Blaiss:&nbsp;OK.&nbsp;Sorry about that.&nbsp;Not sure what happened there.&nbsp;Going back to the slide, how do&nbsp;we assess remission in asthma?&nbsp;Because now we are talking&nbsp;about, what things do we do to&nbsp;define it?&nbsp;One is clinical symptoms. So&nbsp;how long do you have sustained&nbsp;absence of symptoms?&nbsp;So some of the definitions we&nbsp;see are six months, some are&nbsp;one year, some are longer, so&nbsp;you have to know that.&nbsp;One is the use of validated&nbsp;instruments in asthma control.&nbsp;Are they using the asthma&nbsp;control questionnaire?&nbsp;And what score are they using?&nbsp;Are they using less than 1.25&nbsp;or 0.75?&nbsp;Less than 0.75 is a higher&nbsp;standard so this patients would&nbsp;fall under the definition of&nbsp;having remission.&nbsp;And does it measure use of&nbsp;bronchodilators or not?&nbsp;Do these definitions of&nbsp;remission monitor&nbsp;bronchodilators?&nbsp;What about no exacerbations?&nbsp;Does that mean no burst of oral&nbsp;corticosteroids, no&nbsp;hospitalizations?&nbsp;No one scheduled doctors visits&nbsp;due to asthma.&nbsp;No one missed school or work&nbsp;due to asthma.&nbsp;What about lung function?&nbsp;Is instable lung function?&nbsp;Is it normal lung function?&nbsp;Do you have to show improvement&nbsp;in lung function?&nbsp;Such as the greater than equal&nbsp;to 100 milliliters Such as the&nbsp;greater than equal to 100&nbsp;milliliters?&nbsp;What about medication&nbsp;requirements?&nbsp;Are there none or do you have&nbsp;to show a decrease in need for&nbsp;medication like inhaled&nbsp;steroids?&nbsp;Do you have to show a decrease&nbsp;in rescue inhaler use?&nbsp;And if we are talking about&nbsp;complete remission, what about&nbsp;normalization of asthma&nbsp;pathophysiology?&nbsp;Do you measure biomarkers or&nbsp;have to have a negative test or&nbsp;show normal histology?&nbsp;The point being here, depending&nbsp;on which of these things you&nbsp;use is going to in fact define&nbsp;again what percent of patients&nbsp;may in fact fall under&nbsp;remission.&nbsp;If we only use two or three of&nbsp;these, a higher percentage may&nbsp;be in remission versus using&nbsp;several of these, so I think we&nbsp;always have to look at that&nbsp;when looking at papers that now&nbsp;are defining remission since&nbsp;there is no true standard.&nbsp;So is remission possible?&nbsp;The answer is absolutely yes.&nbsp;We know spontaneous remission&nbsp;of occurs in our patients with&nbsp;asthma.&nbsp;In fact, it is not uncommon in&nbsp;the pediatric population.&nbsp;It is part of the natural&nbsp;history of the disease.&nbsp;So this is a study that was in&nbsp;the Journal of allergy&nbsp;&#8212; in the Journal of Allergy,&nbsp;Asthma, and Immunology.&nbsp;<\/p>\n\n\n\n<p>They look at childhood asthma&nbsp;at the age of eight.&nbsp;It can predict remission of&nbsp;disease by early adulthood.&nbsp;If we look here, if in fact at&nbsp;the age of eight it is less&nbsp;than 80%, the rate of going&nbsp;into spontaneous remission by&nbsp;young adulthood was between&nbsp;9.5% up to 27.6%.&nbsp;But if it was greater than 80%&nbsp;at the age of eight, it ranged&nbsp;anywhere from 53.8% up to&nbsp;82.6%.&nbsp;So remission we know can occur.&nbsp;Now, this is a study out of&nbsp;Finland, and they looked at&nbsp;asthma remission by age, a&nbsp;diagnosis, and gender in a&nbsp;population study.&nbsp;These were physician diagnosed&nbsp;asthma patients, and they were&nbsp;characterized whether they had&nbsp;early onset asthma between the&nbsp;ages of zero and 11 years of&nbsp;age, intermediate 12 to 39&nbsp;years , and late diagnosis, 40&nbsp;to 69 years.&nbsp;So if you look over on the left&nbsp;and you look at the portion of&nbsp;remission related to age and&nbsp;diagnosis, you will see here&nbsp;that for the zero to 11 group,&nbsp;about 30% went into remission.&nbsp;The 12 to 39 age group, about&nbsp;17%.&nbsp;In the late diagnosed, 40 to 69&nbsp;years, about 5%.&nbsp;If you look at the right, here&nbsp;we are looking at gender, so&nbsp;males and females.&nbsp;You will notice for the zero to&nbsp;11 group that much higher&nbsp;statistically higher rate of&nbsp;going into remission for male&nbsp;children with asthma versus&nbsp;female.&nbsp;OK.&nbsp;Now this paper that was&nbsp;published back in 2020 really&nbsp;started people to look at the&nbsp;Biologics as far as a clinical&nbsp;remission in the patient&nbsp;population.&nbsp;So here was their definition of&nbsp;clinical remission on&nbsp;treatment.&nbsp;That is what we will key on&nbsp;here.&nbsp;They talk about for 12 months&nbsp;or greater so you have to see&nbsp;this for at least 12 months.&nbsp;Sustained absence of&nbsp;significant asthma symptoms&nbsp;based on a validated&nbsp;instrument.&nbsp;Optimized and stabilized lung&nbsp;function.&nbsp;They did not get exactly what&nbsp;they meant there.&nbsp;<\/p>\n\n\n\n<p>Patient and health care&nbsp;provider agreement regarding&nbsp;disease remission.&nbsp;That to me is kind of a soft&nbsp;measure because I am not sure&nbsp;any of us know exactly how to&nbsp;define remission as yet.&nbsp;And no use of systemic&nbsp;corticosteroid therapy for&nbsp;exacerbation treatment or&nbsp;long-term disease control,&nbsp;which I think is something we&nbsp;could all agree on.&nbsp;Now, what we have seen over the&nbsp;last few years is numerous&nbsp;countries, different societies&nbsp;in these countries,&nbsp;pulmonology, allergy, that in&nbsp;fact have developed definitions&nbsp;for clinical remission.&nbsp;This is not the whole list, but&nbsp;I put it on here.&nbsp;There are five of these here.&nbsp;Germany, Spain, Italy, Japan.&nbsp;And that U.S.&nbsp;guidelines we will talk about&nbsp;in a minute.&nbsp;So you can see here symptom&nbsp;assessment.&nbsp;And again, you can see&nbsp;differences here.&nbsp;Germany and Spain, it says&nbsp;absence of symptoms. If you go&nbsp;over to Italy, you see the ACT&nbsp;and ACQ.&nbsp;Japan uses a very high standard&nbsp;in the control test. Greater&nbsp;than or equal to 23.&nbsp;As I will talk about for the&nbsp;U.S.&nbsp;guidelines that was published,&nbsp;you can use these three&nbsp;validated instruments the ACT,&nbsp;ARQ, or the ACQ with a higher&nbsp;standard of less than 0.75.&nbsp;Lung function, some of these&nbsp;have to be stable.&nbsp;Others say they have to be&nbsp;optimized.&nbsp;All agreed on no exacerbations,&nbsp;no oral corticosteroid use.&nbsp;As you can see for the U.S.&nbsp;one, we added several other&nbsp;things like no missed school or&nbsp;work, no hire than the Ora&nbsp;Media inhaled dose &#8212; no higher&nbsp;than Ora Media inhaled dose of&nbsp;steroid.&nbsp;These are looking at different&nbsp;Biologics and multiple&nbsp;Biologics.&nbsp;These are all post hoc&nbsp;analysis from the Phase 3 or&nbsp;open label extension studies&nbsp;out there.&nbsp;And what we see here if you&nbsp;look at absence of symptoms,&nbsp;you see different standards&nbsp;being used as far as validated&nbsp;instruments.&nbsp;If we look at optimized&nbsp;stabilized lung function, some&nbsp;are using FEV greater than 80%.&nbsp;<\/p>\n\n\n\n<p>Some have to show a 100&nbsp;milliliter increase.&nbsp;Some are not using any lung&nbsp;function data.&nbsp;All have no exacerbations, no&nbsp;oral corticosteroid use.&nbsp;When you look at the prevalence&nbsp;of clinical remission, you can&nbsp;see it can range anywhere from&nbsp;14% to 43%.&nbsp;Again, most of this variation&nbsp;is because people are using&nbsp;different definitions.&nbsp;In just a second, I will show&nbsp;you the 2022 Danish registry&nbsp;where the prevalence of&nbsp;clinical remission was in fact&nbsp;19%.&nbsp;I think it is one of the best&nbsp;studies that has been done so&nbsp;far.&nbsp;Now, one of the things I did&nbsp;was look at all of these&nbsp;studies and in fact look at&nbsp;post hoc analysis.&nbsp;These were all Phase 3 studies.&nbsp;Three different Biologics.&nbsp;They had to do this for at&nbsp;least 12 months.&nbsp;So if we look here for our&nbsp;first asthma control, you will&nbsp;see the one on the left and the&nbsp;one on the right used a higher&nbsp;standard for asthma control, so&nbsp;that will have a difference.&nbsp;Then if we look at lung&nbsp;function, we can see the one on&nbsp;the left showed greater than&nbsp;100 milliliters improvement.&nbsp;With the middle, you just had&nbsp;to show the FEV1 was greater&nbsp;than 80%.&nbsp;And on the right, two&nbsp;definitions could be given&nbsp;including greater than 20% from&nbsp;baseline.&nbsp;When we get to the no oral&nbsp;corticosteroid use, none of&nbsp;these were on maintenance.&nbsp;They did not use any steroids.&nbsp;No severe exacerbations.&nbsp;If you look at the clinical&nbsp;remission rate here, it falls&nbsp;under 14.5%&nbsp;, 20%, 12.7%.&nbsp;Now you will say the one on the&nbsp;right is not as good, but they&nbsp;added another measure.&nbsp;They added the health care&nbsp;professional and patient&nbsp;assessment of severity.&nbsp;So that is probably why their&nbsp;numbers are in fact lower.&nbsp;Again, depending on how you&nbsp;define remission, you will get&nbsp;different clinical remission&nbsp;rates, so do not be fooled.&nbsp;Now, this is the study&nbsp;published this year in chest&nbsp;that looked at clinical&nbsp;response and remission.&nbsp;, it was part of the Danish &#8212;&nbsp;it was part of the Danish&nbsp;severe asthma registry.&nbsp;They are placed on a biologic&nbsp;in Denmark and go on this&nbsp;registry.&nbsp;They defined clinical response&nbsp;after 12 months was either a&nbsp;50% reduction in exacerbation&nbsp;or greater than 50% reduction,&nbsp;maintenance, or corticosteroid&nbsp;does.&nbsp;We want to keep on their&nbsp;definition for clinical&nbsp;remission.&nbsp;It is not super rigorous.&nbsp;Sensation of exacerbations and&nbsp;maintenance of oral&nbsp;corticosteroids, normalization&nbsp;of lung function FEV<\/p>\n\n\n\n<p>[LAUGHTER]<\/p>\n\n\n\n<p>Greater than 80% &#8212; lung&nbsp;function, FEV1 greater than&nbsp;80%, and a CQ of &#8212; ACQ less&nbsp;than 1.5.&nbsp;We have 500 patients placed on&nbsp;Biologics in this registry.&nbsp;What you will notice in the red&nbsp;part of the pie chart over on&nbsp;the left, that is no response.&nbsp;The kind of dark blue is the&nbsp;clinical response.&nbsp;And then the gray is in fact&nbsp;remission.&nbsp;So you will notice all the&nbsp;Biologics.&nbsp;There was about 21% that had no&nbsp;response to the biologically&nbsp;replaced on.&nbsp;79% had a clinical response.&nbsp;If we look over at the right of&nbsp;the pie chart, now we are&nbsp;looking at what percent of&nbsp;patients that got a clinical&nbsp;response met their definition&nbsp;of remission.&nbsp;Of that, it was 24%.&nbsp;Out of the total patients that&nbsp;were placed on a Biologic, 19%&nbsp;went into remission.&nbsp;And then it lists some things&nbsp;here I will not go over in&nbsp;detail of things that say&nbsp;distinguished likelihood of&nbsp;clinical response versus&nbsp;clinical remission.&nbsp;In other words, if we look&nbsp;here, females were less likely&nbsp;to go into clinical remission.&nbsp;Patients with a higher BMI were&nbsp;less likely to go into&nbsp;remission.&nbsp;If we look at nasal polyps,&nbsp;they were more likely to go&nbsp;into remission.&nbsp;Now, what I showing you here is&nbsp;the criteria that they use in&nbsp;Denmark as far as determining&nbsp;when to put a patient on a&nbsp;biologic and then which&nbsp;biologic.&nbsp;It pretty much falls in line&nbsp;with what we doing the United&nbsp;States.&nbsp;Maybe a little stricter.&nbsp;<\/p>\n\n\n\n<p>These are patients on a high&nbsp;dose of steroid and at least&nbsp;another controller.&nbsp;They could have been on&nbsp;maintenance oral&nbsp;corticosteroids.&nbsp;They had at least two&nbsp;exacerbations in the last 12&nbsp;months or steroids 50% of the&nbsp;time.&nbsp;Used pretty much the same&nbsp;definitions that we use for&nbsp;these Biologics decide which&nbsp;one to put the patient on.&nbsp;Allergy symptoms after exposure&nbsp;to allergen&nbsp;, the drugs related to blood,&nbsp;and for the offer products,&nbsp;exhaled nitric oxide.&nbsp;Now we will look at the results&nbsp;of which biologic the patient&nbsp;was placed on.&nbsp;So if we look at the top of the&nbsp;pie chart, we are looking at&nbsp;ANTI-IGE.&nbsp;28% had no response.&nbsp;Out of the total group, 6% went&nbsp;into remission.&nbsp;If we look at the IL5 drugs,&nbsp;22% had no response.&nbsp;Of the total, 19% went into&nbsp;remission.&nbsp;If we look at the offer drugs,&nbsp;8% had no response.&nbsp;30% of the total went into&nbsp;remission.&nbsp;If you look at the right, we&nbsp;are looking at characteristics&nbsp;that may help tell us which&nbsp;patients.&nbsp;If you look at the top, you&nbsp;will notice not surprising that&nbsp;the higher they were, the more&nbsp;likely the offer drugs would&nbsp;show clinical remission.&nbsp;If we look at total IGE, kind&nbsp;of interesting.&nbsp;Anti-IGE, there was not any&nbsp;relationship, but there was&nbsp;with the anti-IL5 products.&nbsp;And then for inhaled nitric&nbsp;oxide, not surprising again the&nbsp;offer drugs more likely go in&nbsp;remission.&nbsp;If you look at anti-IGE, they&nbsp;are less likely to infect fact&nbsp;go into remission.&nbsp;I think this is some&nbsp;interesting data.&nbsp;Everyone using the same&nbsp;measure, it gives you an idea&nbsp;of what one may see using the&nbsp;modified criteria for clinical&nbsp;response.&nbsp;<\/p>\n\n\n\n<p>This is an interesting study&nbsp;out of Israel that was also&nbsp;published this year in&nbsp;respiratory medicine.&nbsp;It is looking at a comparison&nbsp;of clinical remission for&nbsp;severe asthma patients&nbsp;receiving biologic therapy.&nbsp;So these were adults.&nbsp;They had to have been on the&nbsp;Biologics for at least six&nbsp;months.&nbsp;And then they used lots of&nbsp;different definitions.&nbsp;The reason I am trimming this&nbsp;is to show you that depending&nbsp;on what definitions are used&nbsp;will determine what percent of&nbsp;patients are &#8220;in remission.&#8221;&nbsp;They look at things like no&nbsp;steroid use for six months or&nbsp;12 months.&nbsp;No exacerbations for six months&nbsp;or 12 months.&nbsp;They used four different&nbsp;criteria for lung function.&nbsp;So things like a FEV1 or&nbsp;improvement of 100 milliliters&nbsp;or 10%.&nbsp;For asthma symptom control,&nbsp;they used ACQ &#8212; ACT and they&nbsp;used the different ACQ scores,&nbsp;less than 1.5 and less than&nbsp;0.75.&nbsp;Now, these were the treatments&nbsp;that were used.&nbsp;What they saw here was 31 of&nbsp;these patients, 12 or 31%&nbsp;received at least one biologic&nbsp;before the current and three&nbsp;had two different Biologics&nbsp;previously.&nbsp;The most common reason again,&nbsp;and we see this in the clinic,&nbsp;is in response to treatment.&nbsp;That was 83.3%.&nbsp;So again, kind of like we saw&nbsp;from the Danish study.&nbsp;This is looking at these&nbsp;different criteria.&nbsp;What percent of the patients&nbsp;met that criteria for&nbsp;remission.&nbsp;If you look at no&nbsp;corticosteroid use, the top&nbsp;one, number one, if it was six&nbsp;months, 71 .5% made that as far&nbsp;as remission.&nbsp;If you go to 12 months, it&nbsp;drops to 74.4%.&nbsp;You see the same type of thing&nbsp;for exacerbations if you look&nbsp;at six months versus 12 months.&nbsp;Again, less at 12 months.&nbsp;If you look at lung function,&nbsp;you will see a big difference&nbsp;here.&nbsp;If you measure the FEV1 greater&nbsp;than or equal to 0.75, it was&nbsp;only 48.7%.&nbsp;If it was approved by greater&nbsp;than 100 milliliters, it was&nbsp;76.3%.&nbsp;And then if you look at symptom&nbsp;control, you can see here.&nbsp;Look at 4B and 4C.&nbsp;4B was the lower standard.&nbsp;But if you use a higher&nbsp;standard, it drops down to&nbsp;38.5%.&nbsp;So when you kind of put all of&nbsp;this together, if you look over&nbsp;at the right, the combined&nbsp;criteria with no systemic&nbsp;steroids or exacerbations for&nbsp;12 months, the total rate of&nbsp;remission depending on how you&nbsp;define it goes anywhere from as&nbsp;high as 41% to an fact as low&nbsp;as 20.5%.&nbsp;So again, depending on what is&nbsp;used in the definition of&nbsp;remission, it is going to make&nbsp;a major difference in patients&nbsp;that in fact have remission.&nbsp;That is what you look at that&nbsp;when you look at studies&nbsp;purporting this particular drug&nbsp;had a high level of remission.&nbsp;They may not have used a very&nbsp;strong criteria.&nbsp;OK.&nbsp;So the remainder of the time I&nbsp;want to spend on the college&nbsp;and Academy and ATS framework&nbsp;for on treatment clinical&nbsp;remission.&nbsp;So in this definition, in fact,&nbsp;it includes things you have&nbsp;already heard a lot.&nbsp;No exacerbations requiring oral&nbsp;steroids.&nbsp;Stabilized, optimized FEV1.&nbsp;And using symptom controlled&nbsp;validated measures.&nbsp;ACQ with the higher standard.&nbsp;But also, we felt information&nbsp;has to be a higher standard&nbsp;than control, so we added&nbsp;several other things we think&nbsp;should be added.&nbsp;<\/p>\n\n\n\n<p>We think patients should not&nbsp;have to have high dust inhaled&nbsp;steroid which can have side&nbsp;effects, slow to medium dose&nbsp;inhaled steroid &#8212; so low to&nbsp;medium dose inhaled steroid.&nbsp;They should not be missing days&nbsp;of school or work and they&nbsp;should rarely need to use upper&nbsp;reliever treatment.&nbsp;So why did we develop this&nbsp;consensus statement?&nbsp;And the reason was that we felt&nbsp;it had to be on the&nbsp;professional mama &#8212; the&nbsp;professional medical societies&nbsp;that do this.&nbsp;GINA hopefully will do&nbsp;something in the future.&nbsp;Maybe we can all come together,&nbsp;but we really felt that it&nbsp;needed to be the organizations.&nbsp;As I probably already told you,&nbsp;there is a left confusion out&nbsp;there &#8212; a lot of confusions&nbsp;out there with definitions.&nbsp;We really need over time to&nbsp;come to some kind of consensus.&nbsp;The real reason we put this&nbsp;together again as we felt this&nbsp;definition had to be higher&nbsp;than asthma control.&nbsp;Otherwise, all we are talking&nbsp;about his glorified control.&nbsp;So we felt this consensus&nbsp;statement was a framework.&nbsp;It is not what has to be, but&nbsp;it is a framework.&nbsp;It is a first step as far as a&nbsp;unified definition.&nbsp;Hopefully again the different&nbsp;groups can come together and&nbsp;again get a unified definition&nbsp;like we have for asthma&nbsp;control.&nbsp;So the above organizations and&nbsp;the American Academy of&nbsp;pediatrics had members on this&nbsp;consensus report.&nbsp;It was also endorsed by a&nbsp;European group, the European&nbsp;forum for research and&nbsp;education in allergy and airway&nbsp;diseases.&nbsp;So how did the work group come&nbsp;up with the six criteria?&nbsp;So we used the modified Delphi&nbsp;approach.&nbsp;We all worked together and went&nbsp;back and forth developing&nbsp;definitions and then getting at&nbsp;least a consensus of the&nbsp;members to agree to it.&nbsp;So there were two things that&nbsp;was unanimous.&nbsp;That was no exacerbations&nbsp;requiring physician visit,&nbsp;emergency care,&nbsp;hospitalization, steroid use&nbsp;for asthma.&nbsp;The other thing that is not in&nbsp;the other remission definitions&nbsp;you have seen again is this no&nbsp;missed school or work over a 12&nbsp;month period due to asthma&nbsp;related symptoms. We thought&nbsp;that was important because we&nbsp;want a higher standard than&nbsp;just control.&nbsp;Then we said stable and&nbsp;optimized lung functions over&nbsp;the 12 month period with a&nbsp;minimum of two measurements&nbsp;during the year.&nbsp;All of these other definitions&nbsp;can use only one.&nbsp;But does not really tell you&nbsp;what is going on over a 12&nbsp;month period?&nbsp;So we felt it had to be a&nbsp;minimum of two.&nbsp;One of the things we did not&nbsp;say is FEV1 greater than 80% or&nbsp;a particular improvement in&nbsp;lung function.&nbsp;The reason we did not do that&nbsp;is because we know that some of&nbsp;these patients are going to&nbsp;already have remodeling.&nbsp;They are going to have a degree&nbsp;of fixed obstructive lung&nbsp;disease, especially if you have&nbsp;severe asthma.&nbsp;We did not want any absolute&nbsp;numbers.&nbsp;So to give you an example here,&nbsp;if you have a patient with FEV1&nbsp;65% over 12 months and they&nbsp;improved to 70% but they still&nbsp;meet all the other criteria we&nbsp;have for remission, we would&nbsp;say that patient is in&nbsp;remission because we have&nbsp;optimized their lung function.&nbsp;They just have an element of&nbsp;fixed lung disease.&nbsp;And number four here we felt&nbsp;also very strongly about.&nbsp;<\/p>\n\n\n\n<p>That is, what medications can&nbsp;the patient still be on?&nbsp;To say in fact they are in&nbsp;remission.&nbsp;Our thought here was, again,&nbsp;that if the patient is on&nbsp;Biologics and still needs high&nbsp;dose inhaled corticosteroid,&nbsp;window that can lead to&nbsp;systemic side effects.&nbsp;So again, if we wanted a higher&nbsp;standard than just control, we&nbsp;felt that the inhaled&nbsp;corticosteroids needed to be&nbsp;tapered down to a low to medium&nbsp;dose.&nbsp;We know there are no long-term&nbsp;studies validating this, but&nbsp;they need to be done.&nbsp;But to us, we felt that again&nbsp;if we are going to call it&nbsp;remission, it needs to be a&nbsp;higher standard.And then the&nbsp;symptoms as far as being&nbsp;measured with validated&nbsp;instruments, ACT, ARQ, ACQ, we&nbsp;thought that there has to be a&nbsp;minimum of two measurements&nbsp;over a year period of time.&nbsp;Remember, these questionnaires&nbsp;ask the patient how they have&nbsp;been over the last four weeks&nbsp;so even if you only do two,&nbsp;that is eight weeks or to month&nbsp;out of the 12.&nbsp;This is a higher standard than&nbsp;other people have set.&nbsp;And then very importantly we&nbsp;felt that you needed to measure&nbsp;reliever use.&nbsp;Reliever use is measured in&nbsp;control.&nbsp;We mentioned that previously.&nbsp;We thought it had to be a&nbsp;higher standard than what&nbsp;asthma control is.&nbsp;We came up and this took a lot&nbsp;of discussion back and forth&nbsp;and a lot of debate between the&nbsp;different members.&nbsp;We came up with a consensus&nbsp;that it should be no more than&nbsp;one time that they need to use&nbsp;reliever therapy over a&nbsp;one-month period.&nbsp;We know this is just a starting&nbsp;point.&nbsp;And again, I think all of us&nbsp;around the world interested in&nbsp;asthma and remission would&nbsp;eventually need to come&nbsp;together and make some decision&nbsp;here, but we felt that it had&nbsp;to be a higher standard than&nbsp;what was seen with asthma&nbsp;control.&nbsp;So we felt or needed some way&nbsp;to evaluate symptoms. The good&nbsp;news is exacerbations in oral&nbsp;steroid bursts are not regular&nbsp;events in the vast majority of&nbsp;our asthma patients.&nbsp;So rescue use, missing days of&nbsp;school and work really give us&nbsp;more information on how the&nbsp;patient is doing daily.&nbsp;And again, this is a step up&nbsp;from asthma control.&nbsp;So what we are dealing with&nbsp;here is in most cases we could&nbsp;get control of the patients&nbsp;now.&nbsp;There may be a small percentage&nbsp;of patients that can in fact&nbsp;reach clinical remission&nbsp;depending on what definition is&nbsp;used.&nbsp;Hopefully in the future we can&nbsp;get to complete remission where&nbsp;we see histologic changes back&nbsp;to normal.&nbsp;And then obviously what we want&nbsp;for all of our patients and&nbsp;hopefully one day we will have&nbsp;that is a true cure for this&nbsp;condition.&nbsp;So what I want to leave you&nbsp;with is in fact remission is an&nbsp;evolving process here.&nbsp;So be careful when you hear&nbsp;somebody say that this&nbsp;patient&#8217;s asthma is in&nbsp;remission, because we don&#8217;t&nbsp;really have a definitive&nbsp;definition yet.&nbsp;We need to take all of this.&nbsp;It needs to be validated,&nbsp;refined, and to come to a&nbsp;consensus worldwide exactly&nbsp;what we mean by remission and&nbsp;asthma.&nbsp;The good news is GINA this year&nbsp;did a talk about remission in&nbsp;their paper.&nbsp;And hopefully we will see may&nbsp;be the future they will develop&nbsp;a criteria.&nbsp;They talked about validating&nbsp;proposed criteria for remission&nbsp;on treatment will depend on&nbsp;intended purposes.&nbsp;They are kind of looking at it&nbsp;right now, looking at different&nbsp;things.&nbsp;Whether you have remission as&nbsp;an assessment tool for clinical&nbsp;practice, and I don&#8217;t think we&nbsp;are anywhere near there and&nbsp;will never tell a patient at&nbsp;this point they are in&nbsp;remission.&nbsp;Prognosis for continued&nbsp;long-term stability and for&nbsp;identifying new targets of&nbsp;therapy.&nbsp;So in conclusion, remission in&nbsp;asthma is a concept in motion.&nbsp;<\/p>\n\n\n\n<p>There is an ongoing debate&nbsp;about the exact criteria for&nbsp;clinical remission in asthma.&nbsp;Everyone agrees on those&nbsp;systemic corticosteroids and no&nbsp;asthma exacerbations.&nbsp;Really, all the other aspects&nbsp;are still under discussion.&nbsp;Most workgroups have stated all&nbsp;criteria needs to be done for&nbsp;at least 12 months.&nbsp;All remission guidelines agree&nbsp;that excellent asthma control&nbsp;and improved or stabilized lung&nbsp;functions are essential, but&nbsp;the best way is not clear yet.&nbsp;Whereas biologic medications&nbsp;seem to increase remission&nbsp;rates based on some&nbsp;definitions, these rates are&nbsp;still low, 20% to 30%.&nbsp;Remember, the Danish study I&nbsp;said was 19%.&nbsp;No studies yet use the stricter&nbsp;criteria we developed in the&nbsp;U.S.&nbsp;consensus paper.&nbsp;At least in my opinion that&nbsp;would lead to a lower remission&nbsp;rate percentage related to the&nbsp;Biologics.&nbsp;So there is no doubt biologic&nbsp;medications have revolutionized&nbsp;asthma treatment, especially in&nbsp;our severe asthma patients.&nbsp;But I think it is important to&nbsp;realize they alone are not a&nbsp;guaranteed path to remission,&nbsp;let alone a complete remission.&nbsp;We need even better treatments&nbsp;for our patients with asthma&nbsp;and much more research is&nbsp;needed in remission for all of&nbsp;our patients suffering with&nbsp;this condition.&nbsp;So I am going to stop there.&nbsp;I apologize for the&nbsp;interruption we had.&nbsp;I am happy to answer any&nbsp;questions.&nbsp;Thank you.<\/p>\n\n\n\n<p><strong>Lynda:<\/strong>&nbsp;Thank you, Dr. Blaiss. That was&nbsp;really a wonderful presentation&nbsp;about some exciting&nbsp;opportunities to have asthma&nbsp;remission when it was not&nbsp;possible in the past. We do&nbsp;have some questions.&nbsp;I have a feeling once we get&nbsp;started some more on come in.&nbsp;The first one we had was &#8220;thank&nbsp;you for your insightful&nbsp;presentation.&nbsp;I know exacerbations informs a&nbsp;lot of the definitions.&nbsp;Are exacerbations consistently&nbsp;defined or assessed by&nbsp;different clinical societies,&nbsp;clinicians, and researchers?&#8221;&nbsp;Dr. Blaiss:&nbsp;That is a wonderful question.&nbsp;Generally, we are talking about&nbsp;most of these definitions are&nbsp;using severe exacerbation where&nbsp;in cases where patients are&nbsp;ending up requiring a burst of&nbsp;oral steroids or they end up in&nbsp;the emergency department and&nbsp;and up requiring&nbsp;corticosteroids or they are&nbsp;hospitalized.&nbsp;The U.S.&nbsp;consensus because we added&nbsp;rescue treatment would be even&nbsp;what you would consider a mild&nbsp;exacerbation.&nbsp;So again, all of this needs to&nbsp;eventually be worked out.&nbsp;If you look at the Biologics&nbsp;and studies, there have been&nbsp;the post hoc analysis.&nbsp;Those are all severe&nbsp;exacerbation.&nbsp;But we felt that any&nbsp;exacerbation requiring&nbsp;albuterol was significant.&nbsp;If it was more than once a&nbsp;month, it would lead to the&nbsp;patient not in fact having&nbsp;remission.<\/p>\n\n\n\n<p><strong>Lynda:<\/strong>&nbsp;Great.&nbsp;Thank you.&nbsp;Next question.&nbsp;This is possible for a patient&nbsp;with asthma who smokes or vapes&nbsp;to obtain clinical remission?&nbsp;Is there a definition statement&nbsp;on this?&nbsp;Would it be helpful or&nbsp;motivating for those with&nbsp;asthma to quit or increase the&nbsp;potential for experiencing&nbsp;remission?<\/p>\n\n\n\n<p><strong>Dr. Blaiss:<\/strong>&nbsp;So, one, there is no definition&nbsp;or anything like that in the&nbsp;consensus statement or from any&nbsp;of the other countries that I&nbsp;have seen.&nbsp;Obviously, patients that smoke&nbsp;and vape we no intent to have&nbsp;more severe disease and do not&nbsp;respond as well to the&nbsp;particular treatment.&nbsp;We could tell those particular&nbsp;patients that are much less&nbsp;likely to go on remission.&nbsp;But I also want to make some&nbsp;comment here.&nbsp;I would never use at this point&nbsp;in time remission in an asthma&nbsp;patient in the clinical&nbsp;situation.&nbsp;One is we do not have a true&nbsp;definition.&nbsp;Two, I get concerned that when&nbsp;patients hear they are doing so&nbsp;well and now you defined them&nbsp;as in remission that they are&nbsp;going to cut back treatments,&nbsp;whether it is there Biologics&nbsp;or other treatments, because if&nbsp;I am in remission, why in the&nbsp;world do I need to take&nbsp;medication?&nbsp;I think one has to be very&nbsp;careful in a clinical situation&nbsp;to tell a patient that in fact&nbsp;they meet someone&#8217;s criteria&nbsp;for remission.<\/p>\n\n\n\n<p><strong>Lynda:<\/strong>&nbsp;Great.&nbsp;Thank you.&nbsp;Next question.&nbsp;All the studies seem to focus&nbsp;on Th-2 asthma for those with&nbsp;Biologics.&nbsp;Can you comment on information&nbsp;as possible for non-TH-2&nbsp;patients?<\/p>\n\n\n\n<p><strong>Dr. Blaiss:<\/strong>&nbsp;The answer is yes.&nbsp;If you look at the consensus&nbsp;statement, you can have it on&nbsp;inhaled corticosteroids.&nbsp;If you are on a low dose&nbsp;inhaled corticosteroid and you&nbsp;meet all of those other&nbsp;criteria and you are not using&nbsp;albuterol more than once a&nbsp;month and you have not missed&nbsp;any days of school or work, by&nbsp;definition you are in&nbsp;remission.&nbsp;The definition is not just the&nbsp;way we did this for severe&nbsp;asthma, but it has for any&nbsp;severity of asthma, whether you&nbsp;want to talk about mild,&nbsp;moderate, or severe.&nbsp;As long as you meet those&nbsp;criteria.&nbsp;So we felt that is extremely&nbsp;important, but it should not be&nbsp;restricted to only patients on&nbsp;Biologics.&nbsp;It should be any patient with&nbsp;asthma that meets that specific&nbsp;criteria.<\/p>\n\n\n\n<p><strong>Lynda:<\/strong>&nbsp;Thank you for that.&nbsp;So I was just talking with a&nbsp;colleague, and she was just&nbsp;talking about how even if&nbsp;somebody is on Biologics, you&nbsp;still need good environmental&nbsp;controls, indoor controls, or&nbsp;you will still have the&nbsp;symptoms even if you are on the&nbsp;best medication for you.&nbsp;I think that is what this next&nbsp;question is.&nbsp;Can you give us your thoughts&nbsp;on environmental controls and&nbsp;clinical remission like airflow&nbsp;attrition using cleaners or&nbsp;personal products, air quality&nbsp;in general?&nbsp;Can you comment on that?<\/p>\n\n\n\n<p><strong>Dr. Blaiss:<\/strong>&nbsp;I think air quality and allergy&nbsp;importance are important.&nbsp;&#8212; allergy avoidance are&nbsp;important.&nbsp;Anything to avoid the patient&nbsp;having an exacerbation.&nbsp;I think it is also important&nbsp;that we talk about not just&nbsp;medication, but in fact are we&nbsp;controlling underlying&nbsp;comorbidities that could be&nbsp;making the patients&#8217;s asthma&nbsp;worse.&nbsp;Are they having problems with&nbsp;GERT or sleep apnea?&nbsp;Do they have underlying&nbsp;allergic rhinitis that could be&nbsp;worsening their condition or&nbsp;chronic rhino sinusitis with&nbsp;nasal polyps?&nbsp;I think environmental treatment&nbsp;is extremely important.&nbsp;Allergy avoidance, clean air,&nbsp;all of that is very important.&nbsp;I think looking for&nbsp;comorbidities that can in fact&nbsp;make asthma worse, that can&nbsp;help increase the number of&nbsp;patients that in fact would get&nbsp;under better control and&nbsp;possibly remission.&nbsp;So I think it is not just&nbsp;treating patients with&nbsp;medicine.&nbsp;I think asthma is so much more&nbsp;than that is the person asked&nbsp;this question.&nbsp;The environment is extremely&nbsp;important.&nbsp;Controlling comorbidities.&nbsp;Adherence to treatment.&nbsp;The vast majority of patients&nbsp;that are referred to me for&nbsp;asthma in my clinic in fact&nbsp;have poor adherence or an fact&nbsp;are not using their inhalers&nbsp;correctly.&nbsp;So they are going to end up&nbsp;having more exacerbations and&nbsp;end up on stronger medications&nbsp;including Biologics where they&nbsp;may not even need them.&nbsp;I think we have to do, and the&nbsp;GINA guidelines have a nice&nbsp;thing on this, every time we&nbsp;see a patient, to assess&nbsp;everything going on and make&nbsp;sure in fact we are doing all&nbsp;of these other things that can&nbsp;improve their asthma.&nbsp;No smoking, no vaping as we&nbsp;heard from the other question.&nbsp;The environmental, the&nbsp;comorbidities.&nbsp;We know obesity can lead to&nbsp;worsening asthma.&nbsp;Now that there are treatment&nbsp;for obesity, we have to look at&nbsp;that in those patients that are&nbsp;having significant problems&nbsp;with their asthma.&nbsp;All of that along with&nbsp;treatment needs to be done to&nbsp;get optimal improvement in our&nbsp;patients.<\/p>\n\n\n\n<p><strong>Lynda:<\/strong>&nbsp;Great.&nbsp;I got time for one more&nbsp;question or so.&nbsp;Is there any biomarker yet&nbsp;available to predict the 19% to&nbsp;30% remission rates after a&nbsp;biologic?<\/p>\n\n\n\n<p><strong>Dr. Blaiss:<\/strong>&nbsp;So we know from the Danish&nbsp;study and there is also a&nbsp;German study that generally the&nbsp;higher the ENO&#8217;s are, the&nbsp;higher the inhaled nitric&nbsp;oxide, those patients tend to&nbsp;have a much higher rate of&nbsp;going into remission with one&nbsp;of the type to Biologics&nbsp;because they are very type two&nbsp;types of patients but it is by&nbsp;no means 100%.&nbsp;And what you did see, and I&nbsp;wanted to make sure it is&nbsp;clear, there are a lot of&nbsp;patients that do not respond to&nbsp;the first or second biologic.&nbsp;The problem is the biomarkers&nbsp;we have right now, nitric&nbsp;oxide and others are not as&nbsp;accurate as we need.&nbsp;There is work going on trying&nbsp;to find more accurate&nbsp;biomarkers.&nbsp;At this point in time,&nbsp;generally the higher the ENO&nbsp;, more likely to see remission&nbsp;with one of the type two&nbsp;Biologics.<\/p>\n\n\n\n<p><strong>Lynda:<\/strong>&nbsp;Great.&nbsp;Thank you.&nbsp;I will ask one more question if&nbsp;you don&#8217;t mind.&nbsp;With regard to your slideshow&nbsp;and the summary of remission&nbsp;across different societies, I&nbsp;have to look for the question&nbsp;so bear with me for a second.&nbsp;The question is, given the&nbsp;variances &#8212; oops, it just&nbsp;moved on me.&nbsp;Bear with me.&nbsp;Given the variances across&nbsp;definitions and measurement&nbsp;tools, I am looking for a&nbsp;high-level summary of key&nbsp;improvement criteria.&nbsp;Are there any?<\/p>\n\n\n\n<p><strong>Dr. Blaiss:<\/strong>&nbsp;So as far as for all of those&nbsp;countries, they have all&nbsp;published exactly what all&nbsp;their criteria is.&nbsp;And so what I did on that chart&nbsp;was just a very quick summary.&nbsp;Some are not as detailed as&nbsp;others where they kind of do&nbsp;not give an exact objective&nbsp;definition.&nbsp;We see that with lung function&nbsp;at times.&nbsp;We also see that in certain&nbsp;cases with symptom control.&nbsp;So I think if you are reading a&nbsp;paper and they talk about&nbsp;remission, what you&#8217;ve got to&nbsp;do is go to the methods.&nbsp;You&#8217;ve got to see what criteria&nbsp;they are using for remission&nbsp;and what standards they are&nbsp;using for validated instruments&nbsp;and lung function.&nbsp;Because you cannot compare one&nbsp;paper&#8217;s definition of remission&nbsp;with another&#8217;s and say that&nbsp;this biologic gets a higher&nbsp;remission than Johnny&#8217;s&nbsp;biologic.&nbsp;I think that is leading to a&nbsp;lot of confusion out there.&nbsp;Until we really have a true&nbsp;standard that I think one has&nbsp;to look at all of this with a&nbsp;jaded eye until we have.<\/p>\n\n\n\n<p><strong>Lynda:<\/strong>&nbsp;Thank you so much.&nbsp;So I am just going to summarize&nbsp;by the last comment on chat.&nbsp;This was a fantastic and&nbsp;important presentation and&nbsp;discussion.&nbsp;There were similar comments&nbsp;that came in along the way.&nbsp;So just want to give you a big&nbsp;thanks for taking the time to&nbsp;share this important&nbsp;information with us.&nbsp;And with that, I will say we&nbsp;will move on to tell you about&nbsp;the next webinar.&nbsp;It will be vaccines, new&nbsp;developments, and how to&nbsp;address vaccine have visited &#8212;&nbsp;vaccine hesitancy.&nbsp;Join us on December 5 for that.&nbsp;For those of you who would like&nbsp;to learn more about COPD and&nbsp;the Hispanic, Latino community,&nbsp;we have a virtual conference on&nbsp;December 4.&nbsp;We will send you information&nbsp;about that as well.&nbsp;On behalf of allergy and asthma&nbsp;network, I want to say thank&nbsp;you for joining us today.&nbsp;We will see you next time.&nbsp;Thanks, Dr. Blaiss. Really&nbsp;appreciate it.<\/p>\n\n\n\n<p><strong>Dr. Blaiss:<\/strong>&nbsp;Thank you.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Join us for a Free Webinar on <b>November 12, 2024<\/b> at <b>12:00 PM ET <\/b>learn more about the consensus statement and the outcomes of the working group.<\/p>\n","protected":false},"author":4,"featured_media":19379193,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_kad_blocks_custom_css":"","_kad_blocks_head_custom_js":"","_kad_blocks_body_custom_js":"","_kad_blocks_footer_custom_js":"","_kad_post_transparent":"","_kad_post_title":"","_kad_post_layout":"","_kad_post_sidebar_id":"","_kad_post_content_style":"","_kad_post_vertical_padding":"","_kad_post_feature":"","_kad_post_feature_position":"","_kad_post_header":false,"_kad_post_footer":false,"footnotes":""},"categories":[23,26],"tags":[],"class_list":["post-19375912","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-webinars-updates","category-virtual-events"],"taxonomy_info":{"category":[{"value":23,"label":"Webinars"},{"value":26,"label":"Virtual Events"}]},"featured_image_src_large":["https:\/\/allergyasthmanetwork.org\/wp-content\/uploads\/2024\/10\/Man-patient-Female-Doctor-1080x567.jpg",1080,567,true],"author_info":{"display_name":"Allergy &amp; Asthma Network","author_link":"https:\/\/allergyasthmanetwork.org\/author\/paultury\/"},"comment_info":0,"category_info":[{"term_id":23,"name":"Webinars","slug":"webinars-updates","term_group":0,"term_taxonomy_id":23,"taxonomy":"category","description":"A key part of Allergy &amp; Asthma Network\u2019s mission is to educate patients and healthcare professionals about allergies, asthma and related conditions. 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