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A Better Way to Breathe: Combining Allergy and Pulmonary Care Into One Clinic

Federal Practitioner. 2023 January;40(1)a:16-21 | doi:10.12788/fp.0352
January 16, 2023|Federal Practitioner
Kelly Colas, DO, PhD;Kavita Vyas, MD;Dipa K. Sheth, MD
Author and Disclosure Information

Kelly Colas, DO, PhDa; Kavita Vyas, MDb,c; Dipa K. Sheth, MDa,c,d
Correspondence: Kelly Colas (kcolas@uw.edu)

aDepartment of Allergy and Immunology, University of Washington, Seattle
bDepartment of Pulmonary and Critical Care, Washington DC Veterans Affairs Medical Center
cGeorge Washington University, Washington, DC
dUniformed Services University of the Health Sciences, Bethesda, Maryland

Author disclosures

The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Disclaimer

The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Ethics and consent

The intention of this project was to examine the implementation of a program for the improvement of patient care. As this project is qualitative improvement, it did not qualify for institutional review board approval.

Background: The use of biologic agents for severe asthma has transformed management, decreasing asthma exacerbations, improving lung function, reducing corticosteroid use, and decreasing hospitalizations. However, numerous financial and logistic barriers have complicated the implementation of biologic agents, including long wait times to see specialists and insurance coverage.

Observations: A retrospective chart review was performed for 15 patients enrolled in this severe allergy clinic at the Washington DC Veterans Affairs Medical Center over 30 months. Outcomes examined included emergency department visits, hospitalizations, intensive care unit (ICU) stays, forced expiratory volume (FEV1), and steroid use. The average use of steroids decreased from 4.2 to 0.6 tapers per year following the initiation of biologics. There was an average 10% improvement in FEV1 after starting a biologic. Thirteen percent of patients (n = 2) had an emergency department visit for an asthma exacerbation since starting a biologic agent, 0.6% of patients (n = 1) had a hospital admission for an asthma exacerbation, and no patients had an ICU stay.

Conclusions: Biologic agents have significantly improved outcomes for patients with severe asthma. The model of a combined allergy/pulmonology clinic can be particularly efficacious in the treatment of severe asthma, as it reduces the need for multiple appointments with different specialties, reduces wait time before starting a biologic agent, and offers the perspective of 2 specialists.

If patients continued to experience asthma exacerbations after the initiation of a biologic, a change in agent was considered after 4 to 6 months. Additionally, a complete blood count, respiratory allergy panel, and pulmonary function tests (PFTs) were completed.

If a patient experienced an allergic reaction, the biologic agent was stopped. All patients had access to secure messaging to both the allergist and pulmonologist at this clinic. Figure 1 illustrates the general flow of our severe asthma clinic.

Clinic Patients

Preliminary data were obtained from a retrospective chart review of 15 patients enrolled in the severe asthma clinic over 30 months. The inclusion criteria for chart review consisted of patients aged > 18 years receiving a biologic agent for > 3 months for the treatment of severe asthma. The outcomes examined included steroid use, emergency department (ED) visits, hospitalizations, FEV1, and ICU stays.

Seven patients used benralizumab, 6 used dupilumab, and 2 used omalizumab (Table).

Of the patients examined, 8 had been on a biologic agent for 1 to 2 years while a smaller number of patients had been taking a biologic agent for less than a year (n = 2) or > 2 years (n = 5). Seven patients were referred to the specialty asthma clinic by a VA pulmonologist, 4 were referred by a hospitalist, 3 by an otolaryngologist, and 3 by their primary care physician.

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