Announcer:
0:00
Welcome to the MedEvidence podcast. This episode is a rebroadcast from a live MedEvidence presentation.
Dr. Michael Koren:
0:07
So, Steve, I'm really excited about our time together here. So you're a newbie.
Dr. Steve Dorman:
0:13
Yeah, yeah. Thank you so much for having me. It's an honor and a pleasure to be here today to talk with you guys and have this conversation.
Dr. Michael Koren:
0:24
So Steve is an allergy immunologist and first of all, I'm going to give you a little bit of a hard time. As a new guest, this is your initiation to the fraternity, so I know that Steve made a lot of A's in college and medical school but you didn't have to put them all in your title there.
Dr. Michael Koren:
0:47
What the heck does that stand for with all those A's?
Dr. Steve Dorman:
0:49
Yeah, so the first one, the F, followed by four A's and I is a fellow of the American Academy of Allergy, Asthma and Immunology. And then the following one stands for a fellow of the American College of Allergy, Asthma and Immunology, and so these are two kind of research and educational groups that you have to be a practicing allergy and immunology physician for at least five years, be in good standing, do continuing medical education credits. So it's kind of a higher standard than just being board certified.
Dr. Michael Koren:
1:18
Yeah, you're making me feel inadequate. I only have two A's in my initials and you have all these A's, so I guess it speaks for itself. So, anyhow, we're going to talk about asthma and we always like to remind the audience that you may think it's a free lunch but it really isn't and in fact you've got to kind of work for your lunch here and part of that is getting information back from the audience. So we like to do these audience participation questions want to get a sense for what the audience knows and also have some entertaining discussion around these questions.
Dr. Michael Koren:
1:55
So let's start with this one. Just a little bit of a geography lesson and a lesson of awareness is which is the most challenging city in the United States to live with asthma? Interesting, challenging city? Obviously, asthma patients have a lot of challenges that you can educate us on. Is it Allentown, Pennsylvania? By the way, if you come from any of these places, it's okay to scream and say hey, Allentown. So feel free to speak up. This is definitely audience participation. Is it B? Rochester, New York? C, Detroit, Michigan? All right, there we go. Go Detroit ! D: Springfield, Massachusetts, or E Philadelphia, Pennsylvania, or E Philadelphia, Pennsylvania. Yeah, so it's an interesting question. So this is probably not the right slide, deck Sharon, but Allentown and Philadelphia are neck and neck, so you can see here the most challenging cities. These are the asthma capitals of the world for 2024. And maybe you can talk about why some of these places may be quote considered the most challenging cities versus the least challenging cities.
Dr. Steve Dorman:
3:18
Yeah, if you look at the most challenging cities here compared to the least challenging, we notice a lot of these more challenging places are closer to major bodies of water. You guys see that. So asthma top triggers would be a respiratory infection, followed by allergy, right! And so allergy is mainly driven by pollens of trees, grasses, weeds, mold, and so all of those things need water, need higher amounts of relative humidity. Additionally, dust mite is a top allergen in the US and they require a higher amount of relative humidity to exist. And so you kind of notice the red versus the green, the green being more further removed from larger bodies of water.
Dr. Michael Koren:
4:14
And yeah, it's really interesting. You can see the map is all. The red places are closer to water and that's a great point. I didn't know that, so that's fascinating. And the more green areas are more internal in the mountains. I guess it's less challenging in the mountains compared to at sea level. How does Jacksonville stack up?
Dr. Steve Dorman:
4:32
Yeah, I think Jacksonville is a pretty tough spot. You see Lakeland on there as number seven. I'm looking at this. These major cities will kind of fluctuate head-to-head coastal cities. But I know Jacksonville, North Florida, has been on this list before historically and may be on this list in the future.
Dr. Michael Koren:
4:51
So if you had to guess, we'd be closer to Allentown versus Des Moines. Okay, yeah, so just for everybody's knowledge. So we may not have broken into the top ten this year, but we still have a chance for next year.
Dr. Steve Dorman:
5:05
True, true.
Dr. Steve Dorman:
5:05
Yeah, yeah.
Dr. Michael Koren:
5:07
All right, so let's start getting into some of the facts about asthma.
Dr. Steve Dorman:
5:13
Yeah, so asthma, there's a lot of misconceptions about asthma. Most people think about asthma as this person in their mind that had this disease as a young child, or as an adult, somebody who's constantly, always using inhalers. Asthma is really a gradient of disease, you know. I think about comparing asthma to the term automobile. So inside automobile there are cars, trucks, vans, suvs, blue ones, green ones, purple ones. Inside asthma there are people who have very persistent, very aggressive disease. That's happening all the time and constantly throughout the day.
Dr. Steve Dorman:
5:54
Then there's people who may have symptoms, really just every few years, a little bit of coughing and wheezing, if they have an episode of asthmatic bronchitis. And so if you look at asthma, yes, it's a common, chronic, heterogeneous disease that causes the airways to become inflamed. That inflammation results in constriction and then the symptoms of coughing, wheezing and shortness of breath. So there really are no cures for asthma. It's just a matter of can we kind of help control the symptoms, help control the natural history of the disease? And really the best way to manage this is through avoidance of triggers. Can we avoid respiratory viruses or illnesses? Can we avoid allergens and take preventative medications, if we can?
Dr. Michael Koren:
6:42
Now is asthma the same as COPD, which is a common term. Help people understand that a little bit more
Dr. Steve Dorman:
6:48
Great question.
Dr. Steve Dorman:
6:49
Yeah, great question. So asthma is separate from COPD. Asthma is an intrinsic inflammatory process, whereas COPD oftentimes we have to have exposure with either cigarette smoke or smoke of some sort whether it's wood-burning smoke, et cetera over an amount of time Most experts would say about a 40-pack year history to have COPD would be required.
Dr. Michael Koren:
7:19
So reflecting some chronic damage to the lungs.
Dr. Michael Koren:
7:22
that would be the big difference, I guess
Dr. Steve Dorman:
7:23
yeah.
Dr. Michael Koren:
7:24
Yeah, okay. Well, tell us, how do you diagnose asthma?
Dr. Steve Dorman:
7:28
Yeah, so there's a lot of different tools that we use for the diagnostics of asthma. You know, first off we want to talk to the patient. Some of the hallmark features that people will describe as coughing, wheezing, shortness of breath. One of our main tools as physicians and as healthcare practitioners is to use our stethoscope. You know we'll auscultate the chest. Do we hear expiratory wheezing? And sometimes it's very bad inspiratory wheezing as well, through physical exam.
Dr. Michael Koren:
8:01
Yeah, so wheezing is a key term.
Dr. Steve Dorman:
8:03
Yeah, wheezing is definitely a key term.
Dr. Michael Koren:
8:06
Is all wheezing asthma or is some wheezing?
Dr. Steve Dorman:
8:10
Yeah, great question, great question. There are many disease states that can wheeze, you know whether it's upper airway or lower airway obstructive processes. Aside from asthma, copd can wheeze as well. That we kind of touched on. So wheezing is part of the game but not the whole thing per se. We utilize lung function tests many times to diagnose asthma via spirometry. That's a test where we have people breathe through a machine that measures how much you can breathe out in a flow state at one second, all the way through six seconds, breathing out upon expiration, then breathing in upon inspiration. It helps us to see that those numbers based on age matched controls et cetera.
Dr. Michael Koren:
8:58
So yeah Now, um, when we were in medical school, the TV show Saint Elsewhere was very popular. It's probably way before your time. Who heard of Saint Elsewhere in the audience? Okay, you see more people, my age out there Anyhow. So one of the things we used to do in my medical school was to pick on the show to find mistakes that they made. Yeah, and so this may be an example of that. So there's an x-ray there, and do you need an x-ray to diagnose asthma?
Dr. Steve Dorman:
9:28
You actually don't.
Dr. Steve Dorman:
9:29
Yeah, yeah, yeah, that's a common misconception. There are features on x-ray that can be seen if somebody's having an asthma exacerbation such as hyperinflated lungs or bronchial tissue inflammation can sometimes be seen on x-rays, but more often than not, asthma remains unseen on x-ray and on CAT scan many times, especially if somebody is currently asymptomatic. But yeah, very, very common misconception, right?
Dr. Michael Koren:
10:00
So you can have a completely normal chest x-ray and still have asthma.
Dr. Steve Dorman:
10:04
True statement, yeah, yeah, true statement.
Dr. Michael Koren:
10:05
Yeah, yeah, true statement, yeah. The other thing we used to do back in the St. Elsewhere days is to make sure they put the x-rays up correctly. So this is a little ambiguous, because usually you want the heart shadow on the left side. Yeah, now he's kind of looking he or she. I don't know if it's a he or she, but he or she is kind of looking at the x-ray. So you don't know if it's appropriate for that person's perspective or it's appropriate for the audience. But my question, big question, is why is this person wearing just one glove?
Dr. Steve Dorman:
10:39
That's a great question. Great question, not certain about that one.
Dr. Michael Koren:
10:44
Yeah, I can't think of well, maybe we can't think of procedures where you'd only be wearing one glove.
Dr. Steve Dorman:
10:50
But hopefully not in the operating room.
Dr. Steve Dorman:
10:52
Yeah, certainly Certainly
Dr. Michael Koren:
10:54
Okay. So back to the audience work. We're going to try to identify the groups that are at the highest risk for having asthma. So curious to see what people think which ethnic group in the US has the highest rate of asthma: White caucasian puerto Rican, southeast Asian, native American or black Americans? Okay, we'll do one by one who thinks it's white Caucasian Caucasian? Who thinks it's Puerto Rican? Who thinks it's Southeast Asian? Who thinks it's Native Americans? Who black Americans? Okay? Who voted twice? Okay, now, I saw one hand in the back of the room that got it correct, but I happen to know she's also the one that made up the slide, so I think that's probably cheating.
Dr. Michael Koren:
11:50
So Puerto Ricans have the highest rate. Any good reason for that?
Dr. Steve Dorman:
12:00
Yeah, it's somewhat interesting. There's a lot of theories on why the short and sweet answer and why. I'd maybe point back to the first part of our presentation. If you look at Puerto Rico, what is it? Surrounded by Water. Yeah, yeah, yeah. And if you look at the cities that have a higher prevalence and incidence of asthma and severe asthma, those places were also, you know, kind of near water, right?
Dr. Michael Koren:
12:23
And so that would make sense. And then socioeconomics is also what. Are there some details about that that we should know?
Dr. Steve Dorman:
12:33
Yeah, Certain groups have higher risk factors for certain allergens that will provoke asthma. You know specifically that comes to mind Dust, mite, mold and cockroach allergy are higher among individuals who live in inner cities and a little bit lower socioeconomic status, I see.
Dr. Michael Koren:
12:54
So I was at risk for asthma when I was living in my 400-square-foot apartment in Manhattan that had more crawling creatures than you can imagine.
Dr. Michael Koren:
13:06
Those were all risk factors for asthma.
Dr. Michael Koren:
13:08
That's amazing. I got through that without it. How about kids versus adults and asthma? Do you want to comment on that?
Dr. Steve Dorman:
13:15
Yeah, we generally wait until about age six to diagnose asthma. Prior to that it's treated very similarly. There's a condition called reactive airways disease. But then you can kind of make the diagnosis of asthma at age six and a lot of the treatments for pediatric or child patients do mirror the adult patients as well.
Dr. Michael Koren:
13:40
If you haven't had asthma and then at age, say, 60, you develop wheezing. Is it asthma or is it something else?
Dr. Steve Dorman:
13:49
Yeah, that's a great question. Classically, if we look at individuals who develop asthma, many times it is earlier on in life childhood years, teenage years, 20s, 30s. There's also many diagnoses that are made 40s, 50s, 60s and beyond. I mean it can happen at almost any point in our life Age. There's really no specific hey. If you get past here, you're good. It can happen at any point.
Dr. Michael Koren:
14:19
Interesting, so let's talk about some of the risk factors.
Dr. Steve Dorman:
14:25
Yeah, Looking at this list, this is a really nice list. Poverty and so having poor access to health care can certainly worsen asthma. If you do have asthma, Kind of dovetailing with that lack of health insurance, you know, if you can't get your medicines, can't see a healthcare practitioner or provider, it makes asthma more challenging to deal with. Exposure to air pollution you know, certainly if you think about it, this somewhat makes sense to all of us in this room. If you're sitting on the back of my truck with me and I turn on the engine, breathing in those fumes can be very harmful, very caustic to the lungs and cause exacerbations. And certainly there's a higher incidence in major cities with smog, such as LA.
Dr. Steve Dorman:
15:16
Poor indoor air quality we know that there's a higher risk of things like dust, mite and mold allergy indoors that can provoke asthma with poor indoor air quality. Pollen allergy you know, if you look at individuals who have asthma under age 18, about 80% of them have some sort of arrow allergen and the vast majority is pollen allergy. And then if we look at adults over age 18 who do have asthma, over 60% of them have allergic sensitization to trees, grasses, weeds, et cetera. Among the other allergens. Certainly smoking or inhaling things that are not great to go in our lungs can worsen and crescendo the progression of asthma or result in asthmatic processes worsening. And lack of access lack of access to specialists who can treat and manage asthma.
Dr. Michael Koren:
16:19
That's a super interesting comment. So someone can look at that skeptically and say wasn't that a commercial that was put in by the Allergy Society to promote their business? But I think there's maybe another element and correct me if I'm wrong, but if you have more specialists in the area, there's just more awareness of the condition and ways to mitigate the factors that lead to the problem in the first place.
Dr. Steve Dorman:
16:43
No, you're 100% right. I would agree with that.
Dr. Michael Koren:
16:46
Yeah, so interesting. So you mentioned Los Angeles as being a place where there may be a lot of pollution and have some exacerbation of lung disease because of that. They also have a lot of plastic surgeons in LA and I would imagine that there's a lot more discussion at cocktail parties about plastic surgery in LA than in Jacksonville or Puerto Rico for that matter. So all these things can have influence on how diseases present themselves in a community. And I guess there's a couple other bullet points Asthma, quick relief medicine use. Do you want to comment on that?
Dr. Steve Dorman:
17:22
Yeah, so there are some clinical studies indicating that if somebody's using a short-acting bronchodilator on a repeated basis in a very short circumstance or short period, that that's been associated with worsening asthma.
Dr. Michael Koren:
17:38
Okay, all right, so let's talk a little bit about the management of asthma in general terms. I guess there are a number of guidelines that have come out, .
Dr. Steve Dorman:
17:49
So again, asthma is a very heterogeneous disease where many people have different types of asthma. One of the main things we like to do with asthma is to figure out what type somebody has Is it mild, is it moderate, is it severe? And once we figure that out, based on symptoms and medication use and lung function testing, we also like to figure out are you allergic or not allergic and inside allergy, are there specific therapies that may be more tailored towards your type of asthma versus the next person's type of asthma? So it's really trying to personalize the management strategy depending on what may be driving the asthma.
Dr. Michael Koren:
18:34
So this is interesting. Genomic profiling, that's an interesting concept. Do you actually do gene studies in people to help guide treatment, or is that more aspirational?
Dr. Steve Dorman:
18:47
I think at this point it's still aspirational. It's not the standard of care, but we're hoping that can be the case in the future.
Dr. Michael Koren:
18:55
And help people understand what a biomarker is and how that would potentially drive the treatment.
Dr. Steve Dorman:
19:00
Yeah, great question. Great question If you look at a lot of the newer therapies that tend to work quite well for asthma, they're very specific in nature, for example, people who have allergic asthma. There are certain tailored therapies that we know may work better or worse depending on how high a blood level of a certain protein or cell is in their body. The same thing with other types of non-allergic asthma, such as eosinophilic asthma.
Dr. Michael Koren:
19:33
Yeah, and we had a learning session here maybe six or eight months ago about eosinophils, yeah, and so is anybody here for the eosinophil talk? No, you guys missed that one. But that's a type of white blood cell that's involved in allergic reactions and that would be an example of a biomarker, something that we can measure. That gives us a sense for how severe the disease is. So is that something you would get routinely for patients you're treating, or not necessarily?
Dr. Steve Dorman:
20:02
Yeah. So looking at people who have eosinophilic asthma, there are a couple different medications that will do things like reduce the amount of eosinophils in the body by causing an apoptosis or a suicide signal to the eosinophils. Again, asthma is an inflammatory process and if this is eosinophilic inflammation and we have a weapon that will get at just the eosinophils, it's very exacting with very little collateral damage to the rest of the body and it can really help those patients. There's also eosinophilic asthma medications that will help to inhibit the growth of the eosinophils by cutting off some of their growth factors or things that feed the asthma.
Dr. Michael Koren:
20:47
Yeah, and one of the things we learned at our session months ago was that people who have eosinophilic asthma may also have eosinophilic esophagitis or eosinophilic gastritis. So once the eosinophils get activated, it can infect other organs, not just the lungs.
Dr. Steve Dorman:
21:06
You're right. Yeah, it can be a kind of multi-organ or a systemic disease.
Dr. Michael Koren:
21:12
So let's talk about some of the treatments more specifically.
Dr. Steve Dorman:
21:15
Yeah, inhaled corticosteroids have for decades been the standard of care for more persistent asthma patients, so these medications in particular have been shown to reduce inflammation in the lungs that drives asthma and bronchoconstriction, and hence they improve lung function over time. They decrease exacerbations and they also decrease the amount of injected or oral steroids people get, and so we talk about systemic steroids. We're talking about an injection of a steroid intramuscularly, or taking an oral medication and swallowing it, going into the gastrointestinal system and ultimately into the bloodstream, as opposed to an inhaled steroid acting only locally in the lungs.
Dr. Michael Koren:
22:05
Yeah, so again, just in terms of the details of the picture, you see a mom trying to help her child use the inhaler. Is that a challenge?
Dr. Steve Dorman:
22:19
Yeah, it can be. Certain individuals will have problems with inhalers and coordination, but there are tools that we can use, such as a spacer, and so this is a chamber you can put on the end of the inhaler, pump the medicine into that spacer chamber and then kind of inhale the medicine at your leisure. To make it a little bit easier yeah, yeah.
Dr. Michael Koren:
22:40
The other thing I would say is that the child's, I think, will be a future dentist, since she seems to be taking a keen interest in her mom's mouth and teeth.
Dr. Michael Koren:
22:51
All right, so getting into other treatments for asthma
Dr. Steve Dorman:
22:54
yeah, so kind of starting off here, we alluded to these biologic therapies with the anti-IL-5 therapies. These are directed at the eosinophils. Again, eosinophilic asthma can be allergic or non-allergic in nature. Then we go to the next section, the anti-IgE or omalizumab. That's a biologic therapy directed exclusively at allergic asthma, so people who have very pollen or mold or dust mite-driven asthma, it can offer huge relief. And this was kind of the first medication in this class. It's about 21 years old at this point. We have also other therapies, the interleukin-4, interleukin-13 receptor blockers that also improve asthma as well through several other mechanisms. The benefits here again is they're very targeted, very focused. There's less kind of systemic or collateral damage by these medicines. They reduce exacerbations, improve quality of life, improve lung function.
Dr. Michael Koren:
24:05
Yeah, and for the nerdy people in the audience and I think there may be a couple interleukins, are these proteins that circulate that amplify the inflammatory reaction? Exactly, yeah, yeah,
Dr. Steve Dorman:
24:17
Yeah, we also look here at small molecule therapies like Montelukast, the leukotriene receptor antagonist, or the phosphodiesterase-4 inhibitors can be of benefit to their oral and they have a quick onset of action, which is very nice for patients.
Dr. Michael Koren:
24:36
Cool and these are very commonly used. All these, would you say your average patient is on this or just on steroids, or has it kind of break down in your practice?
Dr. Steve Dorman:
24:45
Yeah, probably 70% of my patients in my clinic I see do have asthma and I have patients on all of these medicines and I use almost all these medicines every day as part of the arrows and the quiver tools in the toolbox that we use to combat asthma with.
Dr. Michael Koren:
25:05
All right, so now monoclonal antibodies. Wow, tell us about that. I guess the latest and greatest.
Dr. Steve Dorman:
25:11
Yeah, so this is a really interesting category. Here Again, this is growing. It started with this medication on your left, omalizumab, also known as Zolair, so that targets IgE or the allergic antibody in the bloodstream, and it's used for allergic moderate to persistent severe asthma and it's used as an injection every two to four weeks and it's dosed based on weight and then the IgE level in the bloodstream. So these next three mepolizumab, benrolizumab and rezolizumab those are all fighting eosinophilic asthma. They're FDA approved kind of as mentioned six and up to 18 and over. They're for this moderate to severe persistent asthma group, for people who have mainly eosinophilic driven asthma, and they're used again subcutaneously for mepolizumab, abinrolizumab and then intravenously for rezolizumab every you know, between four and eight weeks Moving over here, dupilumab, that one blocks some of these chemical signals on the receptor of interleukin-4, interleukin-13.
Dr. Steve Dorman:
26:33
This is for patients that you don't have to have a specific eosinophilic or allergic subtype. It tends to work it more broadly in this communication cascade of different cells that provoke asthma and very similarly with tezopelumab, all moderate to severe persistent asthma patients. You don't have to be just allergic or have an eosinophilic subtype. It tends to work in almost everybody.
Dr. Michael Koren:
27:03
Now, are there certain go-tos that are more commonly used by allergists versus the others, or are they all pretty much cheaply used?
Dr. Steve Dorman:
27:11
Yeah, that's a great question. If you look, for example, at omalizumab, there's FDA approval for allergic asthma, for chronic rhinosinusitis with nasal polyps, for food allergy and also for chronic idiopathic urticaria. And so those four disease states I see all in my clinic and a lot of times if somebody has one they may have another, and so if we can kind of do two things at once with one medication or to kill two birds with one stone, we tend to kind of gravitate towards that medication. Dr. Koren, you alluded to different eosinophilic diseases, like eosinophilic esophagitis, and so if somebody is having eosinophilic esophagitis plus eosinophilic asthma, we may gravitate more towards one of these anti-eosinophilic medications. Dupilumab is extremely effective in atopic dermatitis or eczema as well as asthma, and so many times we'll see somebody who has allergic skin disease, eczema as well as asthma, and so we may pick dupilumab, so on and so forth. And so tezopilumab this is a newer medication so it has less FDA-approved indications, but it is quite effective for asthma and I do anticipate more FDA-approved indications coming soon for that drug.
Dr. Michael Koren:
28:33
All right. And if you want to impress your friends at a cocktail party or a gathering and you see a drug and it ends with MAB, you can say confidently that that's a monoclonal antibody. Yeah, so that's part of the nomenclature. And if it says UMAB, u-m-a-b, it's a human monoclonal antibody. Yeah, so that really impressed. People Say I know this is a human monoclonal antibody. And they'll say how do you know it? And you'll say I can't tell you. Come to the lectures, okay. So back to the audience questions. Which of the following are considered triggers for asthma? Is it A boring lectures? I hope no one answers that question. A. Is it B nagging spouses. Is it C, waiting in line? Is it D dad jokes, or is it E? Dr Dorman will tell us. Do we hear a, b out there? E and B, okay all right.
Dr. Michael Koren:
29:41
Yeah, so nagging spouses is a punchline we've used on multiple occasions here in this setting, and so it's sort of an inside joke between me and the audience really. So we appreciate that. But I think I'm going to go with E in this case.
Dr. Steve Dorman:
29:57
Yeah. So triggers for asthma, these are all really nice, not a comprehensive list, but very close to it. You know indoor triggers dust, mites, danders, pollen, cigarette smoke. Outdoor triggers you know we alluded to air pollution, places with a lot of you know, smog, et cetera, like Los Angeles Very interesting here cold air.
Dr. Steve Dorman:
30:22
If you look at the classic feature, the classic test that we use now to prove or disprove asthma, it's a test called a methcholine challenge or a mannitol challenge. So before that test was developed to prove you had asthma, if you wanted to be in the Olympics or be excluded, or excluded from the military, they would use cold air inhalation. So imagine if you have asthma they're going to take you into a freezer and make you breathe in really hard and you're going to have an asthma attack. Either you do or you don't, but that's a very classic trigger. Physical triggers some people will have exercise-induced asthma. You know, naturally, if your asthma is poorly controlled, increasing your heart rate, increasing your ventilation, will increase your asthma symptoms. But sometimes just exercise alone can be a trigger for certain individuals and stress, and so there may be something to that nagging spouse thing that was alluded to earlier.
Dr. Steve Dorman:
31:26
Psychosocial stress has been shown to be a trigger for asthma. I did a clinical study over 10 years ago with we kind of partnered with a psychiatry group. We took people who had asthma and we put them in an MRI machine and showed them one of two videos. The first video was kind of like a Caribbean beachside scene really no waves, very peaceful. The other video was of an emergent heart surgery procedure, very stressful, very bloody. And while we were having people watch these videos in the MRI machine we scanned their brain and we're looking at different centers of their brain, either parts of the brain that activate with relaxation or lack of stress, versus very stressed centers of the brain. And you could guess which group of people watching which video had more asthma attacks. It was the people who were watching that cardiac surgery, that emergence, very stressful video. They had more stress centers in their brain anger, fear, fight and flight and more asthma inhaler use while in the MRI machine versus this Caribbean beachside scene. So it's been shown in other studies as well, but I liked that one because I was participating in that.
Dr. Steve Dorman:
32:51
One Food can be a trigger for some people as well. You know we talk about sulfites or food additives, sometimes just more common than that would be reflux. You know, having a little bit of reflux spilling down and aspirating in the lungs can provoke asthma. The number one trigger, kind of towards the bottom here, is respiratory infections and so something like we talked about these vaccines earlier flu, covid vaccines. We really want to get those because those things are killers and people have asthma, something like the common cold and really flare asthmatics. So we have to take that seriously. Then weather changes, you know hot to cold, cold to hot, less humid to more humid can really interfere with. You know the pathophysiology of asthma in the lungs for people.
Dr. Michael Koren:
33:41
So I have a real burning question here. I don't see anywhere on the slide that it says a white dog chewing on a rope as a trigger for asthma. So why is that picture on this? Is there something I'm missing?
Dr. Steve Dorman:
33:59
Yeah, so people can be allergic to their animals. It's very interesting If you look at like in my clinic on a pretty much daily basis we do allergy skin testing or try to define whether somebody is or is not allergic to animals, and so dog is one of these common animals people can be allergic to. But dog can also have a secondary allergy in that they bring the pollens of trees, grasses, weeds indoor on their coats and so you can have the primary dog allergy when you're petting your beautiful pet, but also that can get the pollen on it as well, provoking the asthma. Interesting.
Dr. Michael Koren:
34:29
Interesting. Okay, so obviously one of our points of connection is that we both run clinical trials and we both support how valuable they are for the community. And we like to remind people is that for those of you who have never participated in a clinical trial, it may seem scary, a daunting thing, and in fact, when you do surveys of the general population, both in the United States and in Europe, you find that only 30 to 50 percent of people show a significant interest in participating in a clinical trial. But interestingly, if you survey people who have done a trial and ask them would you do it again, 97% of people said they would do another trial and at our center it's 99%.
Dr. Steve Dorman:
35:18
I believe that.
Dr. Michael Koren:
35:19
So the question is what is it about clinical trials that makes people really comfortable and actually want to do them after they're exposed?
Dr. Steve Dorman:
35:28
Yeah, I think there's a number of reasons. People get treated really well. You know like, for example, in an asthma trial, you're seen by the board certified allergist, who's interested in you and in your disease state specifically, and then you may be seen by the pulmonologist and you get seen at a very high frequency, and so we watch you very, very closely, and so I would argue that the patients who are in clinical trials probably receive the best care. Yeah, yeah.
Dr. Michael Koren:
35:56
Yeah. So my mentor during medical school was a very famous cardiologist named Eugene Braunwald, and I was reminded of this little anecdote yesterday that Eugene would say that he wants to be in the placebo group in a trial when he grows up, because even if you're in the placebo group, you do so much better than you would do otherwise.
Dr. Steve Dorman:
36:16
Yeah.
Dr. Michael Koren:
36:17
Yeah, and it's true, because you just get very close attention, a lot of care, and we often identify other issues that are very, very helpful for the overall healthcare needs of the patients. Yeah, yeah. So with that in mind, maybe should we get into a little bit of the specifics that you may be involved with.
Dr. Steve Dorman:
36:35
Yeah, so we have a new clinical trial for one of these monoclonal antibody therapies, so one of these very specific anti-inflammatory asthma therapies that's not injected intravenously or subcutaneously but actually inhaled. So we know this molecule works already on an injected basis, and so we're trying to figure out whether this is going to work for an inhaled version of this medication as well, and so we're very excited about it, very, very excited.
Dr. Michael Koren:
37:07
Is it enrolling now
Dr. Steve Dorman:
37:08
Coming up? Yeah, I think
Dr. Steve Dorman:
37:10
week is when we start.
Dr. Michael Koren:
37:11
Okay, so it's going to start. So for those of you out there that have asthma or know somebody who has asthma, it's a really nice opportunity for people to get a medicine that they may not otherwise get in any other way, yeah, yeah. And again, this concept is to avoid having to use injectable therapy. So all those monoclonal antibodies that we talked to you about are usually given through injection, and not everybody likes that. So this will be an alternative to get the same benefit of the injection, but using a different means of administration.
Dr. Steve Dorman:
37:41
Yeah, yeah.
Announcer:
37:43
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