The Curbsiders Internal Medicine Podcast

Episode #468: Asthma Update with Cyrus Askin

Date: January 27, 2025
Guest: Dr. Cyrus Askin, Pulmonary & Critical Care Physician, Associate Program Director, El Paso, TX
Hosts: Dr. Matthew Watto, Dr. Paul Williams, Dr. Paul Wertz

Overview

This episode delivers a comprehensive, practice-refreshing update on adult asthma diagnosis, clinical phenotyping, and the latest evidence-backed treatment strategies. Featuring Dr. Cyrus Askin, pulmonary and critical care physician and podcast co-founder ("Critical Care Time"), the discussion answers what’s changed (and what hasn’t) in guideline-driven asthma care, including a deep dive on “SMART” therapy, the evolution away from SABA monotherapy, precision medicine in asthma phenotyping, and managing complex patients—plus loads of pragmatic pearls, patient communication tips, and classic Curbsiders banter.

Key Discussion Points & Clinical Insights

1. Approach to Diagnosing Asthma

[08:51 – 15:08]

• Comprehensive History-Taking
  • Open with patient-centered questions ("What brings you in today?") to elicit symptom patterns, triggers, and impact.
  • Assess for environmental and activity-related factors (climate, allergens, exercise, air quality index).
  • Dig into family and personal history (asthma, atopy, prematurity, childhood asthma).

"I think it's really important to start with an open-ended question...it's a great way to establish rapport and get your patient to share a lot of information."
—Dr. Cyrus Askin [09:00]

• Diagnostic Testing
  • Spirometry with bronchodilator response is gold standard.
  • Peak expiratory flow (PEF) considered only if spirometry unavailable.
  • Methacholine challenge: high sensitivity, considered especially for normal PFTs with ongoing symptoms.
  • Diagnosis should not be made purely clinical except in rare, resource-limited settings.

"Asthma really shouldn't be a clinical diagnosis in most cases—it's a diagnosis that should be supported by spirometric values."
—Dr. Cyrus Askin [79:01]

• Notes on Pregnancy
  • Spirometry can be performed in pregnancy, but results may be confounded by restrictive physiology.

2. Staging & Assessment of Severity

[27:22 – 32:00]

• Shifting Away from Old Terminology
  • Rigid categories like "mild intermittent" are no longer emphasized.
  • Focus on the real-world impact: frequency, severity, and patient’s perception.
  • Asthma Control Test (ACT): a 5-question validated tool for ongoing assessment (score 5-25, with <19 indicating uncontrolled asthma).

“I really focus on more patient-centered language and the patient experience, which...is really important.”
—Dr. Cyrus Askin [27:49]

3. Asthma Treatment: Guideline Updates & SMART/MART Therapy Debate

[31:29 – 49:45]

• Reliever Therapy: Evolution from SABA to ICS/LABA
  • Budesonide-formoterol is now preferred as both reliever and controller (SMART/MART).
  • As-needed low-dose budesonide-formoterol reduces exacerbations, improves control, and allows lower cumulative steroid doses (Sigma 1, Sigma 2, Novel Start trials).
  • Albuterol monotherapy is discouraged except in unusual situations.

"At this point, we have very good data to suggest [albuterol monotherapy] really shouldn't be the approach."
—Dr. Cyrus Askin [34:36]

• For exercise-induced symptoms, patients instructed to use budesonide-formoterol prior to and after exertion, max 12 puffs/24h.

• Practical Barriers

  • Cost and insurance formularies can dictate real-world choices.
  • If SABA is used, only in combo with inhaled corticosteroid; avoid SABA monotherapy due to risk of tachyphylaxis and exacerbations.

• Stepwise Approach

  • Begin with as-needed ICS/formoterol for mild cases.
  • Escalate to maintenance dosing (two puffs BID + prn) if symptoms persist or control is poor, then evaluate for further add-ons.

“You’re really doing the patient a disservice [by not updating therapy]. We know patients have more exacerbations and more severe exacerbations when they’re on SABA monotherapy. That’s not cool.”
—Dr. Cyrus Askin [37:38]

4. The Mandala Trial & Alternative Inhaler Combinations

[46:47 – 49:02]

• Mandala Trial
  • Explored as-needed albuterol-budesonide inhaler: shown to reduce severe exacerbations vs. albuterol alone.
  • However, no head-to-head data vs. formoterol/budesonide; formoterol/budesonide remains preferred pharmacologically.

"Physiologically and pharmacologically, if I had my druthers, I don't really see a great place for that [albuterol-budesonide] combination without."
—Dr. Cyrus Askin [48:32]

5. Stepping Down Inhaled Corticosteroids

[49:02 – 51:10]

• High-level efficacy is achieved at low ICS doses; escalations should be attempted but minimize duration at high doses (risks of thrush, caries, rarely adrenal suppression).
• Step down once control is achieved to minimize steroid exposure.

6. Non-Inhaler/Adjunctive Therapies: Montelukast & Others

[51:16 – 55:11]

• Montelukast

  • Adjunct (not monotherapy) for allergic or exercise-induced asthma.
  • Black box for neuropsychiatric effects (sleep disturbance, anxiety, rare SI) — discuss risks, esp. if psych history.

• Obesity

  • Major contributor to poor control and exacerbations—address through coaching, considering pharmacotherapy (e.g., GLP1) or even surgery as indicated.

• Exercise

  • Do not discourage! Exercise as a trigger: work to optimize control to facilitate normal activity.

"The goal is to facilitate exercise and normalcy...We have to find a way to get you to exercise."
—Dr. Cyrus Askin [58:25]

• Pulmonary Rehab

  • Useful for support, especially in hesitant or more symptomatic patients.

• Immunization

  • Ensure flu, COVID, and pneumonia (per age/asthma guidelines); consider RSV in appropriate patients.

7. Advanced Asthma Phenotyping & Biologics

[60:08 – 67:04]

• High T2/Type 2 (Eosinophilic/Atopic)

  • Allergic, high eosinophils, IgE—consider biologics targeting these pathways (e.g., anti-IL4/IL5/IL13).

• Low T2 (Non-allergic/Non-eosinophilic)

  • Less steroid response, fewer biologic options, possibly candidate for new agents (e.g., tazepelumab).

• Other Subtypes

  • Cough-variant asthma, adult-onset asthma, asthma with persistent airflow limitation (may overlap with COPD).

• When to Refer?

  • If patient uncontrolled despite stepwise therapy, refer for phenotyping and consideration of advanced/biologic therapies.

8. Managing Acute Exacerbations & Action Plans

[67:12 – 78:35]

• Hospitalization/Emergency Care
  • Low threshold for ED evaluation in pregnancy, severe symptoms, high RR, inability to speak, poor PEF, comorbidities.

"If they sound terrible over the phone, I don't mess with that...If I'm wrong, cool. If I'm cavalier, that's not cool."
—Dr. Cyrus Askin [70:46]

• Role of PEF in Monitoring

  • PEF is useful in assessing acute changes (vs. diagnostic use), comparing to patient’s best baseline.

• Treatment of Exacerbations

  • Do NOT use antibiotics unless clear evidence of infection (unlike COPD).
  • Increase ICS/LABA dosing, consider more frequent dosing or switch to nebulizer if unable to inhale adequately.
  • Systemic steroids (prednisone 40-60mg x 5 days standard).

• Asthma Action Plans

  • Underutilized but valuable—tailored “green/yellow/red” zones based on symptoms and PEF. Encourage self-monitoring, earlier recognition, provide guidance on medication adjustment and when to seek care.
  • Safety net: Have a plan but ensure rapid follow-up/communication.

9. Collaborative & Efficient Specialty Referral

[79:01 – 82:12]

• Strive to have at least some baseline evaluation or treatment attempted before referral.
• Prepare CBC with diff, IgE, CRP for advanced workup if considering specialist—optional but can streamline care.
• Build collegial relationships; pulmonologists appreciate thoughtful consults.

Notable Quotes & Memorable Moments

• “Asthma really shouldn’t be a clinical diagnosis in most cases...it should be supported by spirometric values.”
  —Dr. Cyrus Askin [79:01]

• "You’re really doing a patient a disservice... We know patients have more exacerbations and more severe exacerbations when they’re on SABA monotherapy."
  —Dr. Cyrus Askin [37:38]

• “The law of diminishing returns. It's really bad with donuts and then it's like almost as bad with beta agonists.”
  —Dr. Cyrus Askin [38:06]

• "The goal is to facilitate exercise and normalcy. That's one of the triggers that to me is non-negotiable."
  —Dr. Cyrus Askin [58:25]

• “I did the open lung biopsy in my clinic and you know the darndest thing, I still couldn't figure out what's going on."
  —Dr. Cyrus Askin [82:24] (in Curbsiders’ classic humor)

Timestamps for Key Segments

| Timestamp | Topic | |-----------|-------------------------------------------------| | 08:51 | Approach to asthma diagnosis/history | | 13:14 | Role and limitations of spirometry/PEF | | 27:22 | Staging, ACT, and tailoring assessment | | 32:00 | Initiating and dosing inhaled therapies | | 34:36 | Why SMART/MART therapy is now preferred | | 42:56 | Mandala trial and alternatives explained | | 46:44 | Practical dosing & inhaler technique pearls | | 49:02 | ICS step-down rationale and risks | | 51:16 | Montelukast: indications and warnings | | 55:28 | Non-pharmacologic approaches (obesity, exercise) | | 60:08 | Advanced phenotyping/biologics | | 67:12 | Approach to asthma exacerbations/action plans | | 78:56 | Take home points/specialist communication |

Take-Home Points from Dr. Askin

1. Don’t make asthma a solely clinical diagnosis—pursue objective testing (spirometry, PEF, or methacholine).
2. Albuterol monotherapy is now rarely appropriate. Prefer ICS/LABA as reliever and controller (SMART therapy).
3. Escalate (and de-escalate) inhaler therapies thoughtfully, with attention to minimizing steroid exposure.
4. Have a low threshold for acute assessment and don’t overlook alternative diagnoses—most exacerbations shouldn't happen with optimized care.
5. Collaborate efficiently with specialists; initial workup or documentation helps streamline care and gets patients help faster.

Other Memorable Moments

• Dr. Askin’s music/guitar idols: Carlos Santana, John Mayer, Omar Rodríguez-López.
• Repeated inside jokes about “Vlad the Inhaler” [01:02], "security blanket” inhalers, and classic Curbsiders cat and litter banter.
• All hosts lament (with humor) their imperfect use of asthma action plans.

Links & Resources

• GINA Guidelines: www.ginasthma.org (page 144 on biologics, color-coded primary/specialist sections)
• ACT Scoring Tool: [Online calculators/formats available]
• Critical Care Time Podcast: www.criticalcaretime.com

This summary captures the core clinical content—skipping ad reads and non-content banter unless referenced above for color or context.