1. CASE: Use the following patient case to answer questions 1 through 4:
SG is a 39-year-old female who was diagnosed with asthma 9 years ago. She is currently treated with budesonide/formoterol (160 mg/4.5 mg), 2 puffs twice daily, but she has been poorly controlled for the past year, despite good adherence to medications and trigger avoidance. She uses albuterol for symptoms most days. In the past 8 months, she has experienced 2 asthma exacerbations: she sought treatment at an urgent care center and was treated with short courses of prednisone. The patient is concerned about her steroid use due to a strong family history of osteoporosis. Spirometry reveals a forced expiratory volume (FEV 1 ) of 1.6 liters (55% predicted); the FEV 1 improves to 1.9 liters with albuterol. The patient also has allergic rhinitis associated with seasonal pollens for which she uses an intranasal steroid, and she complains of intermittent gastroesophageal reflux for which she uses omeprazole as needed.

Which of the following would be a useful biomarker to assess for SG at this point?

2. Patient CASE, continued:
SG undergoes a comprehensive evaluation for her asthma and the following results are noted: skin testing for aeroallergens is inconclusive, esophageal pH 24-hour probe is negative for reflux, total serum immunoglobulin E (IgE) is 52 IU/mL, and serum eosinophil count is 460 cells/μL. The fractional exhaled nitric oxide (FeNO) result is 95 ppb, serum periostin is 40 ng/mL, WBC count is 7500K, and Hgb is 14 g/dL. Spirometry reveals an FEV1 of 1.5 L, which improves to 1.8 L after albuterol, and a methacholine challenge test reveals a PC20 result occurring at 0.125 mg/mL, which suggests moderate to severe bronchial hyperreactivity.

What is the most appropriate assessment of SG's asthma endotype?

3. For SG, which of the following therapies is most appropriate to consider at this time?

4. Which of the following agents is considered the backbone of a chronic asthma regimen for a patient with asthma like SG?

5. What is the target for reslizumab and mepolizumab?

6. Which of the following is the most clinically relevant outcome parameter when assessing the efficacy of pharmacotherapy with a biologic agent for severe asthma?

7. Which of the following therapies is most appropriate to use for a patient with skin-test documented allergies to multiple aeroallergens, poorly controlled asthma despite oral corticosteroids, a total serum immunoglobulin E (IgE) of 200 IU/mL, and a serum eosinophil count of 120 cells/microliter?

8. An insurance company plans to cover a particular biologic agent for asthma under the pharmacy benefit through which a patient will receive the medication from a pharmacy and take it to the physician's office for administration. Which of the following terms describes this type of practice in specialty pharmacy?

9. A patient with severe, uncontrolled asthma characterized by eosinophilia is under evaluation for a biologic therapy. The patient indicates an interest in self-administering the medication at home. Which of the following products is most appropriate to recommend?

10. When using biologic agents that block interleukins involved in asthma, there is an increased risk of which of the following adverse events?

Evaluation Questions

11. How confident are you in your treatment approach for treating SG?

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