Management of patients with type 2 inflammatory diseases
Patients who present with a primary type 2 inflammatory disease should
be asked about symptoms related to other type 2 inflammatory comorbid
diseases (Table 1). Biomarkers, such as eosinophils and IgE in addition
to FeNO for asthma, should be used in the clinical assessment of the
status of type 2 inflammation, and it would be useful to have validated
biomarkers of type 2 inflammation relevant to atopic dermatitis.
Consensus was not achieved on whether, from the patient perspective, the
combined symptoms related to multiple moderate type 2 inflammatory
diseases may be more burdensome compared with the symptoms of a single
severe type 2 inflammatory disease. At the virtual meeting, the experts
highlighted that disease burden can be assessed only by the patient. In
addition, patients with a single severe type 2 inflammatory disease may
be eligible for effective treatments to alleviate their symptoms, which
may not be available for patients with multiple moderately severe type 2
inflammatory diseases. Where clinical settings allow it, specialists
should work together when managing patients with highly complex cases of
multiple concurrent type 2 inflammatory diseases.
Although consensus was achieved regarding the most serious cases taking
priority in multidisciplinary team conferences, it was not agreed that
some patients with multiple concurrent, refractory, moderate type 2
inflammatory diseases may benefit from having their cases discussed in
this setting. At the virtual meeting, the experts highlighted the cost
of organising multidisciplinary team conferences as a potential barrier
to these patients being discussed in this manner and said that patients
with severe disease should be given priority.
Impact on the holistic care of patients with type 2
inflammatory
diseases
In the dermatologists’ breakout session, it was noted that some
dermatologists in the Nordic region ask their patients about asthma but
not about upper-airway symptoms or eosinophilic esophagitis. This is
partly due to the limited time available for consultations but also
stems from difficulties in assessing the severity of other
comorbidities. A detailed knowledge of respiratory disease, for example,
is not traditionally part of the dermatology specialty. It was noted
that patient-reported outcome tools should be developed to assess the
severity of comorbidities so that patients can be referred to an
appropriate specialist. In addition, the importance of patient education
to promote awareness of multi-organ disease was highlighted.
A key challenge highlighted by the dermatologists was the identification
of patients with multi-organ disease even though patients may not
mention non-dermatological comorbidities to their dermatologist. All
participants agreed that a question guide would be useful to identify
comorbidities proactively and facilitate appropriate holistic care for
patients with type 2 inflammatory diseases.
Following the proposals in the dermatologists’ breakout session, all
specialties involved in this initiative contributed to the preliminary
draft of a question guide (Table 4), intended as an indication of scope.
It is anticipated that the questions would be rephrased in appropriate
patient-friendly language and undergo validation with patient groups
prior to clinical use.
In the pulmonologists and paediatricians’ breakout session, it was noted
that there may not be as much overlap between type 2 inflammatory
diseases as the literature suggests. This may be because specialist
clinics mostly see patients with severe and complex diseases, who are
more likely to have type 2 inflammation-driven multi-organ disease,
rather than patients who have milder disease(s). Ideally, a
multidisciplinary team would discuss the optimal management and care of
patients with type 2 inflammation-driven multi-organ disease, but the
participants recognised the geographic and economic challenges
associated with this approach.
In the breakout session that included the ENT, internal medicine,
clinical immunology and allergy specialists, it was noted that patients
with severe asthma and CRSwNP often experience overlapping symptoms.
Therefore, the development of a composite score to holistically assess
the severity of symptoms in patients with severe asthma and CRSwNP was
recommended.