When to breathe easy about asthma remission

"I think that asthma’s at a great time right now for some really cool interventions moving ahead that can maybe make big differences in our patients’ lives."
  —Dr. William Anderson

On this episode of The Allergist, Dr. Mariam Hanna is joined by Dr. William Anderson to explore one of the most pressing and evolving questions in asthma care: remission. Together, they unpack the concept of asthma remission, what it truly means for patients and physicians, and how modern therapies are shaping its future.

Dr. Anderson helps break down:

• What remission really means: The key criteria—from absence of symptoms to stable lung function—and the differences between spontaneous remission and remission on treatment.
• The role of biologics: Are these cutting-edge therapies just controlling asthma, or could they be disease-modifying?
• Risk factors for persistent asthma: Why early exacerbations, smoking, and other factors can influence the trajectory of the disease.
• Transitioning from pediatric to adult care: How to ensure adolescents stay on track with self-management during this critical handoff.
• Future directions in asthma care: The exciting possibilities of AI, early interventions, and electronic medication monitoring to improve outcomes.

If you’re curious about the potential for asthma remission or looking for actionable ways to refine your approach to care, this episode is packed with valuable insights. Equip yourself with fresh perspectives and practical tools to help your patients stay on the path to better health.

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The Allergist is produced for CSACI by PodCraft Productions

Transcript

Dr. Mariam Hanna:
Hello, I'm Dr. Mariam Hanna, and this is The Allergist, a show that separates myth from medicine, deciphering allergies and understanding the immune system. The other day I sat with a family for consultation on food allergies. Turns out the child uses puffers with respiratory illnesses. Has done this for years. Persistent cough lasts for weeks otherwise, and they note some exertional symptoms, which they relate to deconditioning. At the end of the consult, I really like to summarize the issues. One, food allergy standard discussion, exciting frontier, yada yada, and two, asthma. The mother's eyes stare out of her head at this point, you mean my child has asthma? I resist hard these moments from looking over my shoulder to check if there's a candid camera recording happening there. You just told me they do. You definitely just told me all the signs and all the hallmarks that they do, but no one's ever used that word with us.

No one. Okay. So you see the leap I'm about to make here is, first of all, we barely tell people their actual diagnosis when we're prescribing them puffers. And today I actually want to talk about remission. Does it go away? Because it's like clockwork. First you diagnose, convince them of the chronic nature of this condition, and see them in follow-up. And whether they've stuck to the plan or not is typically actually the flip of a coin. But what they'll all ask is, will it go away? But today I'm grateful to not have to answer this question because, on today's episode, I've brought a dear colleague who answered just that.

It's my pleasure to introduce Dr. William Anderson. Dr. Anderson is board certified in allergy and immunology, pediatrics and internal medicine. He's an associate professor of pediatrics at the Children's Hospital, Colorado and the University of Colorado School of Medicine. Dr. Anderson is the medical director for the allergy and immunology section at the Children's Hospital and directs the Asthma Biologics Program. His scholarly interests include the management of difficult to treat and severe asthma, including the use of biologics and digital interventions, transition from pediatric to adult care, and the development of novel clinical programs that improve care delivery. Dr. Anderson, thank you for joining us and welcome to the podcast.

Dr. William Anderson:
Thank you, Mariam. Very happy to be here today.

Dr. Mariam Hanna:
Okay. You have a tall ask from me. We're going to go through asthma and this remission discussion because it's almost more important to have for some patients than even getting the diagnosis. They're ready to talk about it as soon as they've figured out the diagnosis. So let's start there. What is our current definition of this word? Remission in asthma, or do we have one?

Dr. William Anderson:
So when I think of remission in asthma, I think it's important to start with our basic building block of this idea of disease control. So we're all familiar with this idea of having our asthma good control in terms of not having hospitalizations, not needing oral steroids, and not having symptoms that are impacting us on a day-to-day basis. The next step in that continuum is this idea of remission. And that means that we are not seeing symptoms, we have optimized our lung function, and we're not requiring any steroids whatsoever. And there's two ways that you can have that remission. One is clinically, which essentially is all the symptoms have resolved and you're not needing any therapies. And this other is this idea of remission on treatment, which is saying that you're still having none of these symptoms, but it's all secondary to being on good control with medications.

Dr. Mariam Hanna:
And there's not one that's psychologically where the patient feels that they're well controlled, but they're actually uncontrolled, and their spirometry is horrendous.

Dr. William Anderson:
Well, we certainly see that in our practice that patients have their own perception of what they consider to be control, and what we may see is very different. You bring up a great example where they're not feeling anything, but you look at their lung function and it's terrible. And it's mainly because they've now found a way to compensate for all their activities. One of my favorite questions to ask people is, how does your asthma interfere with activity? And they'll say, oh, it doesn't at all. The next question is, are you actually active? And they're like, no, because if I'm active, then I have terrible asthma symptoms. So it's all about this idea of really being objective and understanding how it is impacting them on a day-to-day basis.

Dr. Mariam Hanna:
Okay. So do we know the rate that spontaneously resolve asthma without any pharmacotherapy?

Dr. William Anderson:
Yeah, so we have some good studies that have looked at patients from childhood onward whenever we're thinking about these kids that started to have recurring wheezing episodes. So if we start off early, let's say in the preschool age range, we know that those kids that have recurrent episodes of wheezing, which can be up to about 25 to 40% of all preschool students. So just because you see a kid that's wheezing doesn't necessarily mean they're going to go on to asthma, but it's not infrequent to see a kid that is going to have wheezing episodes. But out of those, we know that depending on which study you look at, upwards of 30% may have persistent asthma in their school age if it's started in preschool age. We then know that out of those kids that were preschool wheezers, about 27% of them will go on to have asthma in adolescence.

And then the idea is about three to 5% of those will then have it persistent in adulthood. There will be some new patients that will develop asthma later than preschool age, and we can talk about that today with risk factors and what may happen with that. But if we're starting with that group that is those very young ones you're looking at, that is their course overall, that about 30% of them may go on to have persistent asthma in school age. And then after that, you might have about 5% of them having it into adulthood as well.

Dr. Mariam Hanna:
And if I were to flip the question on you and say, well, since the majority resolve in adulthood, can we just leave the majority of asthmatics off treatment and only pick off the ones that have severe exacerbations?

Dr. William Anderson:
So I think what's important to recognize is that none of our therapies to date have been disease modifying. That means whether it's the inhaled steroids, long-acting beta agonists, or biologics, we have no evidence that any of them will change or make the asthma go away. But our key here is to help control symptoms as much as possible because we do have some good evidence that shows that with each exacerbation you have, it causes a hit to your underlying lung function. And this can be seen very early in life. In some cohort studies, they found that even by five years of age, those patients who had recurrent exacerbations have lower lung function than their peers. So we definitely want to have them on medications to prevent exacerbations that may subsequently reduce their lung function, which may subsequently have them have persistent asthma later in life. The medicines are not going to stop the asthma, but they're going to potentially stop the bad effects of the asthma that can lead to make it more persistent.

Dr. Mariam Hanna:
That's a great way of saying it. Okay. Is remission on treatment the same as spontaneous resolution?

Dr. William Anderson:
No. So I think it's important to recognize that our definitions for the two are going to be similar in that it's going to entail not having symptoms, having preserved or stable lung function, not needing systemic steroids, not having interference with activity. But the main difference between a spontaneous resolution is that you are off of all medicines and you are not having those symptoms versus remission on treatment means that you are on a therapy quite frequently. It can be a higher dose controller or even a biologic and not having those symptoms. So essentially the reason why you're in “remission” is because of the therapy whenever you're having remission on treatment.

Dr. Mariam Hanna:
Got it. And can you change your likelihood of remission?

Dr. William Anderson:
So at this point in time, your likelihood of remission is going to depend on both your underlying biology as well as your exposures. Those patients who maybe have a strong family history of asthma or a strong family history of atopy, they're going to be the ones that are going to be most likely to have a persistent asthma later on. However, as long as you're doing things like avoiding exacerbations, as long as you're trying to avoid smoking or not starting smoking, if you are taking your therapies, these are all things that we think that will help improve your lung function and subsequently help increase your likelihood that you may go into remission. As I said before, with those patients with better preserved lung function being those most likely to go into remission. So I think that there's only so much we can offer our families in terms of what they're able to actively do or change to get their asthma into a state where it could potentially reach remission. 

Dr. Mariam Hanna:
Okay. Let me ask it a different way then. In patients that develop asthma later on in life as adolescents or as adults, is there particular risk factors that they possess that makes them go into this more, like, asthma pathway?

Dr. William Anderson:
So we definitely know that smoke exposure and smoking is a big trigger. Sometimes I think we hear so often about how bad smoking is that we just brush it off a little bit like that it's baked into the cake, but I think it's really important to really recognize how much that can affect them. We also know that patients that develop atopic sensitization or have worsening of their underlying environmental allergies or have more comorbidities are those likely to have a persistent asthma or develop new asthma in their adolescent years.

One teaching that I feel like I got a lot of when I was in training, and maybe you did as well, Mariam, is this idea that boys, their asthma will go away when they hit adolescents, and females, that's when theirs develops. And certainly, there is some evidence that shows that female patients are more likely to develop asthma in adolescence. But when you look at some of these large cohort studies, especially of those patients who have more severe asthma, you're not necessarily seeing the sex difference between the two in the sense that boys are resolving more than girls are. And part of the reason potentially behind this is that maybe the damage has already been done, and even though maybe your sex hormones will have some influence, if you've already damaged your lungs enough with severe exacerbations earlier in life, you're just going to have this idea of persistence. So while we still use this as an axiom and still talk to families about this, if they have severe asthma early in childhood, I may be less likely to talk to them about that or advise that their child who is a boy will outgrow it more than a child who is a girl.

Dr. Mariam Hanna:
Fair. Fair. Are there other risk factors for severe asthma that we should hit on?

Dr. William Anderson:
So I think, Mariam, one thing that's important is to recognize what is actually severe treatment-resistant asthma. Asthma that we would maybe think of that you would require a biologic for versus what is difficult-to-treat asthma. And as we know, severe treatment-resistant asthma really only makes up five to 10% of all patients with asthma. So a lot of the patients I see in my severe asthma clinic are actually patients that have difficult-to-treat asthma, whether that's secondary to psychosocial situations, comorbid conditions that need to be treated that either are exacerbating their asthma or mimicking their asthma, poor medication adherence. These are all factors that we need to consider.

So I think that whenever we are saying what is true severe asthma, it's important first to rule out what is potentially mimicking or making you think that it's severe, but it's actually difficult to treat. All that being said, there is a school of thought out there that how much do you push some of these other factors versus going to a biologic that you know  will work. You hear, for example, about poor adherence and do you use a biologic for direct observed therapy or for more infrequent therapy? That could be a conversation onto itself about the pluses and minuses of that.

Dr. Mariam Hanna:
And it's hard, but again, if we have this kind of available in our arsenal of what can streamline this patient's journey, okay, that's hard. Let me get back on track. 

Dr. William Anderson:
No, I agree with you on that, and it leads to real hard conversations that we have in our clinic about how much are you talking about behavioral change or you're talking about changing dramatic psychosocial factors in a family's life versus using a medication that, while very expensive, can make dramatic differences for them. And what are the pluses and minuses of how much you push on one lever versus the other to get to your ultimate goal of good asthma control?

Dr. Mariam Hanna:
Yeah. Can severe asthma slash difficult-to-treat asthma go on to have remission? I know those are two different entities, but—

Dr. William Anderson:
Yeah, I would say that if you have severe asthma, I think you are more likely to be able to get to remission on treatment than to spontaneous remission for all the reasons we talked about before.  But I think that certainly there are going to be patients that, once you put them on a biologic or get them on good controller therapies, even if they are severe, that can reach that definition of remission.

And there have been studies out there that have looked at this using the biologics. Now mind you, this is all retrospective studies, so it's not like this was the primary goal when they looked at the study. But when they looked at different biologics, they had anywhere, I would say, between 30 and 40% of patients, plus or minus a few. That was the likelihood that those patients were able to meet their definition of remission.

Dr. Mariam Hanna:
Are the biologics that we are using today—and understanding we have an expanding number of choices, and it seems to be changing every month—possible that they are disease modifying more than inhaled corticosteroids were in the past? That we think that eventually they're in remission, they're stable, and we've modified their disease enough that will change things?

Dr. William Anderson:
We don't have evidence now that if you are starting on a biologic for severe asthma that it will necessarily be disease modifying. However, that is the new exciting area. Where I think we're looking at is in these younger kids who potentially have these risk factors that I mentioned before that can put them at increased likelihood of having persistent asthma—just starting a biologic early for them potentially changes the disease course. There's one study right now that's looking at that with omalizumab, but I certainly think that this is something that we should be looking at with our other biologics as well, and it's really going to be interesting findings to see: does it matter what the biologic is? Does it matter how early we intervene? Are there certain risk factors or phenotypic factors that predict this different for kids? These are things that we don't have answers to right now, but I think we will be finding that out in the next few years.

Dr. Mariam Hanna:
Absolutely. Okay. In the patient that achieves remission—now we're just going to go back to our mild, moderate asthmatics that are on inhaled therapies—when they achieve target zero is what I often call it in my clinic. Zero symptoms, zero missed days of school. That's our goal: zero of everything. When they reach that, how do you go about adjusting their therapy? So the step-down part of therapy?

Dr. William Anderson:
Yeah. So we're going to assume that this is a patient that's not on biologics at this point in time. And I would say that my primary goal and my primary focus is to try to lower the inhaled steroid dose first and foremost. There's just been so much data that's come out over recent years showing that inhaled corticosteroids have more of an impact than we think that they may, whether that is on height, whether that is on risk factors for other conditions, especially those kids that are smaller and on higher doses. So I would very much like to pull back on the inhaled corticosteroid first, and then from there, if it's stepping down on their LABA, we can certainly do that next.

I have not had as many kids placed on montelukast as of late secondary to the black box warning that, at least in the United States, is from the FDA regarding the psychological impacts of that drug. So certainly if they are on that, I would probably prioritize that even before the inhaled steroids. But I try to think about these medicines in terms of what may be causing the greatest harm to my patient versus benefit and trying to reduce those ones that potentially are more harmful than others.

Dr. Mariam Hanna:
Okay. And how often do you adjust or scale back on therapy? I run into this cold and flu season. And do I do it during cold and flu season or do I do it during your pollen season and—

Dr. William Anderson:
Yeah, totally. It's a great question. So if you look at the guidelines, they say to reassess every three months, but I oftentimes go a little bit slower, especially in these pediatric patients because did you have a great three months because you just didn't get sick during that time? Or is it because you actually had an improvement during that time? So I often will keep patients on the same course of their therapy during whatever their peak season is. So if that's the winter with viruses, if it's the spring and summer with allergens, whatever that might be, I'm going to be hesitant to reduce then, even if it may fall within that three to four month window where we might be stepping them down. If you have a child though that has viral illnesses triggered asthma and pollen-triggered asthma, you're going to have to pick your poison when you want to do it. And it's a shared decision-making conversation with the family, understanding what they understand to be the risks versus the benefits, making sure they really understand their asthma therapy plan really well to know what to do if the patient starts getting worse during that time when you're stepping down. And so I think that it is going to be that shared decision-making with the family that comes into play in those more complex patients who may not have a typical symptom-free season.

Dr. Mariam Hanna:
Fair. And then let's briefly touch on our severe patients or the patients that were put on biologics. So as a prescriber of biologics, I have come to the awareness that a lot of people become non-compliant with their daily medications because the biologics are just working oh, so well.  And then it becomes a challenge to say, you're doing great, but you're not on any inhaled medications right now, or basically treating as reliever therapy whenever you need to. How do you go about having these conversations of stepping them down? Or do you ever—

Dr. William Anderson:
You are not alone in having your patients stopping their other therapies whenever they're starting on a biologic because they're doing so well. And honestly, if it's working for them, I'm not going to be harping on them to go back to a medicine or to really change their regimen that's working well for them, especially after we've tried so hard. I'm sure insurance companies are not going to hear me say that, and I'm sure other regulatory people don't want to hear that either. But if they're doing well with intermittent use of their inhaled steroids and their other therapies and the biologic, we've reached our goal.

And so I think that we, once again, if it's a long period of time of good control and understanding maybe that a biologic is an expensive medication and it's also an invasive medication, then maybe we would have that conversation of needing to go thinking about stopping our biologic, but recognizing that we might have to go back on other therapies as well. But I think a lot of patients will self-regulate, as you have experienced, whenever they're going on these biologic therapies.

Dr. Mariam Hanna:
Just because of what I learned about your unique role in helping with transitions of care between adolescents and adults, I get a lot of these stories about, I had brutal asthma, and then as an adult, it's fine. And I'm like, were you just lost to follow-up, as most adults are? Or how do you ensure that this transition occurs appropriately?

Dr. William Anderson:
Yeah, certainly. So I think that if we want to first talk about just what makes the elements of a good transition to adult care, I think it all goes back to great self-management education—having patients understand what is their disease, what are the medicines they're taking, why do they need to take these medicines, what to do in an emergency, and really empowering them in that regard. There are stepwise processes that are disease agnostic, if you will. Gottransition.org is a great website to go to that you can get some of this guidance for the nitty-gritty nuts-and-bolts details.

But to your point of that example of a patient who says, I had terrible asthma, and now it's gone, I would really like to have that patient come in and see somebody because, to what I discussed at the very beginning, how much of this is the asthma actually gone, or you have just stepwise changed your lifestyle so much that you don’t think you have the asthma anymore, or you accept something to be basic, I have asthma, so I can clearly not do the same level of exercise, and that’s the way it should be because I don’t have asthma. No, that’s not the case. You’ve just made some decisions amongst yourselves.

I would also be curious about following their lung function over time as well, too. So I’m really trying to have that process in place where you’re empowering the adolescent for their care. If you’re able to follow them throughout their life, fantastic. If you’re at a pediatric center and need to transfer to an adult center, helping to create that warm handoff would be great.

Dr. Mariam Hanna:
What do you see changing in asthma management over this next decade? Now, biologics are in the game, right? So what do you see changing—technology, AI?

Dr. William Anderson:
Yeah, so I think that idea of both early intervention for disease modification as well as early intervention, even if we're not modifying disease, to get it under better control is really crucial. There have been some ups and downs with this idea of electronic medication monitoring, but I still think there’s a lot of promise in that technology—not just to be a reminder of, okay, did you take your meds or you’re not? But really understanding what’s happening at home. We see patients maybe one day for 30 minutes every three months. We’re getting such a small snapshot of what’s really happening, and having a better idea of what’s happening at home could be really exciting.

I also think that if we’re able to use AI to do predictive models to see, are you at risk for having an exacerbation and catching it before you end up in the hospital or in the emergency room would be super exciting too. So I think that asthma’s at a great time right now for some really cool interventions moving ahead that can maybe make big differences in our patients’ lives.

Dr. Mariam Hanna:
I agree. Asthma has never been as exciting. Alright, time to wrap up and ask today's allergist, Dr. Bill Anderson, for his top three key messages to impart to patients and physicians on today’s topic—remission in asthma. Over to you. 

Dr. William Anderson:
All right. Number one, if patients are asking you what's the likelihood that either their own or their child's asthma may resolve, you want to be talking to them about having their asthma under good control because we know mild disease is more likely to resolve, preserving their lung function by preventing exacerbations and avoiding smoke exposure.

Number two, the general components of asthma remission include absence of symptoms, absence of oral steroids, absence of exacerbations, and stable lung function. But recognize that your definition of how aggressive you want to be with those parameters may determine whether or not they've reached that remission.

And number three, and maybe most importantly, this idea of remission is still very new. It's still being explored in clinical practice and research. And so your goal of keeping a patient well controlled should be where your North Star is, and not necessarily driving for remission, but rather how can we keep these patients well controlled overall.

Dr. Mariam Hanna:
Thank you, Dr. Anderson, for joining us on today's episode of The Allergist.

Dr. William Anderson:
Thank you so much for having me, Mariam. It was a pleasure.

Dr. Mariam Hanna:
This podcast is produced by the Canadian Society of Allergy and Clinical Immunology. The Allergist is produced for CSACI by PodCraft Productions. The views expressed by our guests are theirs alone and do not necessarily reflect the views of the Canadian Society.

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