Dr. Maria Mascolo, Pulmonologist
I am Dr. Jeff Kingsley and this is another edition of Riding in Cars With Researchers! Today we are going to be talking to Dr. Maria Mascolo, a pulmonologist who has been doing research with us for about 11-12 years. She has a lot of great experience under her belt.
Dr. Mascolo, from my perspective, we have not had outstanding breakthroughs in pulmonary medicine – asthma treatments, COPD treatments, idiopathic pulmonary fibrosis. Why?
I think our understanding of COPD has been poor for a number of years. With advances in microbiology and general pathways of inflammation, we know more now, which has allowed us to be better equipped to treat the disease at its root cause. Up to this point, the treatment of COPD and asthma has been somewhat unsatisfying to treat as a physician as we are really just working on symptom control. Therapies for asthma and COPD have really targeted symptom control, rather than getting to the root of the problem. Dealing with the underlying cause of the inflammatory process which leads to the long-term sequelae we see in untreated asthma and COPD.
One of the ways that I’ve explained this to patients in the past and correct me if I am wrong, I’ve said today we have this basket of people that we all label as COPD and I think in the future we are going to end up with a lot of subcategories. Today what we are calling 1 disease is really 3 or 4 different diseases caused by completely different mechanisms. And we’ll have unique therapies for each one, I think.
I agree. I described COPD to my patients as a basket term. COPD includes asthma, emphysema, chronic bronchitis, bronchiectasis, cystic fibrosis, Alpha-1 antitrypsin deficiency. All of those cause COPD which just mean chronic obstructive pulmonary disease. That’s nothing more than a finding on a pulmonary function test. Each of these disorders has its own causative mechanism, which I do agree over time we will be targeting those causative mechanisms. We are doing some now with Alpha-1 antitrypsin deficiency, which is simply a disorder that looks and acts like COPD, with the exception of an additional medication that treats the underlying cause. In regard to Alpha-1 antitrypsin deficiency, if you don’t have the genetic mutation that causes it, that treatment doesn’t do anything for your COPD if your COPD is caused by smoking. So, absolutely, I think that is the correct way to describe COPD and over time we are going to find certain subsets that we treat differently and that we even diagnose differently by doing different testing.
Breakthroughs in Pulmonology
What breakthroughs have you seen?
My first trial with IACT Health was with Daliresp, which is the only drug in its class, as the first drug that was supposed to decrease acute exacerbations in patients with chronic bronchitis. It’s been great for patients and some patients have enjoyed the side effect of losing weight on it. At the end of the day what Daliresp does is reduce the exacerbation rate in chronic bronchitis. So again, we are treating symptoms, not necessarily getting to the underlying cause, but working towards that in targeting a different pathway. In addition to that, we’ve had some new drug combinations come out in different types of inhalers which have allowed us to consolidate treatment in patients. For instance, the trilogy study with GSK where we have triple therapy available for patients, that has been great from the standpoint of treating symptoms, targeting symptoms patients have with COPD, but not necessarily getting to the underlying cause. But instead making available to patients a convenient treatment regimen that they can basically use once a day in lieu of taking several treatments several times a day. So that has been beneficial as well. We have not had a lot of major breakthroughs.
But those combinations improve compliance and it’s cheaper. It’s good, but not great.
The Cusp of Something Big
Do you think we are on the cusp of something big in pulmonology?
I hope so! It does seem that with biologics that are a very active area in research with asthma, and becoming a more active area in COPD, that if we can find a therapy or niche for those drugs in these diseases and their underlying causes, we may actually be treating patients differently than we were 5 years ago. It will be interesting to see in those drugs, which are actively being investigated in multiple studies coming down the pikes if we move forward with biologics for patients. In asthma, there has been an explosion in biologics, and we are prescribing biologics more and more for that group of patients. We are not quite there with COPD yet, but I certainly think that as companies or Sponsors see that biologics are very useful in asthma, they will get behind the idea of targeting the inflammatory processes that occur in COPD. This is an area of great interest and we will be seeing more over the next several years.
Lab Work Helps
Are you starting to use lab work to guide therapy?
Yes, for asthma we are doing that. All of my asthmatics now get a CBC and IgE in RAST testing and some go on to see an allergist. We’ve never done that before. And depending on their response to conventional therapies, we are very quickly applying for Nucala or Zolair depending on the lab work. There are a huge number of options for patients that we didn’t have before. I will say that in my anecdotal experience, in patients that I’ve actually treated with these drugs, it’s made a huge difference. People who were in the ER once a week, or once a month, aren’t in the ER and not on Prednisone every 8 weeks. It’s been huge.
And those are subsets of patients that years ago we didn’t know they were different from other asthmatics. It’s a different mechanism for those patients.
Yes, and I think we are going to be using those drugs more going forward. Obviously, I expect more research on more biologics that target different pathways and treat different causes of asthma and emphysema.
So many times, that is all it takes. It takes that one “aha” moment and the whole industry goes in a different direction and there’s a flood of innovation.
Pulmonologists in Research
You are a pulmonologist, a sleep medicine specialist, and a researcher. What would you say to the pulmonologists that are watching today who aren’t doing research?
I think you are missing out if you are not doing research. There are some great therapies that are hopefully going to be available to patients relatively quickly. The nice thing about doing things the way I do it is I get early access to those therapies. It’s been a great help to my patients, it’s been great for me helping me to stay up to date. If you are not doing research, certainly keep an eye on the horizon because things are coming, and I think there will be some great therapies we will be able to offer patients in the near future.
Working with IACT Health
How would you describe how you interact with IACT Health? Does IACT Health help you or hinder you in doing research?
I believe we have a great relationship! We have been doing research for quite some time now. My practice is very open, and we have a culture in my practice where my patients are actively asking for new trials. IACT Health has been a huge help in providing therapies and general medical care to make sure that patients who participate in trials get that extra attention of a clinical research coordinator. They get help with their medications and get education, which we don’t always have time to provide in the clinical setting. For me, IACT Health has been a huge help in helping to coordinate care for my patients and offering cutting-edge therapies to patients in a way that they may not get coming to a rural community practice. From a standpoint of working with the IACT Health staff, you have a great staff, and everyone is very caring and has a great relationship with my patients, my clinical staff. With the corporate office in Columbus, we have worked well together overall and certainly make my job easier by helping to identify trials for me. We talk about what trials are suitable for my practice, and I don’t have to take care of the bureaucratic things – I’m just taking care of the patients and running the trials. Which is great! I, personally, enjoy it and think that it keeps me involved in the academic setting in a way, which I otherwise wouldn’t have had the opportunity to do if I wasn’t doing research. It’s helped me to keep up to date and helps me to offer something to my patients that not every physician can offer.
I am happy to have introduced you to Dr. Maria Mascolo! Pay attention to pulmonary! There are obviously changes coming and it’s going to accelerate – you can feel that we are right on the edge of some really great breakthroughs in pulmonary medicine.
Thanks for riding along!
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