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.