[00:00:00] non: You are listening to the ATS Breathe Easy podcast, brought to you by the American Thoracic Society.
[00:00:18] Amy: Hello and welcome to part two of our talk on anti-inflammatory therapies for asthma with Dr. Njira Lugogo. I'm your host, Dr. Amy Attaway, in case you missed our first episode. Today's guest, Dr. Lugogo, is a clinical professor of medicine and director of the University of Michigan Asthma Program. We'll be talking about some of the barriers to treatment for anti-inflammatory therapies and asthma, such as insurance coverage, and also about advocacy.
And then we'll dive into, her research career. I think also the, some other barriers maybe getting insurance. I think that's one of the things. Yeah,
[00:00:56] Njira: yeah. When something is new, it's always like that. Yeah. [00:01:00] but you have to, you know, you have to engage in advocacy. So we've partnered with. Blue Cross Blue Shield of Michigan.
We are doing this QI initiative in the state. We have about 800 participating providers and 18, physician organizations, both independent and employed physicians. And so what we did early on before, you know, we had, ICS, albuterol on the market is we met with them and we presented the case. We should be covering two, you know, formoterol containing inhalers a month for people who needed to be on maintenance and reliever therapy.
And, you know, we managed, we talked to them, we presented the data, and we argued the case and they changed their formulary. Wow. To allow two inhalers a month for people who needed it. Mm-hmm. And Michigan Medicaid also covers it. So I think as clinicians, we underestimate our impact, our health, you know, our health plans wanna [00:02:00] save money also.
And so, you know, they want their patients to do well. They wanna save money. Those ED visits and hospitalizations are very costly because, you know, the patients ultimately go and get all kinds of scans stem to stern, a lot of, you know, very expensive testing. And so, you know, it behooves us to really partner with them and say, Hey, these are some really.
Very strong evidence-based strategies to help these kinds of patients. Now that we have, you know, Albea and budesonide, initially it had just come to market. The URA study hadn't been published, which was published this year. So now we, we have an idea that, okay, you know, this, this, drug, helped.
Reduce exacerbation. So much so that they had to stop the study early because the impact on those patients was so significant in terms of exacerbation reduction. So I think it's time to go back and have conversations. I know the [00:03:00] company provides coupons, to allow. People with commercial insurance to get it, a little bit cheaper.
We have been successful in prior authorizations, you know, describing the need and explaining why it's necessary. And I think we need to now start partnering with some of our spon, you know, our, um. Our, insurance companies and Medicaid and, and really advocate for this therapy as a way of like reducing healthcare resource utilization.
You know, when you spend $85 billion to treat people with asthma and 10 people still a day are dying and people's outcomes are not improving, the number of ER visits didn't change. We are doing something wrong and we really need to change that terms of education to patients very. I'll tell you, many of them have no idea that asthma is inflammation and constriction.
They dunno anything about smooth muscle or anything about what the [00:04:00] disease is. And when you educate them about it, they really comprehend that. And they are more, accepting of this treatment paradigm. And so far people have found it useful, both maintenance and relieve therapy. With Omoro and this new, ICS budesonide therapy, they find it really helpful.
They come back and say, wow, it, it, I feel like it helps me more. And then, you know, for providers, we've been trying, we, we got a grant, we are doing a, we, created a. a webinar. We are going to record the webinar. We've given it live. I'm going to give, grand rounds tomorrow. We are going to record this webinar on anti-inflammatory reliever, the science behind it, the practical Implications, and we're going to publish that.
We've done some things within our health system to flag when someone is prescribing a Saba. Hey. You know, there's new information out there saying that they are better [00:05:00] strategies and we have a smart set that makes it very easy to order, anti-inflammatory reliever therapy. And so that's some work my colleague Dr.
Mohan has been doing. And we've seen those prescriptions going down. And as a matter of fact, people used to give. Albea with 12 refills and you know, if you take 11 refills in a year and you are really taking that medicine, your risk of dying is 31 times higher. So we just need to point that out to our providers.
And so we've seen a reduction and we're continuing to educate providers, including launching a maintenance of certification opportunity for people to do a small QI project in their clinics. To figure out how to tackle some things on a system level, like maybe a best practice advisory flag, or figuring out who's on Saba monotherapy and targeting those people first, particularly those with a healthcare resource utilization visit.
So I think there are all these kinds of strategies we just need to. [00:06:00] The drums and showing up everywhere and, you know, talking to everybody ad nauseum and hopefully we'll see, a change. And I, I feel like we've seen a huge change just in the last year or year and a half where people are really like, oh wow, this.
This is makes so much sense and we see that they're embracing this much more readily.
[00:06:24] Amy: Mm-hmm. Well I have to, that was one of the things like think about how far asthma has come Yeah. In just the last five, 10 years. So, so exciting. I love that you're like, you know, we identified a problem and you know, you highlighted advocacy and how we can, we can make that change, which is just amazing, to hear from you.
So, and then thank
[00:06:46] Njira: you.
[00:06:47] Amy: Finally, finally. So we wanted to, also kind of hear if you could give us a little bit of, a story about your journey. And how, because you're such a successful, you know, [00:07:00] top of your field, provider and, and clinician, master clinician, how did it, it's not, and I think a lot of early career investigators kind of wonder what the path was.
'cause it's often not a straight path. So do you wanna talk a little bit about, she's shaking her head in case anyone's wondering, but, do you, you wanna talk a little bit about that and kind of what brought you to where you are right now?
[00:07:24] Njira: Yeah. So, I'll start out by saying that I, I was drawn to pulmonary because of critical care.
Hmm. And so I think that's a common, theme for a lot of people. as a medical student, you really don't see that much pulmonary, you don't know that much about it. and so when I was finishing medical school, I went into internal medicine. I would say still, you get more inpatient. Exposure and a little clinic exposure.
But unless you seek it out, you really don't get a ton of, [00:08:00] subspecialty clinic exposure. And I think our cardiology colleagues are much better at enticing people to, to do cardiology, you know? And so when I was, training, I, I sort of said, well, you know, I'll do pulmonary, but I love the icu. It was so exciting to me, you know, like, the acute changes in physiology, the immediate feedback and patients are getting better and, you know, you just really get hooked on it.
And so I went into pulmonary for critical care and then I wanted to do clinical research and I thought, well, I wanna learn some clinical research skills. I'm not sure how to do that quite easily in the ICU and I looked around, I was at, duke as a fellow at the time, and Monica Kraft had just come to open the asthma center and she had moved from National Jewish to, to Durham.
And I thought, well, she knows how to do clinical research, so I'll. Learn everything I can [00:09:00] about clinical research. And I was quite naive because I was like, then I'll just use my clinical research skills and do ICU research, which is quite interesting. And I was like, I like, you know, kind like, okay, but how interesting can it really be, you know?
You give people inhalers, like in the ICU. It's so fun, you know? Yeah, yeah. And so I start gonna the asthma clinic, and then I'm like, wow, what is this? You know? It was very nuanced. It was really complex. I love patients, you know, and, I liked this longitudinal care. I was, I was very happy in my primary care practice.
I just didn't wanna do primary care. But I loved that longitudinal aspect. And, you know, I'll be honest with you, a lot of the asthma patients looked like me. You know? they were people who came from a variety of backgrounds and. Some people who were [00:10:00] like in their thirties and forties and, you know, and, and you started to identify with this journey and as you saw the more refractory patients, that was back in the early two thousands.
You know, we had omalizumab, we weren't using it quite as much. They were OCS dependent patients and they were being ravaged by asthma. And we were over there trying to figure out whether to trim methotrexate or CellCept or what do you do? And, I spent some time. Working with Monica, we were on these large, networks.
I was part of the a CRN studies and the AsthmaNet studies and, we did translational research. so we would do bronchoscopies on patients and take the lab, the samples to the lab. I became very, humbled by that experience because, you know, I, I remember one day doing a procedure, you know, we did an experiment and it was a, a Western blot, and then at the very last minute, you know, you go into the dark room to.[00:11:00]
Prepare your Western block to see the band so you can figure out how much protein there is. I believe that's what Western blocks are for. So there you go. That's how
[00:11:10] Amy: bad I was in
the,
[00:11:12] Amy: we still, we still do them. I do like five a day.
[00:11:15] Njira: Okay, there you go. So I'm, I'm standing there in the dark room. I turn the light on and there are no van.
And, I remember standing there and I was like, I see people who are dying. Like, oh my gosh, why can I get a western block to work? You know, and my epithelial cells would die. And you know, it was a very humbling. I learned something very, very important A, that I wasn't very good in the lab or that was a, you know, sometimes you need to to learn what you can and can't do, but I learned the value of translational science and understanding mechanisms of disease and really bringing that back from the bench to the bedside.
So I would say that's one [00:12:00] thing. The second thing is I participated in clinical research studies, not so many pharma, but like. And I funded clinical trials and networks. So in the network I learned, the value of being part of a team and in a collaborative atmosphere and learning from colleagues and seeing how people think about complex problems and try to solve them.
And then the third thing that I learned early on. I never wanted to feel helpless. In fact, I think that's a trait of I've had all through my life is I just don't like the feeling of helplessness. And so I realized that I didn't want to be the person who had to tell the patient that I didn't know what to do.
I didn't have anything to do or offer, and that drove my passion towards. Finding answers and doing clinical trials because I could always tell the patient, Hey, we are working on a new solution. Like maybe I don't have one right now, but we have this study that we are doing, or [00:13:00] this is the pipeline of, of, future development.
And so I will say that, my road was a bit windy. it was, you know, fits and starts. it was always in asthma. I feel like if you wind within a certain band, you might eventually straighten the line a little bit. If you are doing, you know, research in 10 different areas, it becomes a little bit too much.
I. Coupled my passion for clinical care and asthma with a passion for finding answers to treat patients with asthma. And then, you know, I, I learned to say no. I'm still very terrible at saying no, but at least I say yes to things that have to do with asthma. And, I had to at some point start to make some decisions about giving things up.
So, you know, right before COVID, I gave up ICU care, which was a [00:14:00] big. like cross the road from me because, you know, you always feel like, oh my gosh, I, I honed this skill. But then I realized, you know, maybe I won't have the breath. I just have the depth. And so right now I tell people I'm not a very good.
Pulmonary doctor, I'm probably not the best ICU doctor, but I, I'm a very good asthma doctor and so, you know, I, I, I sort of have narrowed my band. I still wind a little bit, but within a. Smaller margin. A coupled a passion with focus. maybe first start with passion and then hone it in and maybe get a little focus over time.
Increase your depth as you go. And, you know, you just eventually will find your way. And I've said yes to some crazy ideas along the way that have panned out. So, you know, that's really where I would, I would say you [00:15:00] should go and I'll give more advice after you ask me some additional, questions, but I have some thoughts about.
Future potential opportunities in this area for young people who might be listening to this podcast.
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[00:15:45] Amy: Oh, that's great. No, I was just, I think I just say like, passion and focus. and then, but that's, that's the end, right? Like it, it started out you tried things that you didn't.
Think you were gonna like, so you have to really, you have to like put [00:16:00] yourself out there, be uncomfortable, you know, do something that you never thought you were gonna do. Be, because we all have these ideas in our head and they're probably completely different, like 15, 10 years down the road than what we were thinking.
So, but what were you, what I think additional advice would you say?
[00:16:21] Njira: Yeah, well, I would say that, you know, a career in clinical trials is actually really, really fun. I'm going to tell you that, you know, I, I, there were some challenges, you know, sometimes when you are the person doing pharma trials, in an academic setting particularly people may not.
Look at that as a special skillset. You know, if you are doing basic or translational research or you're IH funded, they clearly universal respect for that. People are like, wow, you [00:17:00] got NIH funding. You know, that's, that's serious. That's somebody who's really contributing on a high level high. When you are doing pharma trials, there's a presumption that it's not a special skillset.
Anybody can do it. You just follow a protocol so forth. And I will say there are like a spectrum of ways to engage in this work. when I started out, I just wanted to be a really good site PI and I was energetic, you know, I looked at the protocol and I gave the company's feedback and said, well, this looks like a, a challenge and this thing is a problem and I'm worried about this.
Inclusion. I was just really very engaged initially. you know, I, I would. Sort of say, well, why am I not on publications, for example? But I had a poor understanding of how that happened. So if you're a very successful psych pi, sometimes you can get on publications that way. But a lot of times the people getting on [00:18:00] publications of people who've been there since the beginning, developing the protocol, serving on scientific advisory committees.
They're following the execution of the trial. They're looking at the study results, and then they're participating in publication. So when you start out, I think you need to real focus on becoming a really good pi, engaging with these companies, giving advice and insights that only you have. Given that you are the one actually executing the protocol.
So then over time I started getting asked to participate in advisory meetings. And you know, I would sit in the room and wonder why I was there. I had that imposter syndrome, like, oh, I shouldn't be sitting here next to these people. Like, I read their papers, they do everything. Why am I sitting here? But, you know, I spoke up, I just gave my ideas and, and you know, my clinical.
They have the ability to create the drugs, they don't take care of patients. So you give that invaluable insights into [00:19:00] what's happening on the street and how patients are receiving this, how you are incorporating these new treatment, what are the unanswered questions for you as a clinician. And then, next thing you know, I was invited to some scientific committees where they were.
Saying, Hey, we have this new drug, we wanna design a trial. And I'm like, wow, this is so exciting. And so I gotta contribute there. And now in the last few years I've become, you know, privileged enough to become the international coordinating investigator for some of the international studies. For, for example, the inhaled TSLP studies going on right now, and so I think, you know, that was a 10 or more year process, so you should be patient.
You need to be somebody who's comfortable being uncomfortable, as you said, Amy, because you are inherently a business person, you are. Earning money and you are paying staff and you are managing them, and you need to be [00:20:00] savvy about, you know, the money. It's not as comfortable. Getting an NIH grant is very hard, but once you have it there, little more security.
Like I get this much money each year for five years if I do what I said I was going to do. On the other hand, I'm earning every dollar, like every visit I do generates revenue. I have to. Account for the revenue, figure out if I'm covering my staff, I have to, you know, know how to budget. And so those are skills you need to learn the financial oversight over your research business.
And that's something of course I'm always willing to educate people on. And then, you know, just. You make a difference, you know, you are able to be there. I, I use drugs. I can say, Hey, I, I used tezepelumab before it was available. 'cause I did the phase three study. Then there was an open label study and okay, I didn't have a ton of patients, but I get a lot of experience with this.
I get to be in the know. I really love being in the know, [00:21:00] knowing the data results before they're published and things like that Makes me feel really excited. And now in my. Latter years. I'm not that open, but I'm, you know, I'm transitioning more towards like, okay, what do I wanna spend the last few years doing?
And, you know, I figured out I don't want to manage faculty. I love my colleagues, I love all the pulmonologists out there, but I don't want to be a division chief managing other faculty. I wanna understand implementation science. I didn't start out there. And when I was asked to do this state QI program, I had no QI credentials, but I had passion and knowledge and I felt like I can figure it out.
I can bring in experts that know how to do QI work and. I want to learn how to implement change because you know, we've spent, I've spent 15 years discovering drugs which then aren't being used, and the patient outcomes are not changing. So how do we bridge this gap? And so now I'm [00:22:00] very much more interested in educating other providers and figuring out how to exact change and help people to embrace new treatment paradigms.
And so I think that's where my focus is shifting to continuing. Clinical trials, but more on a high level, empowering my mentees to become site PIs, and then focusing more on, you know, developing new clinical trials, answering questions, and helping. Companies think through that critically, but then focusing on implementation.
So embrace the journey. It's a good career choice to have. I've managed to get promoted doing this kind of work. And so, you know, there is a path for people who are really passionate about clinical research.
[00:22:45] Amy: That's great. I love like embracing the journey and realizing that the person you are when you start, I think is different than the person you are.
Yes. You know, throughout your life. So of course it's gonna change. Your path is gonna change because you've [00:23:00] changed. I, I think that's one of my, my takeaways from that. So Yeah,
[00:23:04] Njira: absolutely. You just have to listen to your gut too, you know? You'll be asked to do certain things when you get to a certain level, and for example, with the issue of administrative work, I've done administrative work.
I ran an asthma, center. I run the, our clinical research unit here at University of Michigan. I've done a lot of administrative work, but I had to really be, you know, truthful with myself similarly to, with the ICU. Give or take, you know, is this, I can do this, but is it where I want to be? And is it, is my passion really?
And I think going back to passion and what drives you and being focused and then sort of like, you know, narrowing the band. And sort of going forth I think is, is like the best way to be successful. And then, you know, tapping into other people that are experts reaching [00:24:00] out. I've been, you know, I've gotten to this point because of all the people both in the US and internationally that I looked up to.
I sat in rooms with, I picked their brain, I learned how they think, and I just sort of developed my own. Unique way of thinking and doing things, but it's been a product of so ma much input from so many people that, you know, I still admire to this day and still get to work with very closely. And lastly, you know, I personally believe that you should never get to drunk on your own hype.
You should always remain humble. And anytime people ask me to do things. I feel privileged. I'm like, thank you so much for asking me. You could have asked anybody else and you came to me and I appreciate that, and I've never lost that childlike wonder, you know, from being in those rooms in the first place and saying, oh my gosh, what am I doing here?
I still have [00:25:00] that similar feeling, except now I'm not sort of like, oh my gosh, what am I doing here? Because these people know way more than I do, but it's, oh my gosh, you could have asked anybody and you still feel like my voice is important. And so I really am so grateful for those opportunities. And now I'm turning around and trying to lift up other, you know, more junior faculty and advocate for them and get them to.
Be in the room so that they too can have those moments of, oh my gosh, what am I doing here? And then grow to become much more experienced and, successful.
[00:25:37] Amy: Wonderful. So I think humility, staying curious, paying it forward. These are never bad things, so thank you. Yes,
absolutely.
[00:25:46] Amy: Well we have taken up a lot of your time and we have really enjoyed it.
but I think all good things have to come to an end. So we just wanna thank you again Dr. Lago, for, for giving all this, all this amazing [00:26:00] insights into, um. Anti-inflammatory rescue therapy and then your a stellar career and the path you took. So thank you again for, joining us on the podcast.
[00:26:10] Njira: Oh, thank you so much for having me.
I'm hoping that, maybe we'll inspire few people to do clinical trials. we really need more people, so.
[00:26:20] Amy: Great. They will. I'll have them all reach out to you, so thank you
[00:26:25] Njira: so much.
[00:26:26] Amy: All right. Thank you so much.
[00:26:28] Njira: You are welcome.
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