2024 Rutherford Medal: Revolutionising the treatment of asthma worldwide

Richard, a clinician researcher, is Director of the Medical Research Institute of New Zealand, Research Physician at Te Whatu Ora Capital, Coast and Hutt Valley, Professor of Medicine at Te Herenga Waka – Victoria University of Wellington, Adjunct Professor at Ōtākou Whakaihu Waka University of Otago and Visiting Professor at University of Southampton in the United Kingdom.

His main research focus has been on asthma, which has been a major health problem both in New Zealand, which has one of the highest rates of asthma in the world, and globally.

Through the 1970s and 1980s, New Zealand experienced two epidemics of asthma mortality, when our asthma death-rate was the highest recorded in the world.

In 1985, Richard was awarded a Fellowship from the Health Research Council of New Zealand and the Wellcome Trust to undertake postgraduate research and training in asthma with Professor (now Sir) Stephen Holgate in Southampton.  

“This was a career-changing experience as I came to appreciate the importance and impact of clinical research,” Richard said.

While in Southampton, Richard led the first detailed study into the airways of adults with mild asthma. The study’s findings were unexpected, with the biopsies showing that there were marked inflammatory changes in the airways, when it had been thought such inflammation was only associated with moderate or severe asthma.

Stopping the epidemic of asthma deaths

On his return to New Zealand, Richard teamed up with Julian Crane, Carl Burgess and Neil Pearce to establish the Wellington Asthma Research Group, with the objective to solve the puzzle of what was causing New Zealand’s asthma mortality epidemic. Through a series of epidemiological and clinical studies, the asthma reliever medication fenoterol was identified as the major cause of the epidemic.

In response to the research findings, the Department of Health issued warnings about the risks of fenoterol, and then Health Minister Helen Clarke advised the Ministry to stop funding fenoterol as a drug, despite considerable pressure not to do so, Richard recalls.

“These regulatory actions directly led to New Zealand’s asthma mortality rate falling dramatically by more than two thirds, to the lowest rate in New Zealand for over 25 years – a great outcome for New Zealand.”

“It led to a paradigm shift in asthma management, whereby the risks of overreliance on relievers was now recognised and greater emphasis was put on anti-inflammatory preventer medications such as inhaled steroids.”

Two-in-one asthma treatment

Despite the recognition in the medical world of the need for inhaled steroids as an asthma preventer, the problem was that most asthma patients did not take their inhaled steroids regularly as prescribed, explained Richard.

This conundrum was solved with the development of the two-in-one inhaler device, in which the steroid is included in the reliever inhaler, so that every time the patient takes their reliever, they get additional preventer with inhaled steroid treatment. 

“This is a really important concept, because as patients take more of their reliever inhaler when their asthma is getting worse, they get more of the preventer, and particularly in the development of a severe asthma attack, they get quite a lot more inhaled steroid, and that has the ability to suppress the severity and stop the progression of the asthma attack.

“This probably has been the biggest paradigm change in asthma treatment over the last decade or two.”

Checking patient safety

Clinical trials had clearly shown the benefit of the two-in-one approach, but these studies “had not really addressed the issue of safety in any rigorous way,” Richard said.

“So we undertook a study which, for the first time, used electronic monitoring to precisely record the date and the time of every inhalation of the randomised treatment in a clinical trial to look at patterns of use.”

This trial was done in a group of high-risk asthma patients, and in whatever way they analysed the data, the two-in-one inhaler proved to be much safer. It reduced asthma attacks by about half, and also reduced over-use episodes where delays in seeking medical treatment can contribute to fatal outcomes.

Reducing health inequities

In response to this research, the New Zealand Asthma Respiratory Foundation called together a group to set guidelines for asthma treatment, and the resulting guidelines were implemented through primary care in New Zealand.

“Looking back, I remember getting feedback at the time that guidelines are a waste of time and it would not be possible to change prescribing in New Zealand from the entrenched blue inhaler to the two-in-one inhaler,” Richard said.

“So, we had a look and found not only that use of the two-in-one inhaler has more than doubled, but there has been a 25% reduction in hospital admissions for asthma. Most importantly for many of us working in this field, the greatest reduction in hospital admissions has been in Māori, who experience the greatest burden from asthma in New Zealand. From my perspective, reducing inequities in asthma in New Zealand is the holy grail.”

Challenging dogma through the Medical Research Institute of New Zealand

Asthma is one of the core research programmes at the Medical Research Institute of New Zealand.

The Institute’s research programmes, predominantly based on clinical trials, have necessitated close engagement with the community, and there are now more than 7,500 volunteers who are active participants in the patient volunteer database. Training emerging clinician researchers has been another goal of the Institute.

When Richard set up the Institute in 2001, his philosophy of the novel research it would undertake was simple: “It must challenge dogma, increase knowledge, and have the potential to improve clinical practice and outcomes—while reducing inequities—both in New Zealand and internationally.

“Amongst the 12 research programmes at the Institute, the intensive-care medicine programme, led by Paul Young, is the jewel in the MRINZ crown” he said.

In accepting the award, Richard said he felt extremely fortunate. “Fortunate to have worked with such hugely talented and committed colleagues within multidisciplinary teams. Fortunate to work and live in a community which is so generous and altruistic, with tens of thousands of volunteers – adults and children – who have taken part in our studies, supported by the GP community and clinical trial collaborators. Fortunate to have institutional support, not just the Medical Research Institute but also Southampton University, Wellington hospital and more recently, Victoria University of Wellington. Fortunate for long-term funding support from the Health Research Council throughout my entire career.

In awarding the Rutherford Medal, the selection committee noted Richard’s extraordinary contribution to asthma research, respiratory medicine and clinical trial science. “He has inspired a generation of doctors, provided specialist research training for some of New Zealand's leading clinical trialists, and has shown, unequivocally, that findings from investigator-initiated clinical research in New Zealand can change clinical practice, reducing morbidity and mortality around the world”.

Richard has previously received the Society’s Hercus Medal (2016) and the Health Research Council of New Zealand’s Beaven Medal (2019). His outstanding international contribution to asthma research has been acknowledged by the American Thoracic Society World Lung Health Award (2002); the Asia Pacific Society of Respirology Woolcock Research Medal (2010); the Asthma Australia National Award (2013); the Thoracic Society of Australia & New Zealand Research Medal (2015); the Global Initiative for Asthma Ambassador Award (2016); and the Asia Pacific Society of Respirology Medal (2019). He was appointed a Companion of the New Zealand Order of Merit in 2008 for services to medical research and elected a Fellow of the Royal Society Te Apārangi in 2015.

Rutherford Medal:
For exceptional research, scholarship, or innovation in any field of engineering, humanities, mathematics, sciences, social science, or technology. The medal is named after Ernest Rutherford, the physicist and Nobel Laureate, and is the most prestigious award offered by the Society.

Citation:
To Charles Richard William Beasley for revolutionising the treatment of asthma worldwide.