A Clinical update in Asthma

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A Clinical update in Asthma. Lee Dobson Torbay Hospital. Questions?. A brief history of asthma management. 2007 SMART. 2001 Symbicort. 1996, 1997 Woolcock & Pauwels Landmark studies. 1990 Serevent introduced. Fostair. 1994 Greening, Ind Landmark study. 1999 Seretide launched. - PowerPoint PPT Presentation

Transcript of A Clinical update in Asthma

  • Lee Dobson

    Torbay Hospital

  • Early 1950sMDI19563M launchThe MDI1965Intalintroduced1972Becotideintroduced1991The 2 agonistdebate1993Flixotideintroduced1995 onwardsGINA1999SeretidelaunchedLate 60sBronchoscope1969Ventolinintroduced1980sMajordevelopmentsin asthmamanagement1990Sereventintroduced1996, 1997Woolcock & PauwelsLandmarkstudies2007SMART1994Greening, IndLandmark studyA brief history of asthma managementHow are we doing?2001Symbicort1997OxisFostair

  • Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s

    NHWS: A population-based cross-sectional survey conducted in 2006 in 2337 patients diagnosed with asthma in France (n=476), Germany (n=486), Italy (n=223), Spain (n=227) and the UK (n=915) Not Well-Controlled defined as Asthma Control Test score 19Not Well-Controlled asthma (% of treated patients) % Patients not Well Controlled

  • Every 6 hours someone dies from asthma2Data includes 590,000 teenagersand 700,000 people over 6511. Where Do We Stand? Asthma in the UK Today. Published December 2004. Available at: http://www.asthma.org.uk/how_we_help [Accessed October 2006.]. 2. General Register Office collated in Office for National Statistics mortality statistics for England and Wales; General Register Office for Scotland; General Register Office for Northern Ireland collated by the Northern Ireland Statistics & Research Agency (2004).

  • It is a myth that only severe asthma can prove fatal

    Asthma deaths occur across disease severity with deaths occurring in those patients whose asthma is considered mild-to-moderate

    Harrison B et al. Prim Care Respir J 2005 Dec; 14: 30313. Number of asthma deaths across disease severity 20012003n=57

  • Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/

  • Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/ 2009 2010

    TCT1019810193

    SD 8276 8481

  • Asthma admissions increased by 30%45 more hospital admissions Asthma bed days decreased by 21%122 fewer bed days

    Source: NHS Information Centre: Hospital Episodes Statistics (HES) Average length of stay decreased by 39%From 3.8 days to 2.3 days

  • British Thoracic Society (BTS)Scottish Intercollegiate Guidelines Network (SIGN)

  • Definition of asthmaDiagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92A chronic inflammatory disorder of the airways in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.

  • The diagnosis of asthma is a clinical one

    There is no standardised definition, therefore, it is not possible to make clear evidence based recommendations on how to make a diagnosis

    Central to all definitions is the presence of symptoms and of variable airflow obstruction

  • Base initial diagnosis on a careful assessment of symptoms and a measure of airflow obstruction

    Spirometry is the preferred initial test to assess the presence and severity of airflow obstruction (use PEF if spirometry not available)

    PEFR spirometry unavailableoccupational monitoring

  • >1 of the following: wheeze, breathlessness, chest tightness, cough, particularly if:worse at night and early morningin response to exercise, allergen exposure and cold airafter taking aspirin or beta blockersPersonal/family history of asthma/atopyWidespread wheeze heard on auscultation of the chestUnexplained low FEV1 or PEFUnexplained peripheral blood eosinophilia

  • Prominent dizziness, light-headedness, peripheral tinglingChronic productive cough in the absence of wheeze or breathlessnessRepeatedly normal physical examination of chest when symptomaticVoice disturbanceSymptoms with colds onlySignificant smoking history (>20 pack-years)Cardiac diseaseNormal PEF or spirometry when symptomatic

  • Without airflow obstructionChronic cough syndromesDBSVocal Cord DysfunctionRhinitisGORDHeart FailurePulmonary FibrosisWith airflow obstructionCOPDBronchiectasisInhaled Foreign BodyObliterative BronchiolitisLarge Airway StenosisLung CancerSarcoidosis

  • Start treatment at the step most appropriate to the initial severity of their asthmaAim is to achieve early control Step up or down with therapyMinimal therapyBefore initiating new drug therapy:ComplianceInhaler techniqueEliminate trigger factors

  • Control of asthma, defined as:No daytime symptomsNo night time awakening due to asthmaNo need for rescue medicationsNo exacerbationsNo limitations on activity including exerciseNormal lung function (FEV1 and/or PEF >80% predicted or best)

    with minimal side effects.

  • Factors that should be monitored and recorded:Symptomatic asthma control using RCP 3 questions, Asthma Control Questionnaire or Asthma Control Test (ACT)Lung function (spirometry/PEF)ExacerbationsInhaler techniqueCompliance (prescription refill frequency)Bronchodilator reliance (prescription refill frequency)Possession of and use of self management plan/personal action plan

  • Factors that should be monitored and recorded:Symptomatic asthma control using RCP 3 questions, Asthma Control Questionnaire or Asthma Control Test (ACT)Lung function (spirometry/PEF)ExacerbationsInhaler techniqueCompliance (prescription refill frequency)Bronchodilator reliance (prescription refill frequency)Possession of and use of self management plan/personal action plan

  • Component of action planResultPractical ConsiderationsSymptom vs PEF triggerStandard written instructTraffic LightSimilar effectConsistently beneficialNot better than standard2-3 action points4 action pointsConsistently beneficialNo better

  • Inhaler devices

  • Prescribe inhaled short acting 2 agonist (SABA) as short term reliever therapy for all patients with symptomatic asthma

    Good asthma control is associated with little or no need for short-acting 2 agonist

    Using two or more canisters of 2 agonists per month or > 10-12 puffs per day is a marker or poorly controlled asthma that puts individuals at risk of fatal or near-fatal asthma

    Patients with high usage of inhaled short-acting 2 agonists should have their asthma management reviewed

  • Inhaled steroids are the recommended preventer drugs for adults for achieving overall treatment goals

    Consider inhaled steroids if any of the following:Using inhaled 2 agonist three times a week or moreSymptomatic three times a week or moreWaking one night a weekExacerbation of asthma in the last two years (adults and 5-12 only)

  • Adults:200-800mcg/day BDP*(reasonable starting dose 400mcg per day for many adults)

    Start patients at a dose appropriate to the severity of the disease

    Titrate the dose to the lowest dose at which effective control of asthma is maintained

  • SteroidEquivalent dose (mcg)Beclomethasone CFC400 BeclomethasoneClenil400Qvar200-300Fostair200BudesonideSymbicort400FluticasoneSeretide200Mometasone200Ciclesonide200-300

  • A proportion of patients may not be adequately controlled at step 2

    Check and Eliminate

    Adults and Children 5-12:First choice as add-on therapy is an inhaled long-acting 2 agonist (LABA), which should be considered before going above a dose of 400mcg BDP* and certainly before going above 800mcg

  • Cant miss their ICS

    More convenient

    Increased compliance

    Pathophysiology?Different inhalers different deposition

    Interaction occurs at single cell level

    Deposition varies from one inhalation to the next

  • If control remains inadequate

  • Still uncontrolled..

    Monitor - Blood pressureDiabetesHyperlipidaemiaBMD

  • Steroid sparing medication-Methotrexate-Ciclosporin-Oral Gold

    ColchicineIVIGSubcutaneous TerbutalineAnti- TNF

  • Stepping down therapy once asthma is controlled is recommended

    Regular review of patients as treatment is stepped down is important

    Patients should be maintained at the lowest possible dose of inhaled steroid

    Reductions should be slow, decreasing dose by ~25-50% every three months

  • Miss BL1984

    Admission Sep 2006

    Exacerbation asthma, PEFR 200 l/min (normal 450)

    Recent LRTI

    1 Admission to hospital this year, usual control adequate

    Known panic attacks this different

  • ? Regular meds becotide

    At university, smokes!..moderate alcohol!

    Acute management?

    Steroids, ICS, ventolin, RNS, OPD

  • Clinic October 2006

    Good recovery, still some SOBOE, started attending gym.

    Nocturnal symptoms none

    Ventolin three times per week.

    What to do?

  • Lifestyle advice

    Compliance

    RNS - Management Plan, Education

    Pre-dose with ventolin

    LABA - Combination inhaler

  • Patient preferences:Treatment as simple as possibleFew inhalersLowest dose of steroid to control symptomsAvoid hospitals when possibleMinimise symptomsHaughney J et al ERS 2006UK qualitative and quantitative study to evaluate patient understanding of their asthma and determine patient preferences regarding the delivery of asthma care and treatment.

  • Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s40% of Not Well-Controlled patients consider themselves Well or Completely Controlled Self-reported level of control by Not Well-Controlled patients % Patients

  • Mrs TL24/10/1984

    Clinic Jul 2006

    Asthma age 12

    2 x pregnancies deteriorated during, brittle++ (Newcastle)

    BIH