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