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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
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Lee Dobson
Torbay Hospital
Early 1950sMDI
Early 1950sMDI
19563M launchThe MDI
19563M launchThe MDI
1965Intal
introduced
1965Intal
introduced
1972Becotide
introduced
1972Becotide
introduced
1991The
β2 agonistdebate
1991The
β2 agonistdebate
1993Flixotide
introduced
1993Flixotide
introduced
1995 onwardsGINA
1995 onwardsGINA
1999Seretidelaunched
1999Seretidelaunched
Late 60sBronchoscope
Late 60sBronchoscope
1969Ventolin
introduced
1969Ventolin
introduced
1980sMajor
developmentsin asthma
management
1980sMajor
developmentsin asthma
management
1990Serevent
introduced
1990Serevent
introduced
1996, 1997Woolcock & Pauwels
Landmarkstudies
1996, 1997Woolcock & Pauwels
Landmarkstudies
2007SMART2007
SMART
1994Greening, Ind
Landmark study
1994Greening, Ind
Landmark study
A brief history of asthma A brief history of asthma managementmanagement
How are we doing?
2001Symbicort
1997Oxis1997Oxis
Fostair
5545 45
61
72
56
01020304050607080
Overall UK Spain Italy Germany France
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 ≤19
Not Well-Controlled asthma (% of treated patients)
% P
atie
nts
not W
ell C
ontr
olle
d
Every 6 hours someone dies from asthma2
Men2.3 million1
Total5.2 million1
Data includes 590,000 teenagersand 700,000 people over 651
Women2.9 million1
1. 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 It is a myth that only severe asthma can prove severe asthma can prove fatalfatal
Asthma deaths occur Asthma deaths occur across disease severity across disease severity with deaths occurring in with deaths occurring in those patients whose those patients whose asthma is considered asthma is considered mild-to-moderatemild-to-moderate
Harrison B et al. Prim Care Respir J 2005 Dec; 14: 303–13.
Asthma severity (%)
Nu
mb
er
of
death
s
0
25
50
75
100
Severe Moderately severe
Mild Unknown
10%16%21%
53%
Number of asthma deaths across disease severity 2001–
2003
n=57
Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/
6.2%6.7%
6.1%6.4%
5.7%
6.5%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
England NHS SouthWest
Torbay CareTrust
Devon PCT PlymouthTeaching PCT
Cornw all &Isles of Scilly
PCT
% p
ati
en
ts r
eg
iste
red
wit
h a
sth
ma
Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/
6.2%
6.8%6.4%6.2%
6.7%
6.1%6.4%
5.8%6.2% 6.5%
5.7%
6.5%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
England NHS SouthWest
Torbay CareTrust
Devon PCT PlymouthTeaching PCT
Cornw all &Isles of Scilly
PCT
% p
ati
en
ts r
eg
iste
red
wit
h a
sth
ma
2006/07 2007/08
2009 2010
TCT 10198 10193
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)British Thoracic Society (BTS)
Scottish Intercollegiate Guidelines Network Scottish Intercollegiate Guidelines Network (SIGN)(SIGN)
Definition of asthmaDefinition of asthma
Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92
“A 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 morning in response to exercise, allergen exposure and cold air after taking aspirin or beta blockers Personal/family history of asthma/atopy
Widespread wheeze heard on auscultation of
the chest
Unexplained low FEV1 or PEF
Unexplained peripheral blood eosinophilia
Prominent dizziness, light-headedness, peripheral tingling
Chronic productive cough in the absence of wheeze or
breathlessness
Repeatedly normal physical examination of chest when
symptomatic
Voice disturbance
Symptoms with colds only
Significant smoking history (>20 pack-years)
Cardiac disease
Normal PEF or spirometry when symptomatic
Without airflow obstructionChronic cough syndromesDBSVocal Cord DysfunctionRhinitisGORDHeart FailurePulmonary Fibrosis
With airflow obstructionCOPD
BronchiectasisInhaled Foreign BodyObliterative BronchiolitisLarge Airway StenosisLung CancerSarcoidosis
Start treatment at the step most appropriate to the Start treatment at the step most appropriate to the
initial severity of their asthmainitial severity of their asthma
Aim is to achieve early control Aim is to achieve early control
Step up or down with therapyStep up or down with therapy
Minimal therapyMinimal therapy
Before initiating new drug therapy:Before initiating new drug therapy:
ComplianceCompliance
Inhaler techniqueInhaler technique
Eliminate trigger factorsEliminate trigger factors
Control of asthma, defined as:Control of asthma, defined as:
No daytime symptomsNo daytime symptoms
No night time awakening due to asthmaNo night time awakening due to asthma
No need for rescue medicationsNo need for rescue medications
No exacerbationsNo exacerbations
No limitations on activity including exerciseNo limitations on activity including exercise
Normal lung function (FEVNormal lung function (FEV11 and/or PEF >80% predicted and/or PEF >80% predicted
or best)or best)
with minimal side effects.with minimal side effects.
Factors that should be monitored and recorded:Factors that should be monitored and recorded:
Symptomatic asthma control using RCP ‘3 questions’, Asthma Symptomatic asthma control using RCP ‘3 questions’, Asthma
Control Questionnaire or Asthma Control Test (ACT)Control Questionnaire or Asthma Control Test (ACT)
Lung function (spirometry/PEF)Lung function (spirometry/PEF)
ExacerbationsExacerbations
Inhaler techniqueInhaler technique
Compliance (prescription refill frequency)Compliance (prescription refill frequency)
Bronchodilator reliance (prescription refill frequency)Bronchodilator reliance (prescription refill frequency)
Possession of and use of self management plan/personal Possession of and use of self management plan/personal
action planaction plan
Factors that should be monitored and recorded:Factors that should be monitored and recorded:
Symptomatic asthma control using RCP ‘3 questions’, Asthma Symptomatic asthma control using RCP ‘3 questions’, Asthma
Control Questionnaire or Asthma Control Test (ACT)Control Questionnaire or Asthma Control Test (ACT)
Lung function (spirometry/PEF)Lung function (spirometry/PEF)
ExacerbationsExacerbations
Inhaler techniqueInhaler technique
Compliance (prescription refill frequency)Compliance (prescription refill frequency)
Bronchodilator reliance (prescription refill frequency)Bronchodilator reliance (prescription refill frequency)
Possession of and use of self management plan/personal Possession of and use of self management plan/personal
action planaction plan
Component of action plan
Result Practical Considerations
Symptom vs PEF triggerStandard written instructTraffic Light
Similar effectConsistently beneficialNot better than standard
2-3 action points4 action points
Consistently beneficialNo better
<80% - increase ICS<60% - oral steroids<40% - urgent advice
PEF on %personal bestPEF on % predicted
Consistently beneficialNo better
Assess when stable, update every few years
ICS and steroidsOral steroids onlyICS
Consistently beneficialUnable to evaluateUnable to evaluate
>400 – steroids200 – increase substantRestart medication
Inhaler Inhaler devicesdevices
Prescribe inhaled short acting Prescribe inhaled short acting ββ22 agonist (SABA) as short agonist (SABA) as short term reliever therapy for all patients with symptomatic term reliever therapy for all patients with symptomatic asthmaasthma
Good asthma control is associated with little or no need Good asthma control is associated with little or no need for short-acting for short-acting ββ22 agonist agonist
Using two or more canisters of Using two or more canisters of ββ22 agonists per month or agonists per month or > 10-12 puffs per day is a marker or poorly controlled > 10-12 puffs per day is a marker or poorly controlled asthma that puts individuals at risk of fatal or near-fatal asthma that puts individuals at risk of fatal or near-fatal asthmaasthma
Patients with high usage of inhaled short-acting Patients with high usage of inhaled short-acting ββ22 agonists should have their asthma management agonists should have their asthma management reviewedreviewed
Inhaled steroids are the recommended Inhaled steroids are the recommended preventer drugs for adults for achieving overall preventer drugs for adults for achieving overall treatment goalstreatment goals
Consider inhaled steroids if any of the following:Consider inhaled steroids if any of the following: Using inhaled Using inhaled ββ22 agonist three times a week or more agonist three times a week or more
Symptomatic three times a week or moreSymptomatic three times a week or more Waking one night a weekWaking one night a week Exacerbation of asthma in the last two years (adults Exacerbation of asthma in the last two years (adults
and 5-12 only)and 5-12 only)
Adults:Adults: 200-800mcg/day BDP*(reasonable starting 200-800mcg/day BDP*(reasonable starting
dose 400mcg per day for many adults)dose 400mcg per day for many adults)
Start patients at a dose appropriate to the Start patients at a dose appropriate to the severity of the diseaseseverity of the disease
Titrate the dose to the lowest dose at which Titrate the dose to the lowest dose at which effective control of asthma is maintainedeffective control of asthma is maintained
Steroid Equivalent dose (mcg)
Beclomethasone CFC 400
Beclomethasone
Clenil 400
Qvar 200-300
Fostair 200
Budesonide
Symbicort 400
Fluticasone
Seretide 200
Mometasone 200
Ciclesonide 200-300
A proportion of patients may not be adequately A proportion of patients may not be adequately controlled at step 2controlled at step 2
Check and Eliminate Check and Eliminate
Adults and Children 5-12:Adults and Children 5-12: First choice as add-on therapy is an inhaled long-acting First choice as add-on therapy is an inhaled long-acting ββ22 agonist (LABA), which should be considered before agonist (LABA), which should be considered before going above a dose of 400mcg BDP* and certainly going above a dose of 400mcg BDP* and certainly before going above 800mcgbefore going above 800mcg
Can’t 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 If control remains remains inadequate…inadequate…
Still uncontrolled..Still uncontrolled..
Monitor - Monitor -
Blood pressureBlood pressure
DiabetesDiabetes
HyperlipidaemiaHyperlipidaemia
BMDBMD
Steroid sparing Steroid sparing medicationmedication
-- MethotrexateMethotrexate
-- CiclosporinCiclosporin
-- Oral GoldOral Gold
ColchicineColchicine
IVIGIVIG
Subcutaneous TerbutalineSubcutaneous Terbutaline
Anti- TNFAnti- TNF
Stepping down therapy once asthma is Stepping down therapy once asthma is controlled is recommendedcontrolled is recommended
Regular review of patients as treatment is Regular review of patients as treatment is stepped down is importantstepped down is important
Patients should be maintained at the lowest Patients should be maintained at the lowest possible dose of inhaled steroidpossible dose of inhaled steroid
Reductions should be slow, decreasing dose by Reductions should be slow, decreasing dose by ~25-50% every three months~25-50% every three months
Miss BL 1984
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 possible Few inhalers Lowest dose of steroid to control symptoms Avoid hospitals when possible Minimise symptoms
Haughney J et al ERS 2006
UK qualitative and quantitative study to evaluate patient understanding of their asthma and determine patient preferences regarding the delivery of asthma care and treatment.
6
3437
11 11
0
5
10
15
20
25
30
35
40
"CompletelyControlled"
"WellControlled"
"SomewhatControlled"
"PoorlyControlled"
"Not at allControlled"
Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s
40% of Not Well-Controlled patients
consider themselves “Well”
or “Completely Controlled”
Self-reported level of control by Not Well-Controlled patients
% P
atie
nts
Mrs TL 24/10/1984
Clinic Jul 2006
Asthma age 12
2 x pregnancies – deteriorated during, brittle++ (Newcastle)
BIH
Night waking, morning dipping, wheeze, SOB – 10/40
Guinea pig and rabbit, shop assistant.
Bec 250 4 puffs bd, SV 4 puffs bd, ventolin and combivent prn.
SaO2 98%, 2.69/3.58 (3.21/3.68).
What to do?
Write to chest consultant RNS review – management plan, education QVAR - Thrush Combination inhaler - tried ?LTRA ?Nebuliser Standby steroids
Clinic Aug 2006
Stable 2.84/3.67 litres Plan – no change
DNA…
23-year old woman with history of childhood asthma
Started fitness campaign but suffers from
breathlessness on exertion
At clinic, PEF normal
What advice would you give Laura?
What therapy would you recommend if a peak flow diary showed a stable baseline but short lived dips after running?
Remember to make an assessment of the probability of asthma.
Diagnose before treating – try to confirm diagnosis with objective tests before long term therapy is started.
Increasing symptoms – some help from blue inhaler
Interested in complementary therapy - Buteyko Husband noticed night time coughing – keeping
him awake!
What would you advise Laura about complementary
treatments for asthma?
Becomes pregnant.
What would you do now if she was: (a) not distressed, slightly wheezy with
respiratory rate of 20 breaths/minute, pulse 100 beats/minute and PEF of 390 L/minute?
(b) looks dreadful, cannot complete sentences, with very quiet breath sounds on auscultation, respiratory rate 30 breaths/minute, pulse 120 beats/minute and PEF of 120 L/minute?
No consistent evidence to support use of complementary or alternative treatments in asthma
Continue usual asthma therapy in pregnancy
Monitor pregnant women with asthma closely to ensure therapy is appropriate for symptoms.
Mr DC 02/09/1969
Clinic Apr 2004 - Exacerbation March 2004
Known asthmatic (eczema) – control not so good recently (nocturnal symptoms, SOB, reliever ++, PEFR down).
Symbicort 200/6 2 puffs bd
Green sputum – cefalexin, prednisolone
What to do?
Question diagnosis? Recent CT scan, alpha-1-antitrypsin level N
Increase dose Symbicort
LTRA trial – previously negative
Bisphosphonate
Clinic June 2004
Ig E > 15,000 RAST Aspergillus >4
Probable Allergic Bronchopulmonary Aspergillosis (ABPA)
Plan - Maintenance prednisolone (10mg), Itraconazole
Clinic Sept 2004
Symptomatic - Prednisolone <20mg
SOB increasing
PEFR <160 l/min, FEV1/FVC 1.42/3.75 (3.71/4.4)
Plan – increase inhaled steroid
Clinic Oct 2004
Recent exacerbation
1.11/3.12
Plan – prednisolone 15mg od, nebuliser
Clinic Jan 2005 onwards…
Cramps
PPI/H2 Antagonist – some benefit
Not taking ICS! Compliance
Deranged Liver function tests
1.57/3.49
Diabetes - ? Steroid induced