Dyslipidemia Management: 5 Things to Consider Before You Treat

Clinical Conversations:Primary Care Managementof Patients With Asthma00-00:331Stephen A. Brunton, MD, FAAFP (moderator)Adjunct Clinical Professor of Family Medicine University of North Carolina, Chapel Hill, North Carolina

LeRoy M. Graham, MD, FCCCPGeorgia Pediatric Pulmonary Associates, PCAssociate Clinical Professor of Pediatrics, Morehouse School of MedicineFounder and Medical Director, Not One More Life, Inc. Atlanta, GeorgiaFaculty

00:34---01:042Please review CME information at:www.jfponline.com CME information00:13-00:453Trends in Asthma Management(1998 vs 2009)

Acute care for asthma in past 12 monthsAsthma Insight & Management Survey 2010. http://www.takingaimatasthma.com/pdf/executive-summary.pdf. N=1788; age 16 yN=2294; age 16 y01:0501:474Case: Brian8-year-old male diagnosed with mild persistent asthma at age 3 yearsCurrent assessment of asthma control:FEV1 68% predicted; FEV1/FVC 79%Often feels short of breath after recess or when playing outdoors; responds to SABA (uses more than twice a week)5-6 nighttime awakenings/monthExperiences an exacerbation every month that requires nebulized albuterol in the office/EDC-ACT score 15Presently treated with low-dose ICS and prn SABAC-ACT, childhood asthma control test; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroid; SABA, short-acting inhaled -agonist. 01:4802:405Case: Brian (cont)Asthma not well controlledImportant questionsIs he adherent?Is he being treated appropriately based on asthma control?02:4103:326Evaluating Treatment AdherenceAsk in a non-threatening mannerAsk how many times a week he is using his ICSInquire about inhaler technique and, if appropriate, use of spacer03:3304:337Evaluating Current Treatment and Symptom ControlAsthma is a disease of chronic inflammationIs the anti-inflammatory dose correct?Is anti-inflammatory therapy being delivered to both large and small airways?Importance of air trapping04:3405:428Role of Small Airways in AsthmaRole of small airways not entirely clearDeposition of ICS into the small airways appears to be inversely related to steroid particle sizeLung deposition studies show that small particles (eg, BDP HFA and ciclesonide) are deposited deeper into smaller airways compared to larger particles (eg, CFC formulation)BDP, beclomethasone dipropionate; CFC=chlorofluorocarbon; HFA, hydrofluoroalkane.05:4306:299ICS Particle SizeRelevance of ICS particle size to clinical outcomes not entirely clearReal-world clinical trial in primary care compared BDP HFA to FP HFA/CFC over 1 year as initial or step-up therapyBDP HFA patients30% more likely to achieve control as initial therapy22% more likely to achieve control as step-up therapySimilar exacerbation ratesPrice et al. J Allergy Clin Immunol. 2010;126:511-518.FP, fluticasone propionate.06:3006:5710Therapy ConsiderationsICS remain as initial anti-inflammatory therapy for persistent asthmaObtaining objective lung function is essentialAsthma SeverityAsthma ControlInitiate Therapy(Not currently on controller therapy)Adjust Therapy(Currently on controller therapy)Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.06:5808:0311Case: Brian, Step-up Options3 choices: ICS to medium dose (good option)Add LABA (good option)Add a different anti-inflammatory (reasonable option)Cromolyn, nedocromil, leukotriene receptor antagonist, 5-lipoxygenase inhibitorSymptom control may be less than with medium-dose ICSLABA, long-acting -agonist.08:0409:1812Long-Acting -AgonistsThe FDA recently concluded that there is an increased risk of severe exacerbation of asthma symptoms leading to hospitalizations in children and adults, as well as of death in some patients with asthma treated with a LABALabeling changes, risk and evaluation mitigation strategiesHowever, some experts question FDA actionsConclusion: LABAsDo have a role in moderate or severe persistent asthmaDo not have a role in mild persistent asthma09:1910:5213Case: Brian, Next StepsFirst, ensure adherence and appropriate inhaler techniqueStep up to medium-dose ICSAdding LABA to low-dose ICS an equally good optionReevaluate in 2 to 6 weeksReview environmental control, early recognition of exacerbation, overall self-management10:5311:1314Action PlansPrincipal objectivesDaily management to keep asthma controlledHow to recognize and handle worsening asthma11:1411:5815Communicating With the PatientShould be seamlessDetermine what is important to patient, and identify shared values and goalsEmphasize that patient can control symptoms11:5913:1716Communicating With the PatientCommunicate in simple, straightforward termsTell patient how response to therapy will be assessedExercise tolerance, nighttime awakening, other symptomsPeak expiratory flow/spirometry

13:1814:2517Action PlanAppropriate therapyAssess limitationsOngoing education14:2615:4318Implementing Action PlanWritten/printed outInvolve staff to talk through action plan with patientHave patient repeat plan to staffHave patient demonstrate inhaler technique15:4417:3719SummaryIncidence of asthma-related morbidity has changed little over past decadeEffective treatments are availableClinicians should set expectations very highPatients should not accept significant symptoms or functional impairment17:3818:1820Stephen A. Brunton, MD, FAAFP (moderator)Adjunct Clinical Professor of Family Medicine University of North Carolina, Chapel Hill, North Carolina

LeRoy M. Graham, MD, FCCCPGeorgia Pediatric Pulmonary Associates, PCAssociate Clinical Professor of Pediatrics, Morehouse School of MedicineFounder and Medical Director, Not One More Life, Inc. Atlanta, GeorgiaFaculty00:34---01:0421Clinical Conversations:Primary Care Managementof Patients With AsthmaPlease visitwww.pceconsortium.org/asthmawebcastto complete the evaluation and receive your CME certificate of participation.

00-00:3322Chart177191625263634

19982009Percentage

Sheet119982009Series 3Hospitalized Overnight772ED Visit19162Other Unscheduled Emergency Visit25263Any of These36345To resize chart data range, drag lower right corner of range.