Asthma guidelines from reality to practice

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Asthma guidelines from reality to practice
Prof. Dr. Samiha Ashmawi Prof. Chest Diseases
Faculty Of Medicine Ain Shams University
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Patients currently achieving control
Only 5 of patientsachieve asthma control
Not Well-Controlled
Well-Controlled
Rabe et al. Eur Respir J, 2000
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Asthma morbidity remains high
Hospitalized in
Past Year
Asia Pacific
Hospital
Emergency Room
Europe
Visits
US
Unscheduled
Emergency Visits
0
10
20
30
40
50
of asthma patients
Rabe et al. 2000 Fulbrigge et al. 2002 Lai et
al. 2002
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Asthma limits daily-life activities
Asia Pacific
Europe
US
60
40
of patients
20
0
Sports
Lifestyle
Sleeping
Career Choice
Housekeeping
Social activities
Normal Physical Activity
Rabe et al. 2000 Fulbrigge et al. 2002 Lai et
al. 2002
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• Despite regular treatment, 2/3 of asthma
  patients maystill be poorly controlled
• Results of a European study in 1921 asthma
  patients on maintenence therapy shows control
  may be sub-optimal as defined by the ACQ,
  asking questions about
• Night-awakenings
• Daily symptoms
• Activity limitations
• Reliever use

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68
Well-controlled
Not well-controlled or uncontrolled
Ref INSPIRE Survey, ACQAsthma Control
Questionnaire, Partridge et al, Eur Respir J
200526(Suppl 49)250s
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Goals of Long-term Management

• Achieve and maintain control of symptoms
• Maintain normal activity levels, including
  exercise
• Maintain pulmonary function as close to normal
  levels as possible
• Prevent asthma exacerbations
• Avoid adverse effects from asthma medications
• Prevent asthma mortality

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Asthma Management and Prevention Program

• Although there is no cure for asthma, appropriate
  management that includes a partnership between
  the physician and the patient/family most often
  results in the achievement of control

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Asthma Control Asthma Goals

• Definition of asthma control is the same as
  asthma goals reducing impairment and risk.

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Clinical Control of Asthma

• No (or minimal) daytime symptoms
• No limitations of activity
• No nocturnal symptoms
• No (or minimal) need for rescue medication
• Normal lung function
• No exacerbations
• _________
• Minimal twice or less per week

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Is it Asthma ?

• Recurrent episodes of wheezing
• Troublesome cough at night
• Cough or wheeze after exercise
• Cough, wheeze or chest tightness after exposure
  to airborne allergens or pollutants
• Colds go to the chest or take more than 10 days
  to clear

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Asthma Diagnosis

• History and patterns of symptoms
• Measurements of lung function
• - Spirometry
• - Peak expiratory flow
• Measurement of airway responsiveness
• Measurements of allergic status to identify risk
  factors
• Extra measures may be required to diagnose asthma
  in children 5 years and younger and the elderly

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Asthma Management and Prevention Program Five
Interrelated Components
1. Develop Patient/Doctor Partnership 2. Identify
and Reduce Exposure to Risk Factors 3.
Assess, Treat and Monitor Asthma 4. Manage Asthma
Exacerbations 5. Special Considerations
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Asthma Management and Prevention
ProgramComponent 1 Develop Patient/Doctor
Partnership

• Educate continually
• Include the family
• Provide information about asthma
• Provide training on self-management skills
• Emphasize a partnership among health care
  providers, the patient, and the patients family

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Asthma Management and Prevention
Program Component 2 Identify and Reduce
Exposure to Risk Factors

• Measures to prevent the development of asthma,
  and asthma exacerbations by avoiding or reducing
  exposure to risk factors should be implemented
  wherever possible.
• Asthma exacerbations may be caused by a variety
  of risk factors allergens, viral infections,
  pollutants and drugs.
• Reducing exposure to some categories of risk
  factors improves the control of asthma and
  reduces medications needs.

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Risk Factors for Asthma

• Host factors predispose individuals to, or
  protect them from, developing asthma
• Environmental factors influence susceptibility
  to development of asthma in predisposed
  individuals, precipitate asthma exacerbations,
  and/or cause symptoms to persist

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Factors that Influence Asthma Development and
Expression

• Host Factors
• Genetic
• - Atopy
• - Airway hyperresponsiveness
• Gender
• Obesity

• Environmental Factors
• Indoor allergens
• Outdoor allergens
• Occupational sensitizers
• Tobacco smoke
• Air Pollution
• Respiratory Infections
• Diet

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Factors that Exacerbate Asthma

• Allergens
• Respiratory infections
• Exercise and hyperventilation
• Weather changes
• Food, additives, drugs

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Component 3 Assess, Treat and Monitor Asthma

• - Assessing Asthma Control
• - Treating to Achieve Control
• - Monitoring to Maintain Control

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Levels of Asthma Control
Characteristic Controlled Partly controlled(Any present in any week) Uncontrolled
Daytime symptoms None (2 or less / week) More than twice / week 3 or more features of partly controlled asthma present in any week
Limitations of activities None Any 3 or more features of partly controlled asthma present in any week
Nocturnal symptoms / awakening None Any 3 or more features of partly controlled asthma present in any week
Need for rescue / reliever treatment None (2 or less / week) More than twice / week 3 or more features of partly controlled asthma present in any week
Lung function (PEF or FEV1) Normal lt 80 predicted or personal best (if known) on any day 3 or more features of partly controlled asthma present in any week
Exacerbation None One or more / year 1 in any week One or more / year 1 in any week
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Component 3 Assess, Treat and Monitor Asthma

• The choice of treatment should be guided by
• Level of asthma control
• Current treatment
• Pharmacological properties and availability
  of the various forms of asthma treatment
• Economic considerations

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Principles of Stepwise Therapy

• The goal of asthma therapy is to maintain
  long-term control of asthma with the least amount
  of medication and hence minimal risk for adverse
  effects.
• EPR -3, Section 4, Managing Asthma Long Term in
  Children 04 Years of Age and 511 Years of Age,
  P. 284

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Principles Of Step Therapy To Maintain Control

• Step up if not controlled.
• If very poorly controlled, consider increase by 2
  steps, oral corticosteroids, or both.
• Before increasing pharmacologic therapy, consider
  as targets for therapy.
• Adverse environmental exposures
• Poor adherence
• Co-morbidities

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Follow-Up

• Visits every 2-6 weeks until control achieved.
• When control achieved, contact every 3-6 months.
• Step-down in therapy
• With well-controlled asthma for at least 3
  months.
• Patients may relapse with total discontinuation
  or reduction of inhaled corticosteroids.

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More than 15 studies Confirmed that addition of
LABA to ICS is more effective than doubling the
dose of ICS when used alone.
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Factors Involved in Non-Adherence

• Medication Usage
• Difficulties associated with inhalers
• Complicated regimens
• Fears about, or actual side effects
• Cost
• Distance to pharmacies

• Non-Medication Factors
• Misunderstanding/lack of information
• Fears about side-effects
• Inappropriate expectations
• Underestimation of severity
• Attitudes toward ill health
• Cultural factors
• Poor communication

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Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled

• When controlled on medium- to high-dose inhaled
  glucocorticosteroids 50 dose reduction at 3
  month intervals (Evidence B)
• When controlled on low-dose inhaled
  glucocorticosteroids switch to once-daily
  dosing (Evidence A)

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Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled

• When controlled on combination inhaled
  glucocorticosteroids and long-acting inhaled
  ß2-agonist, reduce dose of inhaled
  glucocorticosteroid by 50 while continuing the
  long-acting ß2-agonist (Evidence B)
• If control is maintained, reduce to low-dose
  inhaled glucocorticosteroids and stop long-acting
  ß2-agonist (Evidence D)

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Component 4 Manage Asthma Exacerbations

• Exacerbations of asthma are episodes of
  progressive increase in shortness of breath,
  cough, wheezing, or chest tightness
• Exacerbations are characterized by decreases in
  expiratory airflow that can be quantified and
  monitored by measurement of lung function (FEV1
  or PEF)
• Severe exacerbations are potentially
  life-threatening and treatment requires close
  supervision

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Component 4 Manage Asthma Exacerbations

• Primary therapies for exacerbations
• Repetitive administration of rapid-acting inhaled
  ß2-agonist
• Early introduction of systemic glucocorticosteroid
  s
• Oxygen supplementation
• Closely monitor response to treatment with serial
• measures of lung function

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Summary

• The goal of asthma treatment, to achieve and
  maintain clinical control, can be achieved in a
  majority of patients with a pharmacologic
  intervention strategy developed in partnership
  between the patient/family and the health care
  professional

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Summary

• A stepwise approach to pharmacologic therapy is
  recommended. The aim is to accomplish the goals
  of therapy with the least possible medication
• The availability of varying forms of treatment,
  cultural preferences, and differing health care
  systems need to be considered

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Total Asthma Control
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Asthma control means different things to
different people
Normal airway responsiveness
Lymphocyte activation
No cough
Minimal resource utilisation
Cellular infiltrate
No exacerbations
No night-time wakening
Liberation
No absenteeism
Freedom
Normal
Quality of Life
Nohospitilization
Waking peak flow
Antigens
Normal peak flow
No breathlessness
Normal PEF circadian variation
Minimal medication use
No underlying inflammation
IgE
No symptoms
predicted PEF
Prevent remodelling
House-dust mite avoidance
Normal FEV1
RSV
Confidence reliability
No adverse events
No sub-basement membrane thickening
Avoidance of triggers
B Busse Nice 2001
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Asthma control means different things to
different people
Normal airway responsiveness
Lymphocyte activation
No cough
Minimal resource utilisation
Cellular infiltrate
No exacerbations
No night-time wakening
Liberation
No absenteeism
?
Freedom
Normal
Quality of Life
Nohospitilization
Waking peak flow
Antigens
Normal peak flow
No breathlessness
Normal PEF circadian variation
Minimal medication use
No underlying inflammation
IgE
No symptoms
predicted PEF
Prevent remodelling
House-dust mite avoidance
Normal FEV1
RSV
Confidence reliability
No adverse events
No sub-basement membrane thickening
Avoidance of triggers
B Busse Nice 2001
41
Asthma control means different things to
different people
Normal airway responsiveness
Lymphocyte activation
No cough
Minimal resource utilisation
Cellular infiltrate
No exacerbations
No night-time wakening
Liberation
No absenteeism
?
Freedom
Normal
Quality of Life
Nohospitilization
Waking peak flow
Antigens
Normal peak flow
No breathlessness
Normal PEF circadian variation
Minimal medication use
No underlying inflammation
IgE
No symptoms
predicted PEF
Prevent remodelling
House-dust mite avoidance
Normal FEV1
RSV
Confidence reliability
No adverse events
No sub-basement membrane thickening
Avoidance of triggers
B Busse Nice 2001
42
Asthma control means different things to
different people
Normal airway responsiveness
Lymphocyte activation
No cough
Minimal resource utilisation
Cellular infiltrate
No exacerbations
No night-time wakening
Liberation
No absenteeism
?
Freedom
Normal
Quality of Life
Nohospitilization
Waking peak flow
Antigens
Normal peak flow
No breathlessness
Normal PEF circadian variation
Minimal medication use
No underlying inflammation
IgE
No symptoms
predicted PEF
Prevent remodelling
House-dust mite avoidance
Normal FEV1
RSV
Confidence reliability
No adverse events
No sub-basement membrane thickening
Avoidance of triggers
B Busse Nice 2001
43
Asthma control means different things to
different people
Normal airway responsiveness
Lymphocyte activation
No cough
Minimal resource utilisation
Cellular infiltrate
No exacerbations
No night-time wakening
Liberation
No absenteeism
?
Freedom
Normal
Quality of Life
Nohospitilization
Waking peak flow
Antigens
Normal peak flow
No breathlessness
Normal PEF circadian variation
Minimal medication use
No underlying inflammation
IgE
No symptoms
predicted PEF
Prevent remodelling
House-dust mite avoidance
Normal FEV1
RSV
Confidence reliability
No adverse events
No sub-basement membrane thickening
Avoidance of triggers
B Busse Nice 2001
44
Asthma control means different things to
different people
Normal airway responsiveness
Lymphocyte activation
No cough
Minimal resource utilisation
Cellular infiltrate
No exacerbations
No night-time wakening
Liberation
No absenteeism
?
Freedom
Normal
Quality of Life
Nohospitilization
Waking peak flow
Antigens
Normal peak flow
No breathlessness
Normal PEF circadian variation
Minimal medication use
No underlying inflammation
IgE
No symptoms
predicted PEF
Prevent remodelling
House-dust mite avoidance
Normal FEV1
RSV
Confidence reliability
No adverse events
No sub-basement membrane thickening
Avoidance of triggers
B Busse Nice 2001
45
Total Control
B Busse Nice 2001
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