Treatment Objectives

1
Asthma
treatment options guidelines
2
Treatment objectives

• No chronic symptoms
• No asthma attacks
• No emergency visits
• Minimal need for quick relief (as needed)
  ß2-agonist
• Maintain normal physical activity including
  exercise
• Maintain lung function as close to normal as
  possible
• Minimal (or no) adverse effects from medicine

GINA Guidelines 1998
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Treatment strategy

• Identify and avoid triggers that make asthma
  worse
• Achieve control by selecting appropriate
  medication
• Treat asthma attacks promptly and effectively
• Educate patients to manage their condition
• Monitor and modify asthma care to maintain
  effective long-term control

GINA Guidelines 1998
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ß2-Agonists
Virus? Adenosine Exercise Fog
BRONCHOCONSTRICTION
Airway smooth muscle
Mast cell
Antigen
Macrophage
Eosinophil
AIRWAY HYPERRESPONSIVENESS
Virus?
T-lymphocyte
Corticosteroids
Barnes PJ
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Pharmacological Therapy

• Controllers
• Inhaled corticosteroids
• Inhaled long acting ?2-agonist
• Inhaled cromones
• Oral anti-leukotriens
• Oral theophylline
• Oral corticosteroids

• Relievers
• Inhaled fast-acting ?2-agonists
• Inhaled anticholinergics

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Steroid and LA-ß2 vs. LA-ß2 alone
ß2-agonist plus steroid
After
ß2-agonist plus placebo
Before
After
Before
PEF (litres / minute
Time (months)
van Essen-Zandvliet et al, Amr Rev Respir Dis 1992
8
Early intervention with inhaled steroid
Children2
Adults1
Annual change in predicted FEV1
Maximum increase in PEF ()
12
40
p 0.02 for correlation
p 0.0006 for correlation
10
30
8
6
20
4
10
2
0
0
2-3
3-5
gt 5
lt 2
5-10
2-5
lt 6
1-2
6-12
gt10
Duration of symptoms
Duration of symptoms (years)
years
months
2. Agertoft and Pedersen, Respir Med 1994
1. Selroos et al, Chest 1995
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Evolving Treatment Options
Combined use of LA ß2-agonists and ICS Greening
et al, Lancet 1992
FACET
New indications for LA ß2-agonists
Fear of SA ß2-agonists
Large use of short-acting ß2-agonists
Remodelling
Inflammation
Bronchospasm
1980
1985
1990
1995
2000
1992
1975
Bousqet
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STEP 4 SEVERE PERSISTENT

• CONTROLLER daily multiple medications
• Inhaled steroid
• Long-acting bronchodilator
• Oral steroid

• RELIEVER
• Inhaled ß2-agonist p.r.n.

Avoid or control triggers
STEP 3 MODERATE PERSISTENT

• CONTROLLER daily medications
• Inhaled steroid and long-acting bronchodilator
• Consider anti-leukotriene

• RELIEVER
• Inhaled ß2-agonist p.r.n.

Avoid or control triggers
STEP 2 MILD PERSISTENT

• CONTROLLER daily
• medications
• Inhaled steroid
• Or possibly cromone, oral
• theophylline or anti-leukotriene

• RELIEVER
• Inhaled ß2-agonist p.r.n.

Avoid or control triggers
STEP 1 INTERMITTENT

• RELIEVER
• Inhaled ß2-agonist p.r.n.

CONTROLLER none
Avoid or control triggers
TREATMENT
GINA Guidelines 1998
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Step 1
Step 1 Intermittent Asthma
Controller None required

• Reliever
• Inhaled ?2-agonist prn (not more than 3x a
  week)
• Inhaled ?2-agonist or cromone prior to exercise
  or allergen exposure

Avoid or Control triggers
GINA Guidelines 1998
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Step 2
Step 2 Mild Persistent Asthma

• Controller
• Daily inhaled corticosteroid (200-500 ?g),
  cromone, sustained release theophylline, or
  anti-leukotriene
• If needed especially for nocturnal symptoms
  increase inhaled steroid (500-800 ?g) or add
  long-acting bronchodilator

• Reliever
• Inhaled ?2-agonist prn (but less
  than 3-4 times per day)

Avoid or Control triggers
GINA Guidelines 1998
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Step 3
Step 3 Moderate Persistent Asthma

• Reliever
• Inhaled ?2-agonist prn (but less
  than 3-4 times per day)

• Controller
• Daily inhaled corticosteroid 800-2000 ?g
• Daily long-acting bronchodilator
• Consider anti-leukotriene

Avoid or Control triggers
GINA Guidelines 1998
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Step 4
Step 4 Severe Persistent Asthma

• Reliever
• Inhaled ?2-agonist prn (but less
  than 3-4 times per day)

• Controller
• Daily inhaled corticosteroid 800-2000 ?g
• Daily long-acting bronchodilator
• Daily/Alternate day oral corticosteroid

Avoid or Control triggers
GINA Guidelines 1998
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Why dont patients comply with treatment?

• Intentional
• Feel better
• Fear of side effects
• Dont notice any benefit
• Fear of addiction
• Fear of being seen as an invalid
• Too complex regimen
• Cant afford medication

• Unintentional
• Forget treatment
• Misunderstand regimen / lack information
• Unable to use their inhaler
• Run out of medication

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What do patients care about?

• No bad asthma days
• Free from restrictions on their life
• PEF not important to patients
  (but still essential to monitor control and
  exacerbations)

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What do patients need from physicians?

• Clear simple information about treatment
• Concerns listened to
• Involvement in treatment decisions (some)
• Correct approach to suit individual
• paternalistic
• working together
• self-management

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What are physicians responsibilities?

• To educate patient to take measures to avoid
  allergen exposure and recognise if condition is
  deteriorating
• To be up-to-date on latest management guidelines
• To ensure patients take medications correctly and
  teach / check inhaler technique
• To clarify role of physician / nurse
• To establish individual patient expectations
• To avoid inappropriate antibiotic prescription
• To ensure patients understand difference between
  reliever and controller

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House dust mite control measures

• Proven
• Remove carpets and upholstery (mite reservoirs)
• Encase pillows and mattresses in air tight covers
• Wash bed linen once a week in hot water
• Not Proven
• Regular vacuuming
• Chemicals
• - acaricides (to kill mites)
• - fungicides (to remove fungal source of food
  for mites)
• High/Low temperature
• - freezer
• - dry bed linen in hot dryer / sun
• Lower humidity