The Saudi Initiative for Asthma

1. The Saudi Initiative for Asthma On behalf of the SINA group Mohamed S. Al-Moamary, FRCP (Edin) FCCP King Abdulaziz Medical City-Riyadh King Saud bin Abdulaziz Uinversity for Health Scinces June 2010

2. Asthma Diagnosis & Management Enter presenter name Enter the presenter’s institute

3. What is SINA? • SINA is developed by a task force originated from the Saudi Initiative for Asthma Group under the umbrella of the Saudi Thoracic Society • SINA is a practical approach for a comprehensive management of asthma in adults and children and when to refer to a specialist. • International recommendations were customized to the local setting for asthma diagnosis and management • Directed to HCW dealing with asthma who are not specialists in the field.

4. Purpose of SINA • To provide a document that is easy to follow, simple to understand yet totally updated and carefully prepared for use by non-asthma specialist including primary care doctors and general practice physicians

5. Where do you find SINA? • The SINA guideline was published in the Annals of Thoracic Medicine: Al-Moamary MS, Al-Hajjaj MS, Idrees MM, Zeitouni MO, Alanezi MO, Al-Jahdali HH, Al Dabbagh M. The Saudi Initiative for asthma. Ann Thorac Med 2009;4:216-33 (www.thoracicmedicine.org): • The SINA guidelines booklet is available at: www.sinagroup.org

6. Saudi Thoracic Society commitment • The STS is committed to improve the care of asthma by a long term plan: • Periodic scientific meetings • Annual asthma meeting (since 2001) • Frequent asthma courses • Educational brochures • Publishing new and updated asthma guidelines

7. SINA Task Force • Mohamed S. Al-Moamary (Head), College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh • Mohamed S. Al-Hajjaj, College of Medicine, King Saud University, Riyadh • Majdy M. Idrees, Military Hospital, Riyadh • Mohamed O. Zeitouni, King Faisal Specialist Hospital and Research Center, Riyadh • Mohammed O. Alanezi, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh • Hamdan H. Al-Jahdali, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh • Maha M. Al Dabbagh, King Fahd Armed Forces Hospital, Jeddah

8. Acknowledgment The Saudi Initiative for Asthma group would like to thank the following reviewers : • Prof. Eric Bateman from the University of Cape Town Lung Institute, Cape Town, South Africa • Prof. J. Mark FitzGerald from the University of British Columbia, Vancouver, BC, Canada • Prof. Ronald Olivenstein from the Meakins-Christie Laboratories and the Montreal Chest Research Institute, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada.

9. SINA Documents • Published manuscript • Booklet • Electronic version • Slides kit • Flyers • Website: www.sinagroup.org

10. Sections of SINA • Epidemiology • Pathophysiology • Diagnosis • Medications • Approach to Management • Treatment Steps • Special Situations • Acute Asthma

11. Prevalence • Prevalence of asthma has increased between 1986 – 1995 Alfrayyah et al. Ann Allergy Asthma Immunol 2001;86:292–296

12. Burden of Asthma • Asthma is among the most common chronic illnesses in Saudi Arabia • 53% had missed school or work (AIRKSA-2007) • 35% attempted Unconventional therapy (Al Moamary, ATM 2008) • 46% were controlled in Riyadh (AIRKSA-2007) • 36% were controlled in 5 tertiary care centers in Riyadh (Aljahdali SMJ-2008) • 48% were controlled in one center (Al Moamary, ATM 2008)

13. AIRKSA report (Ministry of Health) • 78 % of adults & 84% of kids reported acute asthma over 12 months (AIRKSA) • 54 % of adults & 80% of kids reported ER over 12 months (AIRKSA) • 45-68% of adults & 37-56% of kids reported limitation of activity over 12 months (AIRKSA) • 76 % of adults & 78% of kids never had spirometry(AIRKSA)

14. Pattern of asthma treatment Ann Thorac Med 2006;1:20-5

15. Pathology of Asthma Inflammation Airway Hyper-responsiveness Airway Obstruction Symptoms of Asthma

16. Pathophysiology

17. Inflammation  Remodeling • Inflammation • Airway Hypersecretion • Subepithelial fibrosis • Angiogenesis

18. Diagnosis - History • Episodic attacks: • Cough • Breathlessness • Wheezing • Nocturnal symptoms • Patient could be asymptomatic between attacks • co-existent conditions: GERD, rhinosinusitis.

19. Relevant Questions

20. Physical Examination • Normal between attacks • Bilateral expiratory wheezing • Examination of the upper airways • Other allergic manifestations: e.g., atopic dermatitis/eczema • Consider alternative Dx when there is localized wheeze, crackles, stridor, clubbing

21. Investigations • Measurements of lung function: • Spirometry • Peak expiratory flow (PEF) • Normal Spirometry does not role out asthma • Spirometry is superior to PEF

22. Bronchodilator response

23. Clinical Assessment • Measurements of allergic status to identify risk factors (if indicated) • Chest X-ray is not routinely recommended • Routine blood tests are not routinely recommended • IgE measurement is indicated in severe cases

24. Level of Control: • Control: 20-24 • Partial control: 16-19 • Uncontrolled: < 16

25. Differential Diagnosis • Upper airway diseases • Allergic rhinitis and sinusitis • Obstructions involving large airways • Foreign body in trachea or bronchus • Vocal cord dysfunction • Vascular rings or laryngeal webs • Laryngotracheomalacia, tracheal stenosis, or bronchostenosis • Enlarged lymph nodes or tumor • Obstructions involving small airways • Viral bronchiolitis or obliterative bronchiolitis • Cystic fibrosis • Bronchopulmonary dysplasia • Heart disease • Other causes • Recurrent cough not due to asthma • Aspiration from swallowing mechanism dysfunction or GERD

26. Differential Diagnosis • COPD (e.g., chronic bronchitis or emphysema) • Congestive heart failure • Pulmonary embolism • Mechanical obstruction of the airways (benign and malignant tumors) • Pulmonary infiltration with eosinophilia • Cough secondary to drugs (e.g., angiotensin-converting enzyme (ACE) inhibitors) • Vocal cord dysfunction

27. Asthma in children < 5 years • The diagnosis is challenging • Asthma must be distinguished from other causes of persistent and recurrent wheezing • The earlier the onset of a wheeze, the better the prognosis • A family history of atopy and asthma and maternal atopy are strongly associated with persistent childhood asthma

28. Asthma in children < 5 years • Three categories of wheezing: • Transient early wheezing: • It outgrown in the first three years • It associated with prematurity and parental smoking. • Persistent early-onset wheezing: • Symptoms continue beyond the age of six • Associated with acute viral respiratory infections and have no evidence of atopy • Late-onset wheezing/asthma: • Symptoms persist into childhood and adult life. • Atopic background, often with eczema

29. Asthma in children < 5 years • No tests can diagnose asthma with certainty. • Lung function testing is not very helpful • CXR may help to exclude structural abnormalities of the airway. • A trial of treatment with short-acting bronchodilators and inhaled corticosteroids (ICS) for at least 8 to 12 weeks may provide some guidance as to the presence of asthma.

30. Management

31. Patient/Dr Partnership • Enhance the chance of disease control • Agreed goals of management • Guided self-management plan

32. Asthma Education

33. Drugs: Poor technique of inhaler devices. Regimen with multiple drugs. Occurrence of Side effects from the drugs. Cost of medications. Non-drugs Lack of knowledge about asthma. Lack of partnership in the management. Inappropriate expectations. Underestimation of severity. Cultural issues. Non-Adherence

34. Precipitating Factors • Indoor Allergens and Air Pollutants • Outdoor Allergens • Occupational Exposure • Food and Drugs

35. Self-management plan لكل مريض خطة علاجية ذاتية خاصة به توضع تحت إشراف الطبيب المختص حسب حالته

36. Asthma Medications • Controllersare medications taken daily on a long-term basis to keep asthma under clinical control chiefly through their anti-inflammatory effects. • Relieversare medications used on an as-needed basis that act quickly to reverse • bronchoconstriction and relieve symptoms.

37. Controller Medications • Inhaled glucocorticosteroids • Leukotriene modifiers • Long-acting inhaled B2-agonists • Theophylline • Anti-IgE • Systemic glucocorticosteroids

38. Inhaled Corticosteroids • The most effective antiinflammatory medications for the treatment of asthma • Benefits of ICS: • Reduce symptoms: • improve quality of life • improve lung function • decrease airway hyperresponsiveness • control airway inflammation • reduce frequency and severity of exacerbations, and reduce mortality.

39. Inhaled Corticosteroids • When ICS discontinued, deterioration of clinical control follows within weeks to months in most patients • Most of the benefits from ICS are achieved in adults at relatively low doses • Increasing to higher doses may provide further benefits in terms of asthma control but increases the risk of side effects • Tobacco smoking reduces the responsiveness to ICS

40. Inhaled Corticosteroids • To reach control, add-on therapy with another class of controller is preferred to increasing the dose of ICS • ICS are generally safe and well-tolerated • Though low-medium dose of ICS may affect growth velocity, this effect is clinically insignificant and may be reversible.

41. Inhaled Corticosteroids • Local adverse effects: • oropharyngeal candidiasis • Dysphonia – may be e reduced by using MDI + spacer devices and mouth washing • Systemic side effects are occasionally reported with high doses and long-term treatment

42. Inhaled Corticosteroids

43. Leukotriene modifiers (LTRA) • LTRA reduce airway inflammation and improve asthma symptoms and lung function but with a less consistent effect on exacerbations, especially when compared to ICS. • Alternative treatment to ICS for patients with mild asthma, especially in those who have clinical rhinitis • Some patients with aspirin-sensitive asthma respond well to the LTRA

44. Leukotriene modifiers (LTRA) • Available as Montelokast in Saudi Arabia • Their effects are generally less than that of low dose ICS • When added to ICS, LTRA may reduce the dose of ICS required by patients with uncontrolled asthma, and may improve asthma control • LTRA are generally well-tolerated. There is no clinical data to support their use under the age of six months.

45. LABA • LABA: (formoterol and salmeterol) • Should not be used as monotherapy • Combination with ICS lead to: • improves symptoms • decreases nocturnal asthma • improves lung function • decreases the use rapid-onset inhaled B2-agonists • reduces the number of exacerbations • achieves clinical control of asthma in more patients, more rapidly, and at a lower dose of ICS

46. Combination devices • Sympicort turbohaler: • Budesonide/Formeterol: 160/4.5 • Seretide: • Fluticasone/Salmeterol • Evohaler: 50/8 125/8 250/8 • Diskus: 100/16 250/16 500/16

47. Theophylline • Weak bronchodilator with modest anti-inflammatory properties. • It may provide benefit as add-on therapy in patients who do not achieve control on ICS alone • Less effective than LABA and LTR. • Side effects: • gastrointestinal symptoms • cardiac arrhythmias • seizures, and even death • Drug interaction

48. Anti-IgE • Omalizumab (Xolair) indication: • Uncontrolled severe allergic asthma on high dose ICS and other controllers. • Needs specialist consultation. • Side effects: • Pain and bruising at injection site and very rarely anaphylaxis (0.1%).

49. Oral glucocorticosteroids • Long-term oral glucocorticosteroid therapy may be required for uncontrolled asthma despite maximum standard therapy. • It is limited by the risk of significant adverse effects. • Side effects: • Osteoporosis, hypertension, diabetes, adrenal insufficiency, obesity, cataracts, glaucoma, skin thinning, and muscle weakness. Withdrawal can elicit adrenal failure. • In patients prescribed long-term systemic glucocorticosteroids, prophylactic treatment for osteoporosis should be considered.

50. Reliever Medications • Short-acting inhaled B2-agonists • Anticholinergics • Theophylline