A Clinical update in Asthma

1. A Clinical update in Asthma Lee Dobson Torbay Hospital

2. Questions?

3. 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 1997 Oxis 1980s Major developments in asthma management 1995 onwards GINA How are we doing? 1969 Ventolin introduced 1991 The β2 agonist debate 1993 Flixotide introduced Late 60s Bronchoscope 1972 Becotide introduced 1965 Intal introduced 1956 3M launch The MDI Early 1950s MDI

4. Asthma Burden in Europe 2006 Not Well-Controlled asthma (% of treated patients) % Patients not Well Controlled 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 Desfougeres JL et al. EurRespir J 2007:30 (supple 51):249s

5. Number of people living with asthma in the UK today Total 5.2 million1 Women 2.9 million1 Men 2.3 million1 Data includes 590,000 teenagers and 700,000 people over 651 Every 6 hours someone dies from asthma2 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).

6. 100 75 Number of deaths 53% 50 25 21% 16% 10% 0 Severe Moderately severe Mild Unknown Asthma severity (%) Asthma deaths occur across disease severity • It is a myth that only severe asthma can prove fatal • Asthma deaths occur across disease severity with deaths occurring in those patients whose asthma is considered mild-to-moderate Number of asthma deaths across disease severity 2001–2003 n=57 Harrison B et al. Prim Care Respir J2005 Dec; 14: 303–13.

7. 2007/8 QOF Prevalence of Asthma Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/

8. QOF Prevalence of Asthma 2009 2010 TCT 10198 10193 SD 8276 8481 Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/

9. Asthma admissions increased by 30% 45 more hospital admissions Asthma bed days decreased by 21% 122 fewer bed days Change in Asthma Hospital Admissions, Length of Stay and Bed Days in Torbay Care Trust (2005/06 to 2006/07) • Average length of stay decreased by 39% • From 3.8 days to 2.3 days Source: NHS Information Centre: Hospital Episodes Statistics (HES)

10. International/National Guidance

11. British Guideline on the Management of Asthma British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN)

12. Definition of asthma “A chronic inflammatory disorder of the airways … in susceptible individuals, inflammatory symptoms are usually associated with widespread but variableairflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.” Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92

13. Diagnosis 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

14. Diagnosis • 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 unavailable occupational monitoring

15. Following clinical assessment in adults

16. Features that increase the probability of asthma in adults • >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

17. Features that lower the probability of asthma 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

18. Following clinical assessment in adults

19. Differential Diagnosis • Without airflow obstruction Chronic cough syndromes DBS Vocal Cord Dysfunction Rhinitis GORD Heart Failure Pulmonary Fibrosis • With airflow obstruction COPD Bronchiectasis Inhaled Foreign Body Obliterative Bronchiolitis Large Airway Stenosis Lung Cancer Sarcoidosis

20. Pharmacological Therapy

21. Aims of pharmacological management • Start treatment at the step most appropriate to the initial severity of their asthma • Aim is to achieve early control • Step up or down with therapy • Minimal therapy Before initiating new drug therapy: • Compliance • Inhaler technique • Eliminate trigger factors

22. Aim pharmacological management Control of asthma, defined as: • No daytime symptoms • No night time awakening due to asthma • No need for rescue medications • No exacerbations • No limitations on activity including exercise • Normal lung function (FEV1 and/or PEF >80% predicted or best) with minimal side effects.

23. Monitoring asthma in primary care Factors that should be monitored and recorded: • Symptomatic asthma control using RCP ‘3 questions’, Asthma Control Questionnaire or Asthma Control Test (ACT) • Lung function (spirometry/PEF) • Exacerbations • Inhaler technique • Compliance (prescription refill frequency) • Bronchodilator reliance (prescription refill frequency) • Possession of and use of self management plan/personal action plan

24. Monitoring asthma in primary care Factors that should be monitored and recorded: • Symptomatic asthma control using RCP ‘3 questions’, Asthma Control Questionnaire or Asthma Control Test (ACT) • Lung function (spirometry/PEF) • Exacerbations • Inhaler technique • Compliance (prescription refill frequency) • Bronchodilator reliance (prescription refill frequency) • Possession of and use of self management plan/personal action plan

25. PAAPs

27. Inhaler devices

28. Step 1: Mild intermittent asthma • Prescribe inhaled short acting β2 agonist (SABA) as short term reliever therapy for all patients with symptomatic asthma • Good asthma control is associated with little or no need for short-acting β2 agonist • Using two or more canisters of β2 agonists per month or > 10-12 puffs per day is a marker or poorly controlled asthma that puts individuals at risk of fatal or near-fatal asthma • Patients with high usage of inhaled short-acting β2 agonists should have their asthma management reviewed

29. A stepwise approach

30. Step 2: Regular preventer therapy • Inhaled steroids are the recommended preventer drugs for adults for achieving overall treatment goals • Consider inhaled steroids if any of the following: • Using inhaled β2 agonist three times a week or more • Symptomatic three times a week or more • Waking one night a week • Exacerbation of asthma in the last two years (adults and 5-12 only)

31. Step 2: Regular preventer therapy • Adults: • 200-800mcg/day BDP*(reasonable starting dose 400mcg per day for many adults) • Start patients at a dose appropriate to the severity of the disease • Titrate the dose to the lowest dose at which effective control of asthma is maintained

32. Step 2: Regular preventer therapy

33. A stepwise approach

34. Step 3: Initial add-on therapy • A proportion of patients may not be adequately controlled at step 2 • Check and Eliminate • Adults and Children 5-12: • First choice as add-on therapy is an inhaled long-acting β2 agonist (LABA), which should be considered before going above a dose of 400mcg BDP* and certainly before going above 800mcg

35. Step 3: Initial add-on therapy

36. 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 Is “1” better than “2”? …why?

37. A stepwise approach

38. Step 4: Persistent poor control • If control remains inadequate…

39. A stepwise approach

40. Step 5: Continuous or frequent use of oral steroids • Still uncontrolled.. • Monitor - Blood pressure Diabetes Hyperlipidaemia BMD

41. Step 5: Continuous or frequent use of oral steroids • Steroid sparing medication - Methotrexate - Ciclosporin - Oral Gold Colchicine IVIG Subcutaneous Terbutaline Anti- TNF

42. Stepping down • Stepping down therapy once asthma is controlled is recommended • Regular review of patients as treatment is stepped down is important • Patients should be maintained at the lowest possible dose of inhaled steroid • Reductions should be slow, decreasing dose by ~25-50% every three months

43. A stepwise approach

44. Case 1 • 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

45. Case 1 • ? Regular meds – becotide • At university, smokes!..moderate alcohol! • Acute management? • Steroids, ICS, ventolin, RNS, OPD

46. Case 1 • Clinic October 2006 • Good recovery, still some SOBOE, started attending gym. • Nocturnal symptoms – none • Ventolin – three times per week. • What to do?

47. Case 1 • Lifestyle advice • Compliance • RNS - Management Plan, Education • Pre-dose with ventolin • LABA - Combination inhaler

48. Do we understand what the patients want?

49. Living and Breathing Study UK qualitative and quantitative study to evaluate patient understanding of their asthma and determine patient preferences regarding the delivery of asthma care and treatment. 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

50. Do the patients know what they want?