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Asthma Module 1 Strategies to manage your uncontrolled asthma patients

Asthma Module 1 Strategies to manage your uncontrolled asthma patients. Learning Objective. Upon completion of this program, participants will be able to:. . Implement strategies and apply the evidence to address barriers to optimally control their asthma patients.

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Asthma Module 1 Strategies to manage your uncontrolled asthma patients

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  1. Asthma Module 1Strategies to manage your uncontrolled asthma patients

  2. Learning Objective Upon completion of this program, participants will be able to:  • Implement strategies and apply the evidence to address barriers to optimally control their asthma patients

  3. National Family Physician Survey:“How do you define Overall Asthma Control?” (n=54))

  4. Asthma Control FEV1 = forced expiratory volume in 1s; PEF = peak expiratory flow. †Diurnal variation is calculated as the highest PEF minus the lowest divided by the highest PEF multiplied by 100 for morning and night (determined over a 2 week period).

  5. Discussion Question ? ? What is the primary patient barrier to effective asthma control? ? ?

  6. Challenges Impacting Asthma Control • Chronic disease • Adherence • Comorbidities • Expectations of control • Periods of worsening

  7. Asthma is Not Recognized as a Chronic Disease Asthma is one of the most common chronic diseases managed in primary care1 Chronic inflammation and increased airway responsiveness lead to accelerated declines in lung function 1.7 1.5 No asthma (n=5480) Asthma (n=314) 1.3 1.1 Height-adjusted FEV1 (L) 0.9 0.7 0.5 0.3 20 30 40 50 60 70 80 Age (yrs) Male Nonsmokers Balter MS, et al. CMAJ 2009;181:915-22. Graphic from Lange P et al. NEJM;1998:339:1194-1200.

  8. Patient Non-Adherence is Driven by Education/ Management Issues vs. Cost Beliefs about Prescription Medication1 80% *p<0.0001 for all comparisons 70% 60% 50% Patient Agreement Regarding Medication 40% 30% 20% 10% 0% Improve Condition BenefitsOutweighed Risk KnowledgeableaboutMedication Worried aboutSide-effects ExperiencedSide-effects low income high income Piette JD, et al. Patient Prefer Adherence 2011;5:389-396. Foster JM, et al. Intern Med. 2011; Jun 1. doi: 10.1111/j.1445-5994.2011.02541 Key reasons for non-adherence1,2 • Perceived need for medication • Side effects/safety concerns • Acceptance of asthma chronicity/medication effectiveness • Advice from family/friends • Motivation/routine • Ease of use • Satisfaction with asthma management

  9. Rhinitis:AllergicNonallergicPolypoid HyperventilationGlottic dysfunction ChronicSinusitis GERD Psychopathologies Asthma Obesity SmokeNicotine dependence COPD OSA Hormonaldisturbances Respiratoryinfections Other conditions:Atopic dermatitisABPABronchiectasis Control is Also Impacted by the Comorbidities Associated with Asthma Boulet L-P. Eur J Respir. 2009;33:897-906. Comorbidities may: influence clinical expression impact severity make control harder to achieve alter response to asthma medication

  10. Most Patients Perceive That Their Asthma is Controlled While Objective Measures Indicate the Opposite is True Asthma Control in the Past 4 Weeks Patient Perspective Completely Controlled31% Not Controlled2% Poorly Controlled4% Somewhat Controlled24% Well Controlled40% Control Classification Very poorly Controlled47% Control/symptom occurrence included: daytime, night-time, during exercise, play, or upon physical exertion Well Controlled29% Not well Controlled24% Patient perception: 71% of patients perceive that their asthma is well/completely controlled Clinical reality: <30% of patients are classified as having well controlled asthma AIM Survey 2009

  11. Even Patients with Well Controlled Asthma Experience Periods of Asthma Worsenings* That Require Management Symptoms startto becomebothersome Recovery Signs or warnings (primarily breathlessness) Symptoms at their worst • * Asthma worsening is an increase in symptoms that: • are considered “bothersome” • affect normal functioning or sleep • lead to an increase in rescue medication Mean time from first warnings to peak of worsening = 5.1 days Balter M, et al. Can Resp J 2008;15(Suppl B):1B-19B. Most patients report experiencing early warning signs before an asthma worsening, however proper intervention does not always occur

  12. The Window of Opportunity Tattersfield AE, et al. Am J Respir Crit Care Med. 1999;160:594-599.

  13. Discussion Question ? ? What are the consequences of poor asthma control? ? ?

  14. Consequences of Poorly Controlled Asthma Patients don’t understand control and accept symptoms, impacting QoL, morbidity and mortality Suboptimal use of maintenance therapy Increased reliever use with no improvement in symptoms over the long term Inability to recognize and manage worsenings Lack of plan to prevent exacerbations Symptom deterioration, greater exposure to systemic CS with ↑ in side effect profile, and need for critical care Increase in exacerbations, deterioration of lung function and disease progression 1. Kaplan A. Can J Diagnosis 2010; 27 (12). 2. Kuna P, et al. Int. J Clinical Practice. 2007;61:725-36.

  15. Asthma is a Chronic Inflammatory Disorder Associated with Recurrent Symptoms; if Not Controlled, Severe Exacerbations and Accelerated Remodelling May Occur Inflammation Accelerated structural changes AirwayHyperresponsiveness AirwayObstruction Flare-ups/ Exacerbations Clinical Symptoms Adapted from the Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2011. Airway Remodelling/ Decline in lung function

  16. Exacerbations are Associated with More Rapid Loss of Lung Function Paradigm Shift: • Asthma is not a static disease; exacerbations cause irreversible airway remodelling leading to lung function decline p<0.05 4.1 50 3.6 Patient with 4 exacerbations over 35 years 40 3.1 30 FEV1 L Annual decline in FEV1 mL yr1 2.6 20 2.1 10 # # # # 1.6 0 30 40 50 60 70 Infrequent Frequent Exacerbations Age yrs #: time-point of exacerbation Bai TR, et al. Eur Respir J. 2007; 30:452–456..

  17. Discussion Question ? ? What are strategies to effectively monitor asthma as a chronic disease and counsel patients? ? ?

  18. Clinical Framework to Assess and Manage Control for Asthma Review 1 Assessment of Asthma Control • Consider at EVERY visit • Consider when asked for a new asthma med refill, particularly reliever refill If no to all of the questions If yes to any of the questions 2 Identify Reasons for Poor Asthma Control 3 Asthma Management Review 4 Optimize Treatment Regimen Lougheed MD, et al.,Can Respir J. 2010;17:15-24.

  19. 1 Assessment of Asthma Control At Each Visit Ask the Following to Assess Asthma Control: • Does your asthma bother you during the daytime on 4 or more days a week? • Does your asthma bother you at night 1 or more times a week? • Does your asthma prevent you from being physically active? • Has your asthma kept you from going to work or school? • Have you needed your blue puffer* 4 or more times a week? *fast-acting β2 agonist Lougheed MD, et al.,Can Respir J. 2010;17:15-24.

  20. 2 Reasons for Poor Asthma Control At Each Visit Consider Discussing/Reviewing the Following: Lougheed MD, et al.,Can Respir J. 2010;17:15-24.

  21. Haughney J, et al. BMC Pulm Med. 2007;7:16. Consider: Adherence and Proper Medication Use is All About Simplicity • Patients would trade symptom improvement/relief for simpler treatment regimens • Preference is for as few inhalers as possible and a lower dose of inhaled steroid Relative Importance (RI) of Attribute Ranges Tested

  22. 3 Asthma Management Review At each visit or minimum yearly: Lougheed MD, et al. Can Respir J. 2010;17:15-24.

  23. Education/Action Plan:Partner with Patients to Improve Self-Management Self-management leads to: • Higher ICS adherence levels with a 9-fold greater odds of increased adherence to prescribed dosing • With education adherence preserved at a ratio of 3:1 to end of 24-week trial • Increase in perceived control of asthma, decrease in night-time awakenings, decrease in SABA use Odds ratio for outcomes following individualized self-management educational interventions vs. data collection visit Each patient received three identical 30-minute visits Janson SL, et al. J Allergy Clin Immunol. 2009; 123: 840–846.

  24. 3 Asthma Management Review At each visit or minimum yearly: Lougheed MD, et al. Can Respir J. 2010;17:15-24.

  25. 4 Optimize Treatment Regimen To regain asthma control and/or achieve patient management goals From the Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2011.

  26. Early and Sustained Therapy Will Protect Lung Function Treatment with an ICS, early after diagnosis: reduces the risks of a severe exacerbation as well as attenuating the decline in lung function associated with an exacerbation Budesonide Placebo 100 0 95 p=0.57 -5 90 FEV1 (%) FEV1 (%) Bud/No SARE Plac/No SARE Bud/SARE Plac/SARE p<0.001 85 -10 No SARE SARE 80 0 1 2 3 SARE: Severe Asthma-Related Event O’Byrne PM, et al. Am J Respir Crit Care Med. 2009;179:19–24..

  27. The Goal of Treatment is to Lower Rates of Exacerbations and Hospitalizations GOAL (Gaining Optimal Asthma Control) Study Results 0.7 Fluticasone Salmeterol/fluticasone 0.6 0.5 0.4 Mean exacerbation rate per patient per year 0.3 0.2 0.1 0.0 Steroid-naïve (S1) Low-dose ICS(S2) Moderate-dose ICS(S1) Stratum according to baseline therapy Mean rate of exacerbations requiring either oral steroids or hospitalization/emergency visit per patient per year over Weeks 1–52 according to use of ICS in previous 6 months (S1–S3). p≤0.009 salmeterol/fluticasone vs. fluticasone propionate, all strata Bateman ED, et al. Am J Respir Crit Care Med 2004;170:836-844.

  28. 0.20 0.15 0.10 0.05 0 Single Inhaler Maintenance and Reliever Therapy Further Reduces Exacerbations and Hospitalizations with a Lower Steroid Load Cumulative rate of severe exacerbations Salmeterol/fluticasone (25/125 µg 2 inhalations bid )+SABA Budesonide/Formoterol (320/9 µg 1 inhalation bid )+SABA Budesonide/Formoterol+Budesonide/Formoterol (160/4.5 µg (SMART) 1 inhalation bid) * †† † Exacerbations/patient • Budesonide/Formoterol+Budesonide/Formoterol reduced rate of exacerbations by: • 39% vs. Salmeterol/Fluticasone+SABA • 28% vs. Budesonide/Formoterol+SABA 0 20 40 60 80 100 120 140 160 Days since randomisation *NS ; †P<0.01 ; ††P<0.001 Kuna P, et al. Int J Clin Pract . 2007;61:725–736.

  29. How can you integrate this clinical framework into practice? Discussion Question ? ? ? ?

  30. Summary ASK - Assess asthma control at every visit CONSIDER - Assess and discuss reasons for poor asthma control REVIEW - At each visit or minimum yearly review/educate and update asthma action plan MODIFY - Change the treatment regimen to regain asthma control, limit exacerbations and achieve patient health goals

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