Asthma control (2)

04/11/2023 amr badreldin hamdy MD 1

Asthma Control

Clinical Pearls

04/11/2023 3

Amr Badreldin Hamdy, MD FCCP

Prof of Pulmonary Medicine

Banha University, EGYPTPulmonary Consultant

NEW CAPITAL MEDICAL CENTRE, ABU DHABI

Amr Badreldin Hamdy MD FCCP

Is There A Cure For Asthma?

Asthma cannot be cured, but it can be Controlled

“We should expect nothing less”!

In lay usage, “control” conveys the sense of being reined in or kept within certain boundaries.

The patient’s level of asthma control represents the extent to which the clinical manifestations of asthma have been removed or reduced by treatment.

The goals of asthma treatment are relating not only to the control of patient’s current symptoms, but also to the prevention of future adverse outcomes, such as exacerbations, a rapid decline in lung function and side-effects of treatment.

The assessment of asthma control falls into two broad categories: assessment of the current level of clinical control and assessment of future risk to the patient.

Asthma is a chronic inflammatory disorderof the airways.

This causes an increase in airway hyper-responsiveness leading to

o Wheezingo Breathlessnesso Chest tightnesso Coughing

GINA, 2002

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Asthma is one of the commonest chronic diseases worldwide and is increasing in children and probably also in adults.


Burden of Asthma

The WHO has reported the annual costs of BA exceed those of TB and HIV combined due to poor asthma control and disease management.

Burden of Asthma-cont’d

The evaluation of asthma costs considers both direct costs (medication and treatment) and indirect costs (loss of school or working days and decrease in productivity).


Asthma: limits daily-life activities

0

20

40

% o

f pa

tien

ts

60

Social activities

Career Choice

Housekeeping

Lifestyle

Normal Physical Activity

SleepingSports

Asia Pacific Europe US

Rabe et al. 2000; Fulbrigge et al. 2002; Lai et al. 2002


While it is a worldwide problem, the prevalence of the condition seems to be higher in affluent than non-affluent populations.


Under-diagnosis and under-treatment are major contributors to asthma morbidity and mortality.

Long term preventive treatment is the cornerstone of good asthma control.


Putting primary emphasis on controlling bronchial spasm rather than chronic airway inflammation looks like “putting the cart before the horse”.


Even following administration of one of the many forms of asthma treatment, up to 40% of adults remain symptomatic, and up to 5% of cases are difficult to manage despite multiple forms of treatment.


What Are Benefits Of Long Term Preventive Treatment

Of Asthma?

Achieving asthma control is the focus of all recently developed asthma treatment guidelines.


The goal is effective control of asthma, which strives to ensure that the asthmatic is able to lead a normal and physically active life.

Current clinical control is assessed by direct observation of the patient’s current or recent clinical status on treatment.


Remember!

One must always consider that the goal of total control of asthma must be balanced against the cost and potential adverse effects of asthma control.

The assessment of asthma control has two components: current clinical control (including symptoms, reliever use and simple “bedside” measures of lung function) and future risk of adverse outcomes (e.g. exacerbations, rapid decline in lung function, and side effects).

What is asthma control?As defined by the Global Initiative for Asthma (GINA), 2007

oMinimal to no daytime asthma symptomsoNo limitations on activitiesoNo nocturnal symptoms or awakeningsoMinimal to no need for reliever or rescue

therapyoNormal lung function (FEV1 or PEF)oNo exacerbations

www.ginasthma.org

Exacerbations, by definition and clinical practice, are identified by a change from and return to previous status, i.e. by their time trend.

Exacerbations are events that are more common in poorly controlled asthma but may occur at any level of clinical asthma control.

What are the Key elements of an Asthma Program?


oEducation-motivation.oSelf assessment management.oEnvironmental management.oPharmacological management.


In the assessment of asthma control, there are several important activities that should be accomplished during the periodic visit for asthma:


1. Assessment of psychosocial status.

2. Assessment of adherence-compliance.

3. Assessment of medication use and its side effects.


4. Assessment of asthma triggers.

5. Review of written asthma action plan (as appropriate).

6. Confirmation of asthma diagnosis.


A common misconception is that asthma severity is considered “static”; namely, that once a patient is classified with a given severity level, it remains constant.

Asthma symptoms are a dynamic and often a changing parameter.


Asthma control can be expected to change over time. It should be assessed at every clinical encounter for asthma, and management decisions should be based on the level of asthma control.


If a patient has been stable on an asthma treatment program for a period of time, consideration should be given to try “stepping down” therapy to a less intense level of treatment plan.

Barriers of Effective Treatment


oFailure to agree to set a common goal with the patients.

oPatient resistance/objection to inhalation therapy.

oPoor inhalation technique.oSteroid phobia.oWorry about excessive cost.


Key Goals in Patient Education

With the help of the health-care team, patients can learn to do the following:

o Avoid risk factors.o Understand the difference between “reliever” and

“controller” medications.o Monitor status using symptoms or PEFRo Recognize signs that asthma is worsening and take

action.

Aims of asthma management, which if achieved,indicate overall asthma control

oMinimal (ideally no) symptomsoMinimal (infrequent) exacerbationsoNo emergency visitsoMinimal (ideally no)PRN ß2-agonist useoNo activity restriction, including exerciseoPEF circadian variation less than 20%o (Near) normal PEFoMinimal (or no) adverse effects from medicines

GINA, 2002

Patients currently achieving control

Not Well-Controlled

Well-ControlledOnly 5% of patientsachieve asthma control

Rabe et al. Eur Respir J, 2000

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CAUSES OF NONRESPONSIVE ASTHMA


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1. Wrong diagnosis o COPDo Bronchiectasis, Cystic fibrosis,o Inhaled FBo Recurrent aspiration.o Obliterative bronchitis.o Tumors involving the central airway.o Tracheobronchomalacia.o Vocal cord dysfunction.


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2. Poor Adherence To Therapy

o Patient related.o Drug related.


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3. Unidentified Exacerbation Factorso Unidentified allergieso Occupational exposureo GERDo Systemic diseases (thyrotoxicosis,

carcinoid syndrome, Churg-Strauss Syndrome)

o Drugs (Beta-blockers, ACE-inhibitors)o Rhinitis/sinusitis/sleep apneao Psychological factors


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4. Unstable Asthma

o Nocturnal asthmao Pre-menstrual asthmao Brittle asthma


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5. Corticosteroid Dependant/Resistant Asthma.


Asthma PhenotypesoIntermittent/Persistent

– Mild/Moderate/Severe

oAdult onset wheezing– Primary asthma and secondary causes– Tends to me more severe

oOccupational asthmaoNeutrophilic inflammation

The asthma phenotypes may alter the intensity of treatment required (severity) and, in turn, contribute to the patient’s level of asthma control.

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Do we really avoid the triggers?


Can We Control His Asthma?


How to Avoid Pollution?


Pest Elimination


Pollen Elimination


Asthma and Exercise


Asthma and Fumes, Odors and Strong Scents


Adherence


Adherence Definition

It is a the extent to which a person’s behavior-taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.

Rand CS. AJ Cardiology; 1993,72.


Adherence Incidence

In developed countries, adherence to long-term therapies in the general population is around 50% and is much lower in developing countries.


Evidence shows that adherence rates for the regular taking of preventive therapies are as low as 28% in developed countries.

Reid D et al., Respirology, 2000,5.


Rates of non-adherence among patients with asthma range from 30% to 70%, whether adherence is measured as percentage of prescribed medication taken, serum theophylline levels, days of medication adherence, or percentage of patients who failed to reach a clinically estimated adherence minimum.Bender B et al, Ann Allergy, Asthma, & Immunology, 1997,79.


Types of Non-compliance


oReceiving a prescription but not filling it.o Taking an incorrect dose. o Taking medication at the wrong times.o Increasing or decreasing the frequency

of doses.o Stopping the treatment too soon.oNon-participation in clinic visits.o Failure to follow doctor’s instructions.


o“Drug holidays”, which means the patient stops the therapy for a while and then restarts the therapy.

o“White-coat compliance”, which means patients are compliant to the medication regimen around the time of clinic appointments.


Asthma Compliance Score


Categories of Factors Identified From the Literature Review


(1) Patient –centered FactorsoDemographic factors: age, ethnicity,

gender, education, marriage status.oPsychosocial factors: beliefs,

motivation, attitude.oPatient-prescriber relationship.oHealth literacy.oPatient knowledge.


(2) Therapy-related FactorsoRoute of administration.o Treatment complexity.oMedication side effects.oDuration of the treatment period.oDegree of behavioral change required.o Taste of the medication.oRequirements for drug storage.


(3) Healthcare System Factors

oLack of accessibility.oLong waiting time.oDifficulty in getting prescriptions

filled.oUnhappy clinic visits.


(4) Social and Economic Factors

o Inability to take time off work.oCost and income.oSocial support.


(5) Disease Factors

oDisease symptoms.oSeverity of the disease.


How to Recognize Asthma Deterioration?

o Increasing frequency of severity of symptoms, especially waking at night.

o Increasing use of reliever medication.o Failure of medication to completely

relieve symptoms.o Falling peak flow and /or increasing peak

flow variability.


continuedoPhysical difficulties.oTobacco smoking or alcohol intake.oForgetfulness.oHistory of good compliance.

How to Deal with a Non-responding Patient?


If a patient with asthma is not responding as we think they should, it’s time to “think new thoughts” and see if we are missing something that is undermining our treatment plan.

Incorrect inhaler choice or poor technique

o There is no clinical difference between inhaler devices when used correctly, but each type requires a different pattern of inhalation for optimal drug delivery to the lungs

o Problems with inhaler technique are common in clinical practice & can lead to poor asthma control

o Asthma control worsens as the number of mistakes in inhaler technique increases

o All patients should be trained in technique, and trainers should be competent with the inhalation technique

Inhaler choice and technique

o Take patient preference into account when choosing the inhaler device

o Simplify the regimen and do not mix inhaler device types

o The choice of steroid inhaler is most important because of the narrower therapeutic window

o Invest the time to train each patient in proper inhaler technique:

• Observe technique & let patient observe self (using video demonstrations)• Devices to check technique & maintain trained technique are available (eg, 2Tone

Trainer & Aerochamber Plus spacer for metered dose inhalers; In-Check Dial, Turbuhaler whistle, Novolizer for dry powder inhalers)

o Recheck inhaler technique on each revisitHaughney J et al. Respir Med. 2008;102:1681–93.

Evidence linking asthma & rhinitiso >50% of patients with asthma have rhinitiso Similar epidemiologyo Common triggerso Similar pattern of inflammation:

T helper type 2 cells, mast cells, eosinophilsoNasal challenge results in asthmatic

inflammation & vice versao Rhinitis predicts development of asthma

Thomas M. BMC Pulm Med. 2006;6:S4.

Unintentional versus intentional nonadherence

Perceptual–Practical Model of Adherence(can’t take, won’t take)

UNINTENTIONAL

nonadherence

INTENTIONAL

nonadherence

Capacity & resources

Practical barriers

Motivational

Beliefs/preferences

Perceptual barriers

Horne R et al. 2005. National Co-ordinating Centre for NHS Service Delivery and Organisation R&D, London.

Intentional non adherence derives from the balance between the patient’s beliefs about the personal necessity of taking a given medication relative to any concerns about taking it

Degree of Asthma Control

The terms severity and control should not be regarded as synonymous, as patients with severe asthma may be well controlled on high doses of treatment and patients with mild asthma may be currently poorly controlled, e.g. owing to poor compliance.

Severity is described by the intensity of the treatment required to achieve good control.

The probability of a patient becoming well controlled is independent of their baseline severity (their baseline dose of ICS).

The level of asthma control results from the interaction of the underlying phenotype, the environment (genetic and external) and the response to treatment.


Poor Controlled Asthma

oThe occurrence of prior near fatal episode.

oRecent hospitalization.oRecent emergency room visit.oNight time symptoms.oLimitation of daily activities.


Need for inhaled beta2-agonists several times per day or at night.

FEV1 or PEFR less than 60% predicted.


Well Controlled Asthma

oAsthma symptoms are twice a week or less.

oRescue bronchodilator medication is used twice a week or less.

oThere is no nocturnal or early morning awakening.

oThere are no limitations of work, school, or exercise.


oThe patient and physician consider their asthma well controlled.

oThe patient’s PEF or FEV1 is normal or his/her personal best.


Complete (Total) Controlled Asthma

oNo asthma symptoms.oNo rescue bronchodilator use.oNo night or early morning awakening.oNo limitations on exercise, work, school.oComplete control of asthma by patient

assessment and normal best PEF or FEV1.

Patients Physicians

Healthcare system

TOTAL CONTROL

Raising expectations…

Researchers

Drugs Used for Control

In 1995, the GINA guidelines introduced the concept of the medication required to maintain control.


Preventers

These have anti-inflammatory actions (ICS, Cromones).


Controllers

Drugs which have a sustained bronchial dilatation action, but unproven anti-inflammatory action ( LABA, SR xanthines, Leukotriene receptor antagonists).


Relievers

For acute relief from symptoms.


Referenceso Hess DR: Aerosol delivery devices in the

treatment of asthma. Respiratory Care, 2008; 53(6):699.

o Castro M & Kraft M: Clinical Asthma. Mosby El Servier, 2008.

o Bush RK & Georgitis J.W.: Handbook of Asthma and Allergic Rhinitis. Blackwell Publ. Ltd., 1977.


o Lavorini F. & Corbetta L.: Achieving Asthma Control: The Key Role of Inhalers. Breathe, 2008; 5(2):121.

o Bateman ED et al.: Achieving Guideline-based Asthma control: Does the Patient Benefit?. Eur Respir J 2002; 20:588.

o Soubra S & Guntupalli KK: Acute Respiratory Failure In Asthma. Indian J Crit Care Med 2005; 9(4):225.


o Kankaanranta H et al: Add-on Therapy Options in Asthma not Adequately Controlled by ICS: A comprehensive Review. Respiratory Research 2004; 5:17.

o WHO: adherence to Long-term therapies. Evidence for Action 2003.

o Kristin Casler: Asthma. Questions you have…Answers you need. People’s Medical Society 1998.

THANK YOU

Asthma control (2)

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