Asthma—Here Today, Gone Tomorrow?

Jill Grothusen, MD

University of Kansas Family Medicine Residency

June 8th, 2019

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Jill Grothusen, MD

Originally from Scott City, KS in Western KS. Went to undergrad at Mount Holyoke College and studied biochemistry and nutrition. After graduating I worked in biotech consulting and then ran clinical trials in breast cancer and gynecology oncology. I graduated from medical school at the University of Kansas and completed intern year at Valley Family Medical Residency in Renton, WA.

Learning Objectives

Describe the pathophysiology of asthma and clinical manifestations of asthma exacerbations.

Understand how to diagnose/classify asthma using office spirometry.

Apply the step-wise approach to asthma management.

Understand when to appropriately taper down asthma medications.

Social determinants of health of asthma

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Pathophysiology

Asthma is a heterogeneous disease characterized by chronic airway inflammation, airway hyper-responsiveness, airflow limitations, and respiratory symptoms

Airflow obstruction is typically reversible, either resolving spontaneously or with treatment

Precipitating factors vary as well and include: Allergens/Exposure Exercise Change in weather Viral Illness

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Pathophysiology

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Pathophysiology

Inflammatory cell infiltration with neutrophils, eosinophils, lymphocytes, mast cell activation leading to epithelial cell injury

Persistent changes in airway structure can cause sub basement fibrosis, mucus hypersecretion, injury to epithelial cells/fibrosis, smooth muscle hypertrophy and angiogenesis

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Pathophysiology

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3M Resource Cards Doctors

Designers 11/96

Clinical Manifestations

Respiratory symptoms including: Wheeze

Shortness of breath

Chest tightness

Cough

May vary over time and in intensity

Exacerbations manifest with progressive worsening of above symptoms, increased work of breathing, tachypnea and tachycardia

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Diagnosis

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Respiratory symptoms, HPI/exam consistent

with asthma

Spirometry/PEF consistent with asthma? Treat for Asthma

Repeat spirometry/PEF on another occasion

consistent with asthma?

Consider trial of treatment of other most

likely Dx

yes

No

No

Adapted from Global Strategy for Asthma Management and Prevention 2018,Box 1-1

Diagnosis with Spirometry

Spirometry more accurate than using peak expiratory flow

FEV1/FVC ratio <70% (below 5th percentile) = obstructive defect present

Determine reversibility after bronchodilator: More than 12% change and 200 mL diagnoses asthma

If spirometry is normal and asthma still suspected, perform methacholine challenge

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Treatment

GINA 2018

When to assess response

Improvement can be seen within the first days of treatment with controller therapy, however full effect may not be seen until 3-4 months, or longer if patient has history of chronic disease with no treatment

Reassess 1-3 months after starting treatment, then every 3-12 months

Schedule follow-up within 1 week of exacerbation

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Asthma symptom control

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Asthma symptom control Level of asthma symptom control

In the past 4 weeks, has patient had: Well Controlled Partly Controlled Uncontrolled

Daytime asthma symptoms more than twice/week?

YES NO

“NO” to all 1-2 “YES” 3-4 “YES”Any night waking due to asthma? YES NO

Reliever needed for symptoms more than twice/week*?

YES NO

Any activity limitations due to asthma?

YES NO

GINA 2018

Stepping up

Failure to respond to initial treatment in patients whose symptoms are confirmed to be due to asthma, first: Assess inhaler technique and compliance Modifiable risk factors such as smoking and home

allergens, irritant exposure

Then step up to next therapy level. After 2-3 months review response

If no response of treatment, reduce to previous level, consider alternative treatment options and/or referral

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Stepping down

Consider stepping down if symptoms have been well controlled for 3 or more months and if low risk for exacerbation

Choose time when patient does not have current infection, no planned travel, if seasonal allergies are factor try to avoid specific times of year

Therapy stepped down and close re-evaluation—document symptom control, lung function and risk factors.

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Stepping down

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Current Step

Current Medication/Dose Option for stepping down Evidence

Step 5 High dose ICS/LABA + oral corticosteroids (OCS)

High dose ICS/LABA + other add-on agent

Continue high dose ICS/LABA and reduce OCSUse sputum guided approach to reduce OCSAlternate day OCS treatmentReplace OCS with high dose ICSRefer for consultation

Step 4 Moderate to high dose ICS/LABA maintenance tx

Medium dose ICS/formoterol

High dose ICS + 2nd controller

Continue ICS/LABA with 50% reduction in ICSDiscontinuing LABA may lead to deterioration

Reduce maintenance ICS/formoterol to low dose + continue with PRN relieverReduce ICS by 50% and continue 2nd controller

Step 3 Low dose ICS/LABA

Low dose ICS/formoterol

Moderate- or high-dose ICS

Reduce ICS/LABA to once dailyDiscontinuing LABA may lead to deteriorationReduce maintenance ICS/formoterol to QD dose + continue with PRN relieverReduce ICS dose by 50%

Step 2 Low dose ICS

Low dose ICS or LTRA

Once daily dosing Adding LTRA may allow ICS dose to step down

Consider stopping controller treatment only if no symptoms for 6-12 mo and no major risk factors for severe exacerbation

Asthma remission?

Participants identified as having physician diagnosis of asthma in the previous 5 years, had not smoked cigarettes for at least 10 years, not using long term prednisone, were not pregnant/breastfeeding, no recent MI, stroke or eye surgery

613 participants completed protocol

Tested with spirometry to diagnose asthma. If spirometry normal, then patients underwent MIC testing

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Asthma remission?

Participants with negative bronchial challenge test results who were using daily asthma-controlling medications were gradually tapered

If no acute worsening of symptoms, no variable decline in peak flow measurements and bronchial challenge tests remained negative, then they eventually had their controller medications discontinued

All patient in whom current asthma excluded had follow up bronchial challenge at 6 and 12 months

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Asthma remission?

RESULTS 410 patients (67%) were determined to have asthma

based off spirometry or bronchial challenge• 86 reversible airflow obstruction at first visit

• 287 Bronchial hyper-responsiveness at visit 2, 3, or 4

• 9 with acute worsening of asthma when tapering medication

• 28 with asthma diagnosed by study pulmonologist

203 patients (33%) were determined not to have asthma• 43.8% had no prior confirmation by spirometry, bronchial

challenge or PF measurement

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Discussion

Patients diagnosed with adult-onset asthma may not need to continue treatment indefinitely

Objective testing is essential for proper diagnosis Difficult to determine if cohort of patients in remission

or an incorrect initial diagnosis

Patient population may not be representative to all asthma as patients who were included likely represent more mild disease burden

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Social Determinants of Health

Prevalence of asthma highest among non-Hispanic blacks, women, persons with less than high school education, and low SES (income <25,000)

Up to 1/3 pts with asthma in Georgia could not see a doctor because of costs

Cost of asthma medications is $$$$ and routine visits can become burdensome

Stresses the importance of Correct diagnosis at onset of symptoms

Use of step-down strategies whenever possible

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Citations

National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Full Report 2007

Global Initiative for Asthma. 2018 GINA Report, Global Strategy for Asthma Management and Prevention

Aaron SD, et al. Reevaluation of Diagnosis in Adults With Physician-Diagnosed Asthma. JAMA. 2017 Jan 17;317(3):269-279. doi: 10.1001/jama.2016.19627.

Hollingsworth HM, et al. Asthma-Here Today, Gone Tomorrow? JAMA. 2017 Jan 17;317(3):262-263. doi: 10.1001/jama.2016.19676.

Barreiro T, et al. An approach to interpreting spirometry. Am Fam Physician. 2004 Mar 1;69(5):1107-14.

Johnson JD, et al. A stepwise approach to the interpretation of pulmonaryfunction tests. Am Fam Physician. 2014 Mar 1;89(5):359-66.

Ebell M, et al. The burden and social determinants of asthma for adults in the state of Georgia. J Ga Public Health Assoc. 2017 Spring;6(4):426-434. doi: 10.21633/jgpha.6.406.

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Questions?

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