CHRONIC ASTHMA GUIDELINES IN ADOLESCENTS & ADULTS 2007 Bushra A. Hadi Asthma Guidelines...

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CHRONIC ASTHMA GUIDELINES IN ADOLESCENTS & ADULTS 2007 Bushra A. Hadi Asthma Guidelines Implementation Project

Transcript of CHRONIC ASTHMA GUIDELINES IN ADOLESCENTS & ADULTS 2007 Bushra A. Hadi Asthma Guidelines...

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CHRONIC ASTHMA GUIDELINESIN ADOLESCENTS & ADULTS 2007

Bushra A. Hadi

Asthma Guidelines Implementation Project

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Guidelines for the management of chronic asthma in adolescents

and adults

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Levels of Evidence

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Aims of the Guideline

• to improve asthma care for the greatest number through uniform treatment protocols

• to use the most efficacious and cost-effective drug combinations

• to facilitate teaching of doctors and other health care workers

• to empower patients to understand their disorder, and the types & goals of therapy

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Key Features of New Guidelines

• Emphasis on defining & achieving control of asthma

• The positioning of leukotriene blockers in the treatment of chronic asthma

• New evidence on the safety & optimal use of asthma medications

• The ongoing need to emphasize the use of anti-inflammatory medication as the foundation of asthma treatment

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2006 GINA Goalsof Asthma Management

Achieve and maintain control of symptoms

Maintain normal activity levels including exercise

Maintain pulmonary function as close to normal as possible

Prevent asthma exacerbations

Avoid adverse effects from asthma medications

Prevent asthma mortality

a

b

c

d

e

f

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Essential steps in the Management of Asthma to Achieve

Control:

Establish the diagnosis of asthma

Assess severity

Implement asthma treatment Set goals for control of

asthma Prevent/avoidance measures Pharmacotherapy

Achieve and monitor control

a

b

c

d

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A.ASTHMA DIAGNOSIS

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STEP 1

Suspect asthma on basis of symptoms and signs, particularly if there is variability

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STEP 2

Search for associated factors such as:

a. Atopy - allergic rhinitis, conjunctivitis, eczemab. Family history of asthma or other allergic disordersc. Onset of, or presence of, symptoms during childhoodd. Identifiable triggers for symptoms and relieving factors

such as improvement with a bronchodilator or deterioration with exercise

e. Exposure to known asthma sensitizers in the workplace f. Reversibility shown on lung function tests g. Optional tests include: Full blood count to check the eosinophil count Total serum IgE Skin prick tests or RAST in blood to look for evidence of

atopy Methacholine or histamine or exercise challenge tests

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Diagnostic lung function values

Reversibility: An increase of FEV1 of >12% and 200ml, 15-30min after the inhalation of 200-400mcg salbutamol, or a 20% improvement

in PEF from baseline.Hyper-responsiveness: Methacholine/histamine challenge Exercise: A fall of 20% in PEF (or 15% in FEV1) measured 5-10 minutes apart – before and then after cessation of

exercise (e.g. running for 6 minutes)Diurnal Variation: Diurnal Variation in PEF of more than 20%Distinguishing between COPD and asthma when FEV

shows obstruction: Improvement of FEV1 from baseline (>12% and 200ml) after a 2 week trial of oral prednisone (40mg daily)

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Differentiating asthma and COPD

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Other causes of airway obstruction

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Causes of occupational asthma

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B.ASSESSMENT OF

SEVERITY OR CONTROL

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C.ASTHMA TREATMENT

• Preventative/Avoidance Measures

• Pharmacotherapy

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Preventative/Avoidance Measures

A. Avoid exposure to personal and second-hand tobacco smoke

B. Avoid contact with furry animals

C. Reduce pollen exposure

D. Reduce exposure to house dust mite

E. Avoid sensitisers and irritants (dust and fumes) which aggravate or cause asthma, especially in the workplace

F. Avoid food and beverages containing preservatives

G. Avoid drugs that aggravate asthma such as beta-blockers (including eye drops) and aspirin and non-steroidal anti-inflammatory drugs

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PHARMACOTHERAPY

(A) RELIEVERS : Act only on airway smooth muscle spasm i.e. Cause BRONCHODILATION

symptoms acutely - cough

- SOB- wheeze/tightness

Take when necessary

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PHARMACOTHERAPY

(B) CONTROLLERS : underlying INFLAMMATIONand/or cause prolonged bronchodilation

i.e. • mucosal swelling• secretions• irritability of smooth muscle

Take regularly, even when wellFor ALL asthmatics, except mild intermittent

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ASTHMA DRUG CLASSIFICATION

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All patients should be prescribed inhaled, short-acting ß2 agonists such as salbutamol; 200mcg (2 puffs) as needed for use as symptom relief for acute asthma

symptoms (Evidence A).

All patients should receive inhaled corticosteroids as baseline asthma treatment except those classified as

mild intermittent asthma (Evidence A).

Key prescribing recommendations

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Inhaled Corticosteroids

Mainstay of Rx of chronic asthma

symptoms & lung function decline • give twice daily regularly• direct lung delivery = lower dose• use of spacers delivery & side effects• safe 1000µg BDP/day (800µg Bud/day)

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Inhaled Corticosteroids

Beclomethasone• Beclate • Becotide • Becloforte• Clenil • Viarox • Aerobec

Budesonide• Inflammide • Budeflam

Fluticasone• Flixotide • Flomist

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Equivalent doses of inhaled steroid

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RECOMMENDED ADD-ON Rx

1. Add a LABA if asthma is not well controlled on low dose ICS (Evidence A). This option is preferred to doubling the dose of ICS; however, not all patients respond to LABAs. Never use LABAs alone.

2. An alternative is to double the dose of ICS or add leukotriene modifiers (Evidence A) or slow-

release theophyllines (Evidence B)

3. Oral corticosteroids should only be used as a maintenance treatment with extreme caution.

4. Referral to a specialist is recommended when asthma

is difficult to control

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Long-Acting Beta-2 Agonists

Salmeterol

Formoterol

Combined with steroid

• Serevent

• Oxis• Foradil• Foratec

• Seretide• Symbicord

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Long-Acting Beta-2 Agonists

• cause bronchodilation for 12+ hours• give twice daily regularly• delayed onset of action - Salmeterol

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Patients with poor control despite moderate dose of inhaled steroids especially when:

They should not be used as monotherapy but in combination with inhaled

steroids.

Indications for Long-Acting Beta-Agonists

• nocturnal asthma• wide variation in am & pm PEF• exercise-induced asthma

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Leukotriene Receptor Antagonists

Montelukast - SingulairZafirlukast - Accolate

Advantages: • Unique mode of action • Oral form and “one dose fits all” • Add-on effect when used with inhaled steroids • Anti-inflammatory and anti-bronchoconstrictor

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STEP-WISE Rx of ASTHMA

Only an option for those with mild intermittent asthma at diagnosis or who remain consistently well-controlled and treatment is progressively reduced

STEP 1:• Inhaled beta-agonist PRN

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STEP-WISE Rx of ASTHMA

Start patients with mild chronic persistent asthma at this step

STEP 2:• Inhaled beta-agonist PRN• Low dose inhaled corticosteroid 250-500ug/day (BDP equivalent)

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STEP-WISE Rx of ASTHMA

STEP 3:• Inhaled beta-agonist PRN &• Low dose inhaled corticosteroid 250-500ug/day (BDP equivalent) &• Inhaled long-acting beta-agonist (PREFERRED)OR• Low dose inhaled corticosteroid 250-500ug/day (BDP equivalent) &• Oral leukotriene modifierOR• Moderate dose inhaled corticosteroid 500-1000ug/day (BDP equivalent)

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STEP-WISE Rx of ASTHMA

STEP 4:• Inhaled beta-agonist PRN &• Moderate dose inhaled corticosteroid 500-1000ug/day (BDP equivalent) &• Inhaled long-acting beta-agonist (PREFERRED)OR• Moderate dose inhaled corticosteroid 500-1000ug/day• Oral leukotriene modifierOR• Moderate dose inhaled corticosteroid 500-1000ug/day &• Oral SR theophylline BD

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STEP-WISE Rx of ASTHMA

STEP 5:• Inhaled beta-agonist PRN &• High dose inhaled corticosteroid >1000ug/day (BDP equivalent) &• Inhaled long-acting beta-agonist AND• Oral leukotriene modifierOR• Oral SR theophylline BD

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STEP-WISE Rx of ASTHMA

STEP 6:• Inhaled beta-agonist PRN &• High dose inhaled corticosteroid >1000ug/day (BDP equivalent) &• Inhaled long-acting beta-agonist PLUS• Oral leukotriene modifierPLUS• Oral SR theophylline BDAND/OR• Long term oral corticosteroidsPLUS• SPECIALIST REFERRAL

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Treatment Choices

Depend on:

• availability • cost • efficacy in individual patients • patient preference • side effect profile

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Cost Compromises

• oral steroids vs. inhaled steroids ~ long-term side effects: “save now, pay later”

• oral theophylline vs. inhaled beta-agonists ~ less effective, more side effects, titration difficult

• short-acting vs. long-acting theophyllines• short-acting vs. long-acting beta-agonists• oral vs. inhaled long-acting beta-agonists ~ less effective, more side effects

• MDIs ± spacers vs. dry powder devices

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Therapy to avoid!

• sedatives & hypnotics• cough syrups• anti-histamines• duplication of same type (eg. Ventolin + Berotec)• combination tablets• immunosuppressive drugs• immunotherapy• maintenance oral prednisone >10mg/day

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AsthmaTreatmentAlgorithm

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Asthma Treatment Algorithm

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D.ACHIEVE AND

MONITORCONTROL

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Routine Asthma Questions

1) How many times/week do asthma symptoms (cough, wheeze, SOB) affect you during the day?

2) How many times/week do asthma symptoms disturb your sleep?

3) How many times/week do you use your relievers?

4) Has asthma caused time off work/school or interfered with your usual activities?

5) Have you needed to attend as an emergency since your last visit / over the last year?

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Assessing control

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Monitor Asthma Control

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Managing partly/uncontrolled patients

• Check the inhaler technique• Check adherence and understanding of

medication• Consider aggravation by:

– Exposure to triggers/allergens at home or work

– Co-morbid conditions: GI reflux, rhinitis/sinusitis, cardiac

– Medications: Beta-blockers, NSAIDs, Aspirin• Consider stepping up treatment• Consider need for short course oral steroids• Review self-management plan

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ASSESS GOOD INHALER TECHNIQUE

RINSE MOUTH AFTER INHALATION OF CORTICOSTEROIDS

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ASSESS GOOD SPACER TECHNIQUE

RINSE MOUTH AFTER INHALATION OF CORTICOSTEROIDS

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PREDICTED PEF RATESIN ADULT WOMEN

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PREDICTED PEF RATES ININ ADULT MALES

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Self-management plan• Realistic goals of treatment in terms of symptom relief and/or

PEF• Advice on how to recognise changes in the asthma (via

symptoms and/or peak flow rates) and when to make adjustments to treatment according to a predetermined schedule

• Written instructions on treatment which include the class, name, strength, dose and frequency of each of the asthma medications prescribed

• Instruction on when and how to initiate short courses of oral prednisone

• Details on how to obtain access to medical care in emergencies• The use of a PEF meter and chart, particularly in those requiring

stabilisation or patients who have had a recent exacerbation or deterioration

• Arrangements for a Medic-Alert bracelet for patients on high-dose inhaled or oral corticosteroids, known drug hypersensitivities (like aspirin and penicillin) and brittle asthma

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Indications for Oral Steroid Short Course

• progressive worsening over days• acute deterioration• repeated night wakening• failure of maximum other Rx

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Oral Steroid Short Course

• prednisone 30-40mg x 7-14 days• once daily morning dose• no weaning of dose unless long term

use• inhaled steroids maintained or started• step up maintenance Rx

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Reasons for referral to a specialist

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Managing the well controlled patient

As soon as good control:• Reduce oral steroids first, then

stop• Reduce relievers before

controllers

When good control for 3+ months:

• Reduce inhaled steroids

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