Pediatric Asthma:

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Pediatric Asthma: Pediatric Asthma: Navigating Through Guidelines Navigating Through Guidelines and and Black Boxes Black Boxes Vinit K. Mahesh, M.D. Vinit K. Mahesh, M.D.

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Pediatric Asthma:. Navigating Through Guidelines and Black Boxes Vinit K. Mahesh, M.D. “I have the following financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity:” Research Support from: - PowerPoint PPT Presentation

Transcript of Pediatric Asthma:

Page 1: Pediatric Asthma:

Pediatric Asthma:Pediatric Asthma:

Navigating Through Guidelines Navigating Through Guidelines and and

Black BoxesBlack Boxes

Vinit K. Mahesh, M.D.Vinit K. Mahesh, M.D.

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“I have the following financial relationships with the manufacturers(s) of any commercial products(s) and/or provider

of commercial services discussed in this CME activity:”

Research Support from: Speakers’ Bureau: Astra Zenca and Schering-Plough

It is my obligation to disclose to you (the audience) that I am on It is my obligation to disclose to you (the audience) that I am on the Speakers Bureau for Astra Zenca and the Speakers Bureau for Astra Zenca and Schering Plough.

However, I acknowledge that today’s activity is certified for CME However, I acknowledge that today’s activity is certified for CME credit and thus cannot be promotional. I will give a balanced credit and thus cannot be promotional. I will give a balanced presentation using the best available evidence to support my presentation using the best available evidence to support my

conclusions and recommendations.”conclusions and recommendations.”

““I intend to discuss unapproved/investigative use of a I intend to discuss unapproved/investigative use of a commercial product/device in this presentation”commercial product/device in this presentation”

Discussion of an unapproved/investigative use of a commercial Discussion of an unapproved/investigative use of a commercial product/device is based on the fact that there is no ICS product/device is based on the fact that there is no ICS approved under 1 years of age and no MDI ICS approved under approved under 1 years of age and no MDI ICS approved under 4 years of age.4 years of age.

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How Are These Images How Are These Images Relevant? Relevant?

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Ranking of EvidenceRanking of Evidence(randomly controlled trials)(randomly controlled trials)

►Category ACategory A Rich body of RCTRich body of RCT►Category BCategory B Limited body of data Limited body of data

(RCT)(RCT)►Category CCategory C NRUT, observationsNRUT, observations►Category DCategory D Panel consensusPanel consensus

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Classification of AsthmaClassification of Asthma20032003

►Mild IntermittentMild Intermittent►Mild PersistentMild Persistent►Moderate PersistentModerate Persistent►Severe PersistentSevere Persistent

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ClassificationClassification(changes)(changes)

►Eliminate mild from mild intermittentEliminate mild from mild intermittent►Severity/frequency of symptomsSeverity/frequency of symptoms► Impairment vs riskImpairment vs risk►Meds needed to achieve controlMeds needed to achieve control►Classification is almost retroactiveClassification is almost retroactive

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Intermittent AsthmaIntermittent Asthma

►Symptoms up to twice/weekSymptoms up to twice/week►Brief ExacerbationsBrief Exacerbations►Asymptomatic between episodesAsymptomatic between episodes►Nocturnal symptoms up to twice a Nocturnal symptoms up to twice a

monthmonth►FEVFEV11/PEFR > 80% predicted/PEFR > 80% predicted

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Intermittent TreatmentIntermittent Treatment

►Short-acting beta agonist as neededShort-acting beta agonist as needed► If twice a week or more, change If twice a week or more, change

classificationclassification►Severe exacerbations may require Severe exacerbations may require

maintenance therapymaintenance therapy

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Goals of TreatmentGoals of Treatment

►Reducing ImpairmentReducing Impairment►Reducing RiskReducing Risk►Normalization of PFT’sNormalization of PFT’s►Limited SABA rescue (< 2X/wk)Limited SABA rescue (< 2X/wk)►Nocturnal symptoms (< 2X/month)Nocturnal symptoms (< 2X/month)

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Treatment StepsTreatment Steps

►Start with ICS and push to 400-500 Start with ICS and push to 400-500 mcg/daymcg/day

► If not controlled, equal weight to double If not controlled, equal weight to double ICS vs add LABA in > 12 years oldICS vs add LABA in > 12 years old

► In younger, double ICS to 800-1000 In younger, double ICS to 800-1000 mcg/day preferredmcg/day preferred

►Leukotriene modifiers may also be Leukotriene modifiers may also be addedadded

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Mild PersistentMild Persistent

►Low dose ICS (up to 400-500 mcg/day)Low dose ICS (up to 400-500 mcg/day)►Use of LTM irrelevant for classificationUse of LTM irrelevant for classification

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Moderate Persistent Moderate Persistent

►High dose ICS or low dose ICS plus High dose ICS or low dose ICS plus LABALABA

►> 12 yo, equal preference> 12 yo, equal preference►< 12 yo, high dose ICS preferred< 12 yo, high dose ICS preferred

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Severe PersistentSevere Persistent

►High dose ICS plus LABAHigh dose ICS plus LABA►Xolair (Omalizumab) may be Xolair (Omalizumab) may be

considered if not controlled with aboveconsidered if not controlled with above

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How Much Really Gets In?How Much Really Gets In?

►400 mcg/day X 365 days = 146 mg400 mcg/day X 365 days = 146 mg►At best, one-third stays in bodyAt best, one-third stays in body►146/3 = < 50 mg/yr146/3 = < 50 mg/yr►Single dose of 1-2 mg/kg may full year Single dose of 1-2 mg/kg may full year

of ICSof ICS

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Simplified TreatmentSimplified Treatment

►Most will benefit from ICSMost will benefit from ICS►Reassess and titrate up or downReassess and titrate up or down

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Black Box WarningBlack Box Warning(What a Blackhole?)(What a Blackhole?)

►SMART StudySMART Study► Inner city, impoverished, adolescent, Inner city, impoverished, adolescent,

African American malesAfrican American males►Continue to purchase and use ICSContinue to purchase and use ICS►LABA added as part of studyLABA added as part of study

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What Went Wrong?What Went Wrong?

►Adolescent malesAdolescent males►Was ICS continuedWas ICS continued►Over use of Over use of BB-agonist-agonist

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Does This Change Plans?Does This Change Plans?

►Except for extreme cases, would start Except for extreme cases, would start with monotherapy and push ICS with monotherapy and push ICS

►Should see some response, even if not Should see some response, even if not completecomplete

►Close follow upClose follow up►LiabilityLiability

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ReassessmentReassessment

►Frequency of exacerbationsFrequency of exacerbations►Frequency of exertional/nocturnal Frequency of exertional/nocturnal

symptomssymptoms►Frequency of rescueFrequency of rescue►Systemic steroid useSystemic steroid use►Frequency of ER/hospitalizationFrequency of ER/hospitalization►Peak flow monitoringPeak flow monitoring

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Obstacles to Asthma CareObstacles to Asthma Care

►GERDGERD►SinusitisSinusitis►EnvironmentEnvironment►BehaviorBehavior

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ComplianceCompliance

►76% of prescriptions filled once76% of prescriptions filled once►43% refilled once43% refilled once►36% refilled twice36% refilled twice

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WHO IS RESPONSIBLE???WHO IS RESPONSIBLE???

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Cost Effective MedicinesCost Effective Medicines

►Most costs are ER/hospital relatedMost costs are ER/hospital related►Most cost effective plan is the one the Most cost effective plan is the one the

works!!works!!

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Medicaid SurvivalMedicaid Survival

►MDI ICSMDI ICS Flovent; QVARFlovent; QVAR►Nebulized ICSNebulized ICS *Pulmicort Respule *Pulmicort Respule

(for (for children 5 and children 5 and under)under)

►LTMLTM AllAll►DPI ICSDPI ICS AsmanexAsmanex►LABA/ICS comboLABA/ICS combo Advair, SymbicortAdvair, Symbicort►LABALABA Foradil, SereventForadil, Serevent

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Medicaid Survival (Rescue)Medicaid Survival (Rescue)

►MDI SABAMDI SABA AllAll►Nebulized SABANebulized SABA AlbuterolAlbuterol

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Answers:Answers:

►3,500 people died on September 11, 3,500 people died on September 11, 20012001

►140 people were on Flight 1549140 people were on Flight 1549►714 career home runs714 career home runs

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Can We Do Better?Can We Do Better?

►4,200 asthma deaths in U.S. 4,200 asthma deaths in U.S. ►484,000 hospital discharges484,000 hospital discharges►1.9 million ER visits (1/3 pediatric)1.9 million ER visits (1/3 pediatric)►$16.1 billion health care costs$16.1 billion health care costs