Discrepancy between science and practice
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Transcript Discrepancy between science and practice
Fallacy of Asthma Guideline: Discrepancy
between Science and Practice
Gary Wong
Department of Paediatrics and School of Public Health
Chinese University of Hong Kong
Guidelines from around the world
GINA Asthma Treatment Strategy
GINA Science Committee
10 respirologists and 3 paediatricians
Meet twice a year to review all published trials
Make recommendations of changes for the
Executives to make the final recommendations
Executive Board
8 respirologists, 3 paediatricians,
1 General practitioner
Revision of GINA documents
Minor revision every 12 months
Major revision every 4-6 yrs
2013 : Major revision
PubMed: RCT, asthma, child :4224
Real-life or pragmatic trials,
asthma, child: 33
Asher et al Lancet 2006;368(9537):733-43.
Asthma in Reality in Asia-Pacific (AIRIAP) 2:Study sites
4805 patients with diagnosed asthma
either with active symptoms or taking
anti-asthma drugs in the past 12 months
• 3815 (79.4%) adults, i.e. >16 y
• 57.5% female
• questionnaire survey conducted 9-12/2006
South Korea
China
Areas for both 1 & 2
Areas for 2 only
India
Taiwan
Hong Kong
Vietnam
Thailand
Sri Lanka
Malaysia
Singapore
Lai CK et al. Respirology 2011;16, 688–697.
Wong GW et al. Allergy 2012 (In Press).
Indonesia
The Philippines
AIRIAP 2: Pediatric data (n=988)
*
Use of urgent care
Use of medications
* Between group comparisons :P<0.005
Wong GW wt al. Allergy (In press)
Emerging classification of asthma
Proposed by expert panel from
EAACI/AAAAI
Lotvall et al. Asthma endotypes: A new approach to
classification of disease entities within the asthma syndrome.
JACI 2011;127:355-60.
Asthma endotypes: defined by their
phenotypes and putative pathophysiology
Pediatric Asthma ICON
Allergy 2012; DOI: 10.1111/j.1398-9995.2012.02865.x (epub June 15, 2012)
The many “faces” of pediatric asthma
Major problems with asthma clinical trials
Design of the trial: test the average response
of patient:
Compare mean responses in two arms
Most published asthma trials: adults or
adolescents
Do not consider individual variations of
response to each treatment
Variability of Response to ICS:
3 large studies in Children and Adults With Asthma
40
Adult Study
CAMP
35
ACRN
Patients, %
30
25
20
15
10
5
0
< -20
-20 to -10 -10 to 0
0 to 10
10 to 20
20 to 30
% Change in FEV1 From Baseline
Tantisira KG, et al. Hum Molec Genetics. 2004;13:1353–1359.
30 to 40
>40
BADGER study. Lemanske et al (CARE network)
NEJM 2010;362:975-85.
161/165 patients showed a differential response
Top 3 priorities for REG
Identification/Establishment of database for real-life
studies in paediatric asthma
Establishment of evaluation tools for pragmatic studies
similar to those for evaluating RCT
Influence (political/personal/professional) of guideline
bodies to include pragmatic studies and discuss
limitations of RCT in real world settings