Transcript Need for rescue medications

Controlling Asthma in Children
Regional Asthma Update
Florence, SC
September 30, 2016
C. Michael Bowman, PhD, MD
Professor Emeritus, MUSC
Asthma Champion, SC Chapter AAP
[email protected]
Disclosures
• Recently retired from Med Univ S Carolina
• Member, Board of Directors of SC Asthma
Alliance and Association of Asthma Educators
• No financial relationships to disclose
• Will discuss asthma medications in line with
FDA labeling
• Recognize that FDA age-limitations for asthma
medications are rather chaotic and may
influence formulary choices by payers
Objectives
The audience will be able to:
• Identify a child with asthma
• Understand asthma severity
• Expect appropriate therapy—initial, f/u
• Recognize the level of asthma control
• Recognize therapy choices in stepping
up or down based on control
• Utilize a team for best management
The Asthma “Under-world”
Why is asthma still such a problem?
• Under – recognition
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– “It’s just another cold – of course her sister’s in daycare”
– “He’s just shy”; “we all have sinus”
Under – treatment
– “He just needs albuterol”
– “She’s been so much better”
– “We can stop over the summer”
Under – referral to asthma specialists
– “It’s not that serious”
– “The Orapred did really well”
The Pediatric Asthma “Iceberg”
• Under – recognition
– Intermittent symptoms
– Veterinary medicine
– Patient optimism; “colds”
• Under – treatment
– Avoiding long-term med use
– Steroid phobia
– Poor technique (won’t work!)
– Non-compliance w/ refills
Remember that
asthma is the
most common
chronic illness
in children!
Red Flags for Recognition
• Where are you “meeting” the patient and why?
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School, ER, clinic, after-school activities?
Chronic symptoms (> 3 weeks), recurrent cough,
wheeze, short of breath (observed or described)
Prolonged “colds” (wks) -- chest > nasal sxs
Frequent ER visits & oral steroids – “always sick”
Exercise intolerance – should play daily!
Response to medications
– Short – acting beta agonists (rescue)
– Steroids (? with every cold)
Why Have They Been Missed?
• No one has an “asthma” tattoo
• No one wants the “asthma” label
• Cough vs. wheeze
• “Reactive Airway Disease”
• Attributed to other things – sinus, allergies,
weather
• Recurrent “colds” -- multiple acute vs a
chronic disease
• Fragmented care! Lack of time for thought
Need for Acute “Rescue” Treatment
• Goals: Relieve acute bronchospasm
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and resulting symptoms in 5-10’
Medications
– albuterol
– levalbuterol (Xopenex)
• Device choices – neb, MDI, DPI
• Spacers are crucial with any MDI
• Must have, wherever the child may be
• Use enough to relieve symptoms
• Alb neb dose vs MDI puffs
– 2.5 mg vs 90 mcg (~ 10X)
Need for Chronic Treatment
• Goals: Reduce airway inflammation & damage,
symptoms; but the trade-off is 14 rx per week
• Rule of two’s to start controller use
– Twice a week symptoms
– Twice a month night-time problems
• Need for daily exercise
• Hospitalizations
• Rescue medications – always have available
• Breathing tests can show airway relaxation after
albuterol inhalation
Asthma Severity at Diagnosis
• Intermittent (rescue only) vs. persistent
• Persistent – mild, moderate or severe
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– Frequency of symptoms most telling
Areas (domains) of concern
– Symptoms (severity, frequency)
– Night-time awakening (think of GER as trigger)
– SABA use (remember that an MDI has 200 puffs)
– Interference with activities (including normal play)
– Lung function
– Flare-ups requiring oral steroids
Start somewhere, adjust by control at f/u (soon)
Treatment – Thought Process
• Is a controller needed? Everyone gets rescue
• What level of concern? Low, medium, high
– Singulair, ICS, combination drug, multiple drugs
• Recognize the child’s triggers – avoid or treat!
• What device can the patient use correctly?
– Nebulizer, MDI/spacer, DPI
• Formulary limitations will influence med choices
• Pick the best device; must teach how to use it!
• Use AAPs; include meds for school / daycare
• Start somewhere, adjust by control at f/u (soon)
Asthma Action Plans – What, Why?
• Asthma management instructions for everyone
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– home, school, grandparents, etc.
Medicines to take
– Asthma controllers; other daily medicines
• What and when to take rescue medication
– MDI/spacer, nebulizer
– Increasing dose to treat symptoms
– Often linked to Peak Flow Rate numbers
• When to call for help
• Must always include contact info for 24/7
• Use of AAP is a key area for improvement!
The Controller Buffet
• What can the patient take?
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– Neb vs MDI (use spacer) vs DPI
– Age (~ 15 mos); development
Steroids alone (dosage)
– Pulmicort (neb); Flovent, Qvar, Aerospan, Alvesco (MDIs);
Asmanex (only QD med), Flovent, Arnuity, Pulmicort (DPIs)
• Combination drugs (ICS + LABA)
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– Advair, Symbicort, Dulera (MDIs); Advair, Breo (DPI)
Non-inhaled drugs
– Singulair, other less-common choices
• Health plan formularies dictate choices!
The Controller Buffet—practical tips
• Can show families the
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devices
There are usually dose
counters; use one
device per month!
Devices can look the
same (almost)
Health plan formularies
dictate our choices
most of the time.
Available from www.allergyasthmanetwork.com
The Asthma Coach
• Show families the devices
• Prescriber’s time is very limited
• No one would coach a football or soccer team with
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only written instructions
Poor technique prevents drug getting into the lung
We urge doctors to consider designating someone
in their office to become an asthma educator
Asthma education codes are billable
Coach brings the patient’s care plan alive –
important “teach back” opportunity!
The Well-Treated Asthmatic
• Excellent activity tolerance
– Know pro or Olympic athletes in most sports
• Rare school absences
• “Colds” are short (3 days)
• Uninterrupted sleep
• Rare use of rescue medicines (1 – 2 X / month)
• Infrequent flares / prednisone (1 – 2 X / year)
• No hospitalizations
• Normal pulmonary func, no bronchodilator response
• Few medication side - effects
Patient Contact – Assess Control
• Keep regular appointments, not just flares/ER
• What has happened since the last visit?
– Acute illnesses – how did they go?; sleep?
• How are you doing?
– Exercise tolerance; coughing; wheezing
– If competitive, can you get through full sessions?
– Need for rescue medications (doses per MDI)
– Symptoms of triggering conditions; resolution?
• Medication refills should be documented
• Adjust medication up or down depending on
how well the child’s asthma is controlled
What Happens at Follow-up
Evaluations?
• What season is it–in general and for pt?
• How much control has been achieved?
• What do the pt and family perceive?
• Medication choices: up, down, hold
• If control isn’t great, why?
– Poor medication use
– Uncontrolled triggers (e.g., ETS, environ, GER)?
– Need stronger / better medication, better intake?
• We try to get to lowest doses of ICS only
• Controllers often used ~18 – 36 months
What do we tell the patient?
Our medicines won’t help
your jump – shot…
but you’ll be able to play awesome
defense the whole game!
Asthma Mimicks
• Swallowing incoordination
• Psychogenic/habit cough
• Vocal cord dysfunction
• Sinusitis; GE reflux
• Tracheomalacia
• Airway compression
• Poor conditioning
• Acutely – foreign body aspiration
Asthma Challenges
• Chaotic lifestyles; inability to change; other issues
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may be more compelling (food, sibs, $, job, etc.)
Limited skill / practice reading; poor follow-through
Controller meds often have no obvious effect!
The albuterol works; why take a medicine with no
perceived benefit? (Compare to acne medicine, we
don’t want lungs to “break out”!) steroid phobia?
Must have major trust in care providers fragmentation of care; colds vs chronic disease
Habitual use of ER rather than medical home
Future outcomes and risk often hard to perceive
The Asthma Flare
• Automatic care in the ED isn’t appropriate;
• The Medical Home has to be involved!
• Patients need to be coached/trained to care (via
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AAP, aggressive care) and to call;
What are the symptoms? Likely asthma or other?
What’s been done? Is pt responding to albuterol?
Remember device dose differences (MDI/neb)
Order steroids, must assure follow-up (both
acutely and chronically)
Is there any major uncertainty? Send to ED
Objectives
The audience will be able to:
• Identify a child with asthma
• Understand asthma severity
• Expect appropriate therapy—initial, f/u
• Recognize the level of asthma control
• Recognize therapy choices in stepping
up or down based on control
• Utilize a team for best management
Take – home Messages
• Asthma is sneaky
• Much is hidden, unrecognized
• Must make the diagnosis
• Know when to add controllers
• Recognize/treat/avoid triggers
• Must choose effective chronic
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treatment and coach correct
device technique (team)
Full assessment Q 3 mos
Remember the school
References
• Amer Thoracic Society Documents: An Official ATS Workshop Report:
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Issues in Screening for Asthma in Children. Gerald LB et al. Proc Am
Thorac Soc 2007; 4:133-41.
Amer Thoracic Society Documents: An Official American Thoracic Society
/ European Respiratory Society Statement: Asthma Control and
Exacerbations. Reddel HK et al. Am J Respir Crit Care Med 2009;
180:59-99.
CDC guidelines for the “asthma-friendly school” (also NIH and EPA)
GINA guidelines for asthma control, 2015
National Guidelines for the Management of Asthma 2007 “EPR3” –
www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm
Schatz M et al. Asthma Control Test: Reliability, validity and
responsiveness in patients not previously followed by asthma specialists.
J Allergy Clin Immunol 2006; 117:549-556
Thorsteinsdottir R et al. The ABCs of Asthma Control. Mayo Clinic Proc
2008; 83(7):814-820.