Transcript Overview of Changes to the NAEP Asthma Guidelines

Overview of Changes
to the NAEP Asthma Guidelines
Breathe California’s Clinical Asthma Collaborative
Susan M. Pollart, MD, MS
University of Virginia Family Medicine
June 24, 2009
Overview
 Asthma classification by Severity and
Control
 Level of Severity and of Control relate to
current impairment and future risk.
 ICS Mainstay of treatment
 Low dose ICS plus LABA equal to Medium
dose LABA in adults and children >5
 Written action plans important.
New Classification
 “Classification” is based on SEVERITY
at time of DIAGNOSIS.
 Patient is not taking long-term
controller medication
 Based on two parameters –
impairment and risk
 Can also be determined once asthma
control is achieved.
Assess Control to Adjust Therapy
 Once therapy is initiated, the
emphasis is on control.
 Control determined by two
parameters – impairment and risk.
 Level of control guides decisions
about adjusting therapy.
 Step-up and Step-down still apply
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT
IN YOUTHS ≥ 12 YEARS OF AGE AND ADULTS
Assessing severity and initiating treatment for patients who are not currently taking long-term control medications
Classification of Asthma Severity (≥12 years of age)
Components of Severity
Persistent
Intermittent
Mild
Moderate
Severe
Impairment
Symptoms
≤ 2 days/week
>2 days/week but
not daily
Daily
Throughout the day
Normal
FEV1/FVC:
8-19 yr
85%
20-39 yr 80%
40-59 yr 75%
60-80 yr 70%
Nighttime
awakenings
≤ 2x/month
3-4x/month
>1x/week but
not nightly
Often 7x/week
Short-acting beta2agonist use for
symptom control
(not prevention of
EIB)
≤ 2 days/week
>2 days/week but
not daily, and not
more than 1x on
any day
Daily
Several times per
day
Interference with
normal activity
None
Minor limitation
Some limitation
Extremely limited
FEV1 >80%
predicted
FEV1/FVC normal
FEV1 >60% but
<80% predicted
FEV1/FVC
reduced 5%
FEV1< 60%
predicted
FEV1/FVC reduced
>5%
Lung function
Normal FEV1 between
exacerbations
FEV1 > 80% predicted
FEV1/FVC normal
0-1/year (see note)
Risk
Exacerbations
requiring oral
systemic
corticosteroids
Recommended Step
for Initiating Treatment
≥ 2/year(see note)
Consider severity and interval since last exacerbation.
Frequency and severity may fluctuate over time for patients in any severity category
Relative annual risk of exacerbations may be related to FEV 1
Step 1
Step 2
Step 3
Step 4
or 5
and consider short course of oral systemic
corticosteroids
Key: FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICU, In
intensive
care unitevaluate level of asthma control that is achieved and adjust therapy accordingly
2-6 weeks,
Note: At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (e.g. requiring urgent, unscheduled
care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had ≥ 2 exacerbations requiring oral systemic corticosteroids in the past year may be
considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.
Stepwise Approach for Managing Asthma
in Youths ≥ 12 Years of Age and Adults
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Step 4
Step 3
Step2
Step 1
Preferred:
SABA PRN
Preferred:
Low-dose ICS
Alternative:
Cromolyn,
LTRA,
Nedocromil, or
Theophylline
Preferred:
Low dose
ICS + LABA
OR mediumdose ICS
Alternative:
low-dose
ICS + either
LTRA,
Theophylline, or
Zileuton
Preferred:
Medium-dose
ICS + LABA
Step 5
Preferred:
High-dose
ICS + LABA
Alternative:
AND
Medium-dose
ICS+either
Consider
Omalizumab
for patients
who have
allergies
LTRA,
Theophylline,
or Zileuton
Step 6
Preferred:
High-dose
ICS + LABA +
oral
corticosteroid
AND
Consider
Omalizumab
for patients
who have
allergies
Each step: Patient education, environmental control, and management of comorbidities.
Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma *
Quick-Relief Medication for All Patients
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute
intervals as needed. Short course of oral systemic corticosteroids may be needed
Step up if
needed
(first, check
adherence,
environmental
control, and
comorbid
conditions)
Assess
control
Step down if
possible
(and asthma is
well controlled
at least 3
months)
Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates
inadequate control and the need to step up treatment.
Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. EIB, exercise-induced
bronchospasm; ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta2-agonist
*Immunotherapy for steps 2-4 is based on Evidence B for house-dust mites, animal danders, and pollens; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for
immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults. Clinicians who administer immunotherapy should be prepared and equipped to identify
and treat anaphylaxis that may occur.
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTH ≥ 12 YEARS OF AGE AND ADULTS
Classification of Asthma Control ( ≥ 12 years of age)
Components of Control
Symptoms
Impairment
≤ 2 days/week
Not Well
Controlled
Very Poorly Controlled
>2 days/week
Throughout the day
Nighttime awakenings
≤ 2x/month
1-3x/week
≥ 4x/week
Interference with normal
activity
None
Some limitation
Extremely limited
Short-acting beta2-agonist use
for symptom control (not
prevention of EIB)
≤ 2 days/week
>2 days/week
Several times per day
FEV1 or peak flow
>80% predicted/
personal best
60-80% predicted/
personal best
<60% predicted/ personal
best
0
≤ 0.75*
≥ 20
1-2
≥ 1.5
16-19
3-4
N/A
≤ 15
Validated Questionnaires
ATAQ
ACQ
ACT
Exacerbations requiring oral
systemic corticosteroids
Risk
Well
Controlled
Progressive loss of lung
function
Treatment-related adverse
effects
0-1/year
≥and
2/year
(see
note)
Consider severity
interval
since
last exacerbation
Evaluation requires long-term follow-up care.
Medication side effects can vary in intensity from none to very troublesome
and worrisome. The level of intensity does not correlate to specific levels of
control but should be considered in the overall assessment of risk.
Maintain current
Step up 1 step
Consider short course of oral
step.
and
systemic corticosteroids,
Regular follow ups
Reevaluate in 2Step up 1-2 steps, and
Recommended Action for
every 1-6 months
6 weeks.
Reevaluate in 2 weeks.
to maintain control.
Treatment
For side effects,
For side effects, consider
Consider step
consider
alternative treatment options.
*ACQ values of 0.76-1.4 are indeterminate regarding well-controlled asthma.
down if well
alternative
Key: EIB, exercise-induced bronchospasm; ICU, intensive care unit.
controlled
forofat
treatment
Note: At present, there are inadequate data to correspond frequencies of exacerbations with
different levels
asthma severity.
In general, more frequent and intense exacerbations (e.g. requiring urgent, unscheduled
care, hospitalization, or ICU admission) indicate greater underlying disease severity. Forleast
treatment
purposes, patients who had
≥ 2 exacerbations requiring oral systemic corticosteroids in the past year may be
3 months.
options.
considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.
Asthma Control Test
Copyright 2002, by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated.
Stepwise Approach for Managing Asthma
in Youths ≥ 12 Years of Age and Adults
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Step 4
Step 3
Step2
Step 1
Preferred:
SABA PRN
Preferred:
Low-dose ICS
Alternative:
Cromolyn,
LTRA,
Nedocromil, or
Theophylline
Preferred:
Low dose
ICS + LABA
OR mediumdose ICS
Alternative:
low-dose
ICS + either
LTRA,
Theophylline, or
Zileuton
Preferred:
Medium-dose
ICS + LABA
Step 5
Preferred:
High-dose
ICS + LABA
Alternative:
AND
Medium-dose
ICS+either
Consider
Omalizumab
for patients
who have
allergies
LTRA,
Theophylline,
or Zileuton
Step 6
Preferred:
High-dose
ICS + LABA +
oral
corticosteroid
AND
Consider
Omalizumab
for patients
who have
allergies
Each step: Patient education, environmental control, and management of comorbidities.
Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma *
Quick-Relief Medication for All Patients
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute
intervals as needed. Short course of oral systemic corticosteroids may be needed
Step up if
needed
(first, check
adherence,
environmental
control, and
comorbid
conditions)
Assess
control
Step down if
possible
(and asthma is
well controlled
at least 3
months)
Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates
inadequate control and the need to step up treatment.
Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. EIB, exercise-induced
bronchospasm; ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta2-agonist
*Immunotherapy for steps 2-4 is based on Evidence B for house-dust mites, animal danders, and pollens; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for
immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults. Clinicians who administer immunotherapy should be prepared and equipped to identify
and treat anaphylaxis that may occur.
Preferred Medications






STEP 1 – SABA
STEP 2 – ICS
STEP 3 – ICS plus LABA or med dose ICS
STEP 4 – med dose ICS plus LABA
STEP 5 – high dose ICS and LABA
STEP 6 – high dose ICA and LABA and oral
corticosteroids.
Alternative Medications





Mast cell inhibitors
Leukotriene receptor antagonists
Leukotriene modifier
Theophylline
Omalizumab
Inhaled medication
 Short-acting beta-agonists – albuterol
mentioned as “preferred” in pregnancy
 Long-acting beta-agonists – used w/ low
dose ICS (vs medium dose ICS) as step
up in all but 0-4 age group. Alternative at
step 4 and above in all.
Inhaled medication
 Inhaled corticosteroids (ICS) the
preferred long term controller in all
age groups.
 Low dose ICS alone in step 2 for all.
 Low dose plus add-on OR medium
dose ICS for step 3 except ages 0-4.
Leukotriene modifiers
 Montelukast safe for all patients,of
all ages, as alternative to low dose
ICS or add on to low, medium or
high dose ICS.
 Zafirlukast same role in all but 0-4
age group.
 Zileuton in age > 12 as add on to
low dose ICS + LABA, or to medium
dose ICS
Cromolyn and Nedocromil
 Stabilize mast cells and interfere with
chloride channels
 Can be used as an alternative but
not preferred medication in step 2 in
all.
 Preventive therapy for
exercise/exposure
Theophylline
 Mild to moderate bronchodilator
 May have mild anti-inflammatory
effect.
 Alternative or adjunctive therapy
with ICS in all patients > 5
 Monitoring levels essential.
/wEPDwU
Written Action Plan
 Written action plans
detailing medications and
environmental control
strategies tailored for each
patient are recommended
for all patients with asthma
 Environmental Control
 Awareness and control
Asthma Action Plan Examples
Written Action Plan Components
 Note when and how to treat signs of an
exacerbation
 Adjust meds by increasing SABA, add oral
CS.
 To be effective, patient must have
prescription for oral CS available
 Doubling dose of ICS not part of plan –
not effective during exacerbation.
Peak Expiratory Flow
 PEF based plan particularly useful for
those who have difficulty perceiving
airflow obstruction or have history of
severe exacerbations
 “Gold standard” is patient’s personal best.
 Green/yellow/red zones objective data.
Environmental Control
 House dust mite – mattress covers, pillow
covers, washing in hot water, acaricides
 Cat Allergen – air filters, washing the cat,
keep cat out of the bedroom.
 Cockroach – extermination and thorough
cleaning
No evidence that any of these change
patient oriented outcomes.
Summary
 Asthma classification by Severity and
Control
 Level of Severity and of Control relate to
current impairment and future risk.
 ICS Mainstay of treatment
 Low dose ICS plus LABA equal to Medium
dose LABA in adults and children >5
 Written action plans important.