Transcript asthma

ASTHMA
EBM
Evidence Category
Sources of Evidence
A
Randomized clinical trials
Rich body of data
B
Randomized clinical trials
Limited body of data
C
Non-randomized trials
Observational studies
D
Panel judgment consensus
Global Strategy for Asthma
Definition and Overview
 Diagnosis and Classification
 Asthma Medications
 Asthma Management and Prevention
Program
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Definition of Asthma
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A chronic inflammatory disorder of the airways
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Many cells and cellular elements play a role
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Chronic inflammation is associated with airway
hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness, and coughing and often reversible
airflow limitation
Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD
Mechanisms: Asthma Inflammation
Source: Peter J. Barnes, MD
Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD
Asthma Prevalence and Mortality
Source: Masoli M et al. Allergy 2004
Risk Factors for Asthma
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Host factors: predispose individuals to,
or protect them from, developing
asthma
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Environmental factors: influence
susceptibility to development of asthma
in predisposed individuals, precipitate
asthma exacerbations, and/or cause
symptoms to persist
Factors that Exacerbate Asthma
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Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs
Factors that Influence Asthma
Development and Expression
Host Factors
 Genetic
- Atopy
- Airway
hyperresponsiveness
 Gender
 Obesity
Environmental Factors
 Indoor allergens
 Outdoor allergens
 Occupational sensitizers
 Tobacco smoke
 Air Pollution
 Respiratory Infections
 Diet
Typical Spirometric (FEV1)
Tracings
Volume
FEV1
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)
1
2
3
4
Time (sec)
5
Note: Each FEV1 curve represents the highest of three repeat measurements
Clinical Control of Asthma
 No (or minimal)* daytime symptoms
 No limitations of activity
 No nocturnal symptoms
 No (or minimal) need for rescue medication
 Normal lung function
 No exacerbations
_________
* Minimal = twice or less per week
Levels of Asthma Control
Characteristic
Controlled
Partly controlled
(All of the following)
(Any present in any week)
Daytime symptoms
None (2 or less /
week)
More than
twice / week
Limitations of
activities
None
Any
Nocturnal
symptoms /
awakening
None
Any
Need for rescue /
“reliever” treatment
None (2 or less /
week)
More than
twice / week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or
personal best (if
known) on any day
Exacerbation
None
One or more / year
Uncontrolled
3 or more
features of
partly
controlled
asthma
present in
any week
1 in any week
Asthma Management and Prevention
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
Asthma Management and Prevention Program
Influenza Vaccination
 Influenza vaccination should be
provided to patients with asthma when
vaccination of the general population is
advised
 However, routine influenza vaccination
of children and adults with asthma
does not appear to protect them from
asthma exacerbations or improve
asthma control
Component 4: Asthma Management and Prevention Program
Controller Medications
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Inhaled glucocorticosteroids
Leukotriene modifiers
shorte-acting inhaled β2-agonists
Systemic glucocorticosteroids
Theophylline
Cromones
Long-acting β2-agonists
Anti-IgE
Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug
Low Daily Dose (g)
> 5 y Age < 5 y
Medium Daily Dose (g)
> 5 y Age < 5 y
Beclomethasone
200-500
100-200
>500-1000
>200-400
Budesonide
200-600
100-200
600-1000
>200-400
Budesonide-Neb
Inhalation Suspension
Ciclesonide
250-500
80 – 160
High Daily Dose (g)
> 5 y Age < 5 y
>1000
>1000
>500-1000
>400
>400
>1000
80-160
>160-320
>160-320
>320-1280
>320
Flunisolide
500-1000
500-750
>1000-2000
>750-1250
>2000
>1250
Fluticasone
100-250
100-200
>250-500
>200-500
>500
>500
Mometasone furoate
200-400
100-200
> 400-800
>200-400
>800-1200
Triamcinolone acetonide
400-1000
400-800
>1000-2000
>800-1200
>2000
>400
>1200
Reliever Medications
 Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists
Allergen-specific Immunotherapy
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Greatest benefit of specific immunotherapy
using allergen extracts has been obtained in
the treatment of allergic rhinitis
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The role of specific immunotherapy in asthma is
limited
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Specific immunotherapy should be considered
only after strict environmental avoidance and
pharmacologic intervention, including inhaled
glucocorticosteroids, have failed to control
asthma
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Perform only by trained physician
Treating to Achieve Asthma Control
Step 1 – As-needed reliever medication
 Patients with occasional daytime symptoms of
short duration
 A rapid-acting inhaled β2-agonist is the
recommended reliever treatment (Evidence A)
 When symptoms are more frequent, and/or
worsen periodically, patients require regular
controller treatment (step 2 or higher)
Treating to Achieve Asthma Control
Step 2 – Reliever medication plus a single
controller
 A low-dose inhaled glucocorticosteroid is
recommended as the initial controller
treatment for patients of all ages (Evidence A)
 Alternative controller medications include
leukotriene modifiers (Evidence A)
appropriate for patients unable/unwilling to
use inhaled glucocorticosteroids
Treating to Achieve Asthma Control
Step 3 – Reliever medication plus one or two
controllers
 For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled longacting β2-agonist either in a combination inhaler
device or as separate components (Evidence A)
 Inhaled long-acting β2-agonist must not be used
as monotherapy
 For children, increase to a medium-dose inhaled
glucocorticosteroid (Evidence A)
Treating to Achieve Asthma Control
Additional Step 3 Options for Adolescents and Adults
 Increase to medium-dose inhaled
glucocorticosteroid (Evidence A)
 Low-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
(Evidence A)
 Low-dose sustained-release theophylline
(Evidence B)
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more
controllers
 Selection of treatment at Step 4 depends
on prior selections at Steps 2 and 3
 Where possible, patients not controlled on
Step 3 treatments should be referred to a
health professional with expertise in the
management of asthma
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more controllers
 Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist
(Evidence A)
 Medium- or high-dose inhaled glucocorticosteroid
combined with leukotriene modifiers (Evidence A)
 Low-dose sustained-release theophylline added
to medium- or high-dose inhaled
glucocorticosteroid combined with a long-acting
inhaled β2-agonist (Evidence B)
Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
 Addition of oral glucocorticosteroids to other
controller medications may be effective
(Evidence D) but is associated with severe
side effects (Evidence A)
 Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications (Evidence A)
Treating to Maintain Asthma Control
 When control as been achieved,
ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
 Asthma control should be monitored
by the health care professional and
by the patient
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
 When controlled on medium- to high-dose
inhaled glucocorticosteroids: 50% dose
reduction at 3 month intervals (Evidence
B)
 When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
 When controlled on combination inhaled
glucocorticosteroids and long-acting
inhaled β2-agonist, reduce dose of inhaled
glucocorticosteroid by 50% while
continuing the long-acting β2-agonist
(Evidence B)
 If control is maintained, reduce to lowdose inhaled glucocorticosteroids and
stop long-acting β2-agonist (Evidence D)
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
 Rapid-onset, short-acting or longacting inhaled β2-agonist
bronchodilators provide temporary
relief.
 Need for repeated dosing over more
than one/two days signals need for
possible increase in controller therapy
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
 Use of a combination rapid and long-acting
inhaled β2-agonist (e.g., formoterol) and an
inhaled glucocorticosteroid (e.g., budesonide)
in a single inhaler both as a controller and
reliever is effecting in maintaining a high level
of asthma control and reduces exacerbations
(Evidence A)
 Doubling the dose of inhaled glucocorticosteroids is not effective, and is not
recommended (Evidence A)
Asthma Management and Prevention Program
Component 4: Manage Asthma
Exacerbations
 Exacerbations of asthma are episodes of
progressive increase in shortness of breath,
cough, wheezing, or chest tightness
 Exacerbations are characterized by decreases
in expiratory airflow that can be quantified and
monitored by measurement of lung function
(FEV1 or PEF)
 Severe exacerbations are potentially lifethreatening and treatment requires close
supervision
Asthma Management and Prevention Program
Component 4: Manage Asthma
Exacerbations
Treatment of exacerbations depends on:
 The patient
 Experience of the health care professional
 Therapies that are the most effective for
the particular patient
 Availability of medications
 Emergency facilities
Asthma Management and Prevention Program
Component 4: Manage Asthma
Exacerbations
Primary therapies for exacerbations:
• Repetitive administration of rapid-acting inhaled
β2-agonist
• Early introduction of systemic
glucocorticosteroids
• Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function
Asthma Management and Prevention Program
Special Considerations
Special considerations are required to
manage asthma in relation to:
 Pregnancy
 Surgery
 Rhinitis, sinusitis, and nasal polyps
 Occupational asthma
 Respiratory infections
 Gastroesophageal reflux
 Aspirin-induced asthma
 Anaphylaxis and Asthma
Asthma Management and
Prevention Program: Summary
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Asthma can be effectively controlled in most
patients by intervening to suppress and reverse
inflammation as well as treating
bronchoconstriction and related symptoms
Although there is no cure for asthma,
appropriate management that includes a
partnership between the physician and the
patient/family most often results in the
achievement of control
Asthma Management and
Prevention Program: Summary
 A stepwise approach to pharmacologic
therapy is recommended. The aim is to
accomplish the goals of therapy with the
least possible medication
 The availability of varying forms of
treatment, cultural preferences, and
differing health care systems need to be
considered