Transcript Asthma
Lee Dobson Torbay Hospital A brief history of asthma management 2007 2001 SMART 1996, 1997 Symbicort 1990 Serevent introduced 1969 Ventolin introduced Late 60s Bronchoscope 1980s Major developments in asthma management Fostair 1999 Seretide 1997 launched Oxis 1995 onwards GINA 1991 The β2 agonist debate How are we doing? 1972 Becotide introduced 1956 3M launch The MDI Early 1950s MDI 1994 Greening, Ind Landmark study Woolcock & Pauwels Landmark studies 1965 Intal introduced 1993 Flixotide introduced % Patients not Well Controlled Not Well-Controlled asthma (% of treated patients) 80 70 60 50 40 30 20 10 0 72 61 55 Overall 45 45 UK Spain Italy 56 Germany France NHWS: A population-based cross-sectional survey conducted in 2006 in 2337 patients diagnosed with asthma in France (n=476), Germany (n=486), Italy (n=223), Spain (n=227) and the UK (n=915) Not Well-Controlled defined as Asthma Control Test score ≤19 Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s Data includes 590,000 teenagers and 700,000 people over 651 Total 5.2 million1 Every 6 hours someone dies from asthma2 Men 2.3 million1 Women 2.9 million1 1. Where Do We Stand? Asthma in the UK Today. Published December 2004. Available at: http://www.asthma.org.uk/how_we_help [Accessed October 2006.]. 2. General Register Office collated in Office for National Statistics mortality statistics for England and Wales; General Register Office for Scotland; General Register Office for Northern Ireland collated by the Northern Ireland Statistics & Research Agency (2004). It is a myth that only severe asthma can prove fatal Asthma deaths occur across disease severity with deaths occurring in those patients whose asthma is considered mild-to-moderate Number of asthma deaths across disease severity 2001–2003 100 Number of deaths 75 50 53% 25 21% 16% 0 Severe Moderately severe Mild Asthma severity (%) Harrison B et al. Prim Care Respir J 2005 Dec; 14: 303–13. 10% Unknown n=57 % patients registered with asthma 8.0% 6.7% 7.0% 6.2% 6.0% 6.1% 6.4% 6.5% 5.7% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% England NHS South West Torbay Care Trust Devon PCT Plymouth Cornw all & Teaching PCT Isles of Scilly PCT Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/ 2006/07 % patients registered with asthma 8.0% 6.8%6.7% 7.0% 6.0% 5.8% 5.7% 6.2% 6.2%6.2% 6.1% 2009 2010 6.4%6.4% 2007/08 6.5% 6.5% 5.0% 4.0% TCT 10198 10193 3.0% SD 8276 8481 2.0% 1.0% 0.0% England NHS South West Torbay Care Trust Devon PCT Plymouth Cornw all & Teaching PCT Isles of Scilly PCT Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/ Asthma admissions increased by 30% 45 more hospital admissions • Average length of stay decreased by 39% From 3.8 days to 2.3 days Asthma bed days decreased by 21% 122 fewer bed days Source: NHS Information Centre: Hospital Episodes Statistics (HES) British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN) Definition of asthma “A chronic inflammatory disorder of the airways … in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.” Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 The diagnosis of asthma is a clinical one There is no standardised definition, therefore, it is not possible to make clear evidence based recommendations on how to make a diagnosis Central to all definitions is the presence of symptoms and of variable airflow obstruction Base initial diagnosis on a careful assessment of symptoms and a measure of airflow obstruction Spirometry is the preferred initial test to assess the presence and severity of airflow obstruction (use PEF if spirometry not available) PEFR – spirometry unavailable occupational monitoring >1 of the following: wheeze, breathlessness, chest tightness, cough, particularly if: worse at night and early morning in response to exercise, allergen exposure and cold air after taking aspirin or beta blockers Personal/family history of asthma/atopy Widespread wheeze heard on auscultation of the chest Unexplained low FEV1 or PEF Unexplained peripheral blood eosinophilia Prominent dizziness, light-headedness, peripheral tingling Chronic productive cough in the absence of wheeze or breathlessness Repeatedly normal physical examination of chest when symptomatic Voice disturbance Symptoms with colds only Significant smoking history (>20 pack-years) Cardiac disease Normal PEF or spirometry when symptomatic Without airflow obstruction With airflow obstruction Chronic cough syndromes COPD DBS Vocal Cord Dysfunction Rhinitis GORD Heart Failure Pulmonary Fibrosis Bronchiectasis Inhaled Foreign Body Obliterative Bronchiolitis Large Airway Stenosis Lung Cancer Sarcoidosis Start treatment at the step most appropriate to the initial severity of their asthma Aim is to achieve early control Step up or down with therapy Minimal therapy Before initiating new drug therapy: Compliance Inhaler technique Eliminate trigger factors Control of asthma, defined as: No daytime symptoms No night time awakening due to asthma No need for rescue medications No exacerbations No limitations on activity including exercise Normal lung function (FEV1 and/or PEF >80% predicted or best) with minimal side effects. Factors that should be monitored and recorded: Symptomatic asthma control using RCP ‘3 questions’, Asthma Control Questionnaire or Asthma Control Test (ACT) Lung function (spirometry/PEF) Exacerbations Inhaler technique Compliance (prescription refill frequency) Bronchodilator reliance (prescription refill frequency) Possession of and use of self management plan/personal action plan Factors that should be monitored and recorded: Symptomatic asthma control using RCP ‘3 questions’, Asthma Control Questionnaire or Asthma Control Test (ACT) Lung function (spirometry/PEF) Exacerbations Inhaler technique Compliance (prescription refill frequency) Bronchodilator reliance (prescription refill frequency) Possession of and use of self management plan/personal action plan Component of action plan Result Practical Considerations Symptom vs PEF trigger Similar effect Standard written instruct Consistently beneficial Traffic Light Not better than standard 2-3 action points 4 action points Consistently beneficial No better <80% - increase ICS <60% - oral steroids <40% - urgent advice PEF on %personal best PEF on % predicted Consistently beneficial No better Assess when stable, update every few years ICS and steroids Oral steroids only ICS Consistently beneficial Unable to evaluate Unable to evaluate >400 – steroids 200 – increase substant Restart medication Inhaler devices Prescribe inhaled short acting β2 agonist (SABA) as short term reliever therapy for all patients with symptomatic asthma Good asthma control is associated with little or no need for short-acting β2 agonist Using two or more canisters of β2 agonists per month or > 10-12 puffs per day is a marker or poorly controlled asthma that puts individuals at risk of fatal or near-fatal asthma Patients with high usage of inhaled short-acting β2 agonists should have their asthma management reviewed Inhaled steroids are the recommended preventer drugs for adults for achieving overall treatment goals Consider inhaled steroids if any of the following: Using inhaled β2 agonist three times a week or more Symptomatic three times a week or more Waking one night a week Exacerbation of asthma in the last two years (adults and 5-12 only) Adults: 200-800mcg/day BDP*(reasonable starting dose 400mcg per day for many adults) Start patients at a dose appropriate to the severity of the disease Titrate the dose to the lowest dose at which effective control of asthma is maintained Steroid Equivalent dose (mcg) Beclomethasone CFC 400 Beclomethasone Clenil 400 Qvar 200-300 Fostair 200 Budesonide Symbicort 400 Fluticasone Seretide 200 Mometasone 200 Ciclesonide 200-300 A proportion of patients may not be adequately controlled at step 2 Check and Eliminate Adults and Children 5-12: First choice as add-on therapy is an inhaled long-acting β2 agonist (LABA), which should be considered before going above a dose of 400mcg BDP* and certainly before going above 800mcg Can’t miss their ICS More convenient Increased compliance Pathophysiology? Different inhalers – different deposition Interaction occurs at single cell level Deposition varies from one inhalation to the next If control remains inadequate… Still uncontrolled.. Monitor Blood pressure Diabetes Hyperlipidaemia BMD Steroid sparing medication - Methotrexate - Ciclosporin - Oral Gold Colchicine IVIG Subcutaneous Terbutaline Anti- TNF Stepping down therapy once asthma is controlled is recommended Regular review of patients as treatment is stepped down is important Patients should be maintained at the lowest possible dose of inhaled steroid Reductions should be slow, decreasing dose by ~2550% every three months Miss BL Admission Sep 2006 Exacerbation asthma, PEFR 200 l/min (normal 450) Recent LRTI 1984 1 Admission to hospital this year, usual control adequate Known panic attacks – this different ? Regular meds – becotide At university, smokes!..moderate alcohol! Acute management? Steroids, ICS, ventolin, RNS, OPD Clinic October 2006 Good recovery, still some SOBOE, started attending gym. Nocturnal symptoms – none Ventolin – three times per week. What to do? Lifestyle advice Compliance RNS - Management Plan, Education Pre-dose with ventolin LABA - Combination inhaler UK qualitative and quantitative study to evaluate patient understanding of their asthma and determine patient preferences regarding the delivery of asthma care and treatment. Patient preferences: Treatment as simple as possible Few inhalers Lowest dose of steroid to control symptoms Avoid hospitals when possible Minimise symptoms Haughney J et al ERS 2006 40 35 30 % Patients 25 20 15 10 Self-reported level of control by Not Well-Controlled patients 37 40% of Not Well34 Controlled patients consider themselves “Well” or “Completely Controlled” 11 11 "Poorly Controlled" "Not at all Controlled" 6 5 0 "Completely "Well Controlled" Controlled" "Somewhat Controlled" Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s Mrs TL 24/10/1984 Clinic Jul 2006 Asthma age 12 2 x pregnancies – deteriorated during, brittle++ (Newcastle) BIH Night waking, morning dipping, wheeze, SOB – 10/40 Guinea pig and rabbit, shop assistant. Bec 250 4 puffs bd, SV 4 puffs bd, ventolin and combivent prn. SaO2 98%, 2.69/3.58 (3.21/3.68). What to do? Write to chest consultant RNS review – management plan, education QVAR - Thrush Combination inhaler - tried ?LTRA ?Nebuliser Standby steroids Clinic Aug 2006 Stable 2.84/3.67 litres Plan – no change DNA… 23-year old woman with history of childhood asthma Started fitness campaign but suffers from breathlessness on exertion At clinic, PEF normal What advice would you give Laura? What therapy would you recommend if a peak flow diary showed a stable baseline but short lived dips after running? Remember to make an assessment of the probability of asthma. Diagnose before treating – try to confirm diagnosis with objective tests before long term therapy is started. Increasing symptoms – some help from blue inhaler Interested in complementary therapy - Buteyko Husband noticed night time coughing – keeping him awake! What would you advise Laura about complementary treatments for asthma? Becomes pregnant. What would you do now if she was: (a) not distressed, slightly wheezy with respiratory rate of 20 breaths/minute, pulse 100 beats/minute and PEF of 390 L/minute? (b) looks dreadful, cannot complete sentences, with very quiet breath sounds on auscultation, respiratory rate 30 breaths/minute, pulse 120 beats/minute and PEF of 120 L/minute? No consistent evidence to support use of complementary or alternative treatments in asthma Continue usual asthma therapy in pregnancy Monitor pregnant women with asthma closely to ensure therapy is appropriate for symptoms. Mr DC Clinic Apr 2004 - Exacerbation March 2004 02/09/1969 Known asthmatic (eczema) – control not so good recently (nocturnal symptoms, SOB, reliever ++, PEFR down). Symbicort 200/6 2 puffs bd Green sputum – cefalexin, prednisolone What to do? Question diagnosis? Recent CT scan, alpha-1-antitrypsin level N Increase dose Symbicort LTRA trial – previously negative Bisphosphonate Clinic June 2004 Ig E > 15,000 RAST Aspergillus >4 Probable Allergic Bronchopulmonary Aspergillosis (ABPA) Plan - Maintenance prednisolone (10mg), Itraconazole Clinic Sept 2004 Symptomatic - Prednisolone <20mg SOB increasing PEFR <160 l/min, FEV1/FVC 1.42/3.75 (3.71/4.4) Plan – increase inhaled steroid Clinic Oct 2004 Recent exacerbation 1.11/3.12 Plan – prednisolone 15mg od, nebuliser Clinic Jan 2005 onwards… Cramps PPI/H2 Antagonist – some benefit Not taking ICS! Compliance Deranged Liver function tests 1.57/3.49 Diabetes - ? Steroid induced