Transcript ASTHMA MANAGEMENT and EDUCATION INITIATIVE JOB CORPS 2005 National Health and Wellness Conference Orlando, Florida June 7, 2005 Gary Strokosch, MD Region V Medical Consultant.

ASTHMA MANAGEMENT
and
EDUCATION INITIATIVE
JOB CORPS
2005 National Health and Wellness Conference
Orlando, Florida
June 7, 2005
Gary Strokosch, MD
Region V Medical Consultant
Guidelines for the Diagnosis
and Management of Asthma
-------------------------------------Update on Selected Topics
- 2002 Expert Panel Report (EPR) – Update 2002
 National Asthma Education and Prevention
Program (NAEPP)
 NIH Publication No. 02-5074
 June 2003

PREVIOUS REPORTS

1997 Guidelines for the Diagnosis and
Management of Asthma (EPR-2)
 1991 National Asthma Education and
Prevention Program’s (NAEPP) first report
AVAILABLE NAEPP
PUBLICATIONS
http://www.nhlbi.gov.nhlbi/nhlbi.htm
(National Heart, Lung and Blood Institute)
OBJECTIVE
To give participants the tools to develop
up-to-date individual management plans
for JC students with asthma
SCOPE OF ASTHMA - I

11 million people reported having an
asthma attack in 2000
 More than 5% of all children under 19
report asthma attacks in 2000
 In 2003 14.7% of teens 12-17 years of age
have had asthma diagnosed
SCOPE OF ASTHMA - II

1999: 2 million ER visits
 1999: 478,000 hospitalizations for asthma
 1999: 4426 deaths from asthma
 Mortality is 3 times higher in Black males
than white males
 Mortality is 2 ½ times higher in Black
females than while females
2002 UPDATE OUTLINE

Overview of asthma
 Medication Updates
– Steroids Efficacy & Safety
– Combination Therapy
– Antibiotics

Monitoring Issues
– Written Plans for Management
– Peak Flow Vs. Symptom Monitoring

Management
DEFINITION
Asthma is a chronic inflammatory disorder of
the airways in which many cells and cellular
elements play a role.
----------------------note---------------------The ability to synthesize IgE antibody to
environmental allergens (i.e., atopy) remains a
major risk factor in asthma pathogenesis.
NATURAL HISTORY OF
PERSISTENT ASTHMA

The majority of children who wheeze before 3
years of age do not experience any more
symptoms after 6 years of age.
 A smaller group of children wheezing before 3
years of age go on to have persistent asthma.

A predictive index identified the following risk
factors for developing persistent asthma
PREDICTIVE INDEX
Major and Minor Risk Factors

Physician diagnosis of atopic dermatitis/eczema
- OR  Parental history of asthma
--------- OR -------- Two out of three of the following asthmaassociated phenotypes:
– Peripheral blood eosinophilia (>4%)
– Wheezing apart from colds
– Physician-diagnosed allergic rhinitis
BIRTH COHORT
FOLLOWED FOR 13 YEARS

76% of those diagnosed with asthma after 6
years of age had a positive predictive index
 97% of those without a diagnosis of asthma
after 6 years of age had a negative
predictive index
(Castro-Rodriguez, et.al. 2000)
SPIROMETRY
Recommends tests be done:

At the time of the initial assessment
 After treatment is initiated and symptoms
and PEF have stabilized
 At least every 1-2 years
SYMPTOM CLASSIFICATION

Severe Persistent

Moderate Persistent

Mild Persistent

Mild Intermittent
SYMPTOM CLASSIFICATION

Severe Persistent
– Day: continual
– Night: frequent

Moderate Persistent
– Day: daily
– Night: >1/week

Mild Persistent
– Day: >2/week (<1/day) [3-6/week]
– Night: >2/month

Mild Intermittent
– Day: 2/week
– Night: 2/month
TARGET OF THERAPY - I
1) Acute symptoms of asthma usually arise
from BRONCHOSPASM and require and
respond to bronchodilator therapy.
TARGET OF THERAPY - II
2) Acute and chronic INFLAMMATION affects the
airway caliber and airflow and also causes
bronchial hyper responsiveness, resulting in
susceptibility to bronchospasm. Therapy is with
anti inflammatory drugs but may require weeks to
achieve a successful response.
TARGET OF THERAPY - III
3) Some patients experience persistent
airflow limitations and this REMODELING
has NO current therapy.
INFLAMMATION
This inflammation causes recurrent episodes
of wheezing, breathlessness, chest tightness
and cough, particularly at night and in the
early morning.
INFLAMMATION - I
Airway inflammation in asthma is
found in patients with mild, moderate
and severe disease.
INFLAMMATION – II
Mild / Moderate Persistent
Asthma

Inflammation of airway by inflammatory
cells such as activated lymphocytes &
eosinophils
 Denudation of the epithelium
 Deposition of collagen in the subbasement
membrane area
 Mast cell degranulation
INFLAMMATION – III
Severe Persistent & Deaths from
Asthma

Occlusion of bronchial lumen by mucous
 Hyperplasia & hypertrophy of bronchial
smooth muscle
 Goblet cell hyperplasia
IgE PATHOGENESIS
1.
2.
3.
4.
IgE antibodies are synthesized to environmental
allergens (atopy)
Synthesized IgE binds to mast cells and basophils
via high-affinity IgE receptors
These cells are signaled to release preformed and
newly generated mediators, including histamine &
cysteinyl leukotrienes to rapidly contract airway
smooth muscle
Mast cells also produce a variety of cytokines (proinflammatory proteins) including interleukin (IL
1,2,3,4 &5), granulocyte-macrophage colonystimulating factor, interferon and tumor necrosis
factor-α
ATOPY

Atopy is the genetic susceptibility to produce IgE ABs
directed toward common environmental allergens,
including house-dust mites, animal proteins, and fungi.
 With the production of IgE ABs, mast cells and
possibly other airway cells (e.g., lymphocytes) are
sensitized and become activated when they encounter
specific antigens.
 Atopy has been found in 30 to 50% of the general
population, therefore frequently found in the absence
of asthma.
 Atopy is one of the strongest predisposing factors in
the development of asthma.
EOSINOPHIL PATHOGENESIS
Infiltration seen in all acute inflammation &
many patients with chronic persistent asthma
The granules are the source of inflammatory
mediators
1.
2.
–
–
–
3.
4.
Injure airway epithelium
Enhance bronchial responsiveness
Affect acetylcholine release
Release cysteinyl leukotrienes to contract airway
smooth muscle
Eosinophils are produced & released from bone
marrow via IL-5, migrate to airway via a number
of factors
EOSINOPHIL PATHOGENESIS
Although its role in pathophysiology is less clear,
it is affected by anti-inflammatory therapy.
ASTHMA MEDICATIONS
1.
2.
3.
4.
5.
6.
Beta2-Agonists
Corticosteroids
Leukotriene Modifiers
Methyl Xanthines
Cromolyn and Nedocromil
Anticholinergics
ASTHMA MEDICATIONS
1.
Beta2-Agonists



2.
Corticosteroids


3.
4.
5.
6.
Injected
Short-acting inhaled
Long-acting inhaled
Inhaled
Systemic (oral)
Leukotriene Modifiers
Methyl Xanthines
Cromolyn and Nedocromil
Anticholinergics
COMBINATION
ASTHMA MEDICATIONS
1.
Beta2-Agonists



2.
Corticosteroids


3.
4.
5.
6.
Long-acting inhaled
Inhaled
ADVAIR
100/50, 250/50 & 500/50

Fluticasone DPI 100/250/500 mcg

Salmererol DPI 50 mcg
ASTHMA MEDICATIONS
1.
Beta2-Agonists



2.
Corticosteroids


3.
4.
5.
6.
Injected
Short-acting inhaled
Long-acting inhaled
Inhaled
Systemic (oral)
Leukotriene Modifiers
Methyl Xanthines
Cromolyn and Nedocromil
Anticholinergics
ASTHMA MEDICATIONS
1.
Beta2-Agonists



Short-acting inhaled
2.


3.
4.
5.
6.
Anticholinergics
COMBIVENT
For Use In COPD

Ipratropium 18 mcg/puff MDI
 Albuterol 90 mcg/puff MDI

Ipratropium 0.5 mg/3ml Nebulizer Solution
 Albuterol 2.5 mg/3ml Nebulizer Solution
CORTICOSTEROID
EFFICACY
Does chronic use of inhaled
corticosteroids improve long-term
outcomes with mild or moderate
persistent asthma, in comparison
to the following treatment?

PRN beta2-agonists?
 Long-acting beta2-agonists?
 Theophylline?
 Cromolyn/Nedocromil?
 Combinations of above drugs?
RESULT
Inhaled corticosteroids improve long-term
outcomes with mild or moderate persistent
asthma, compared to previously outlined
treatments.
RECOMMENDATION
Inhaled corticosteroids are the preferred treatment
for initiating therapy for persistent asthma.
CORTICOSTEROID
SAFETY
What are the long term
adverse effects of chronic
inhaled corticosteroid use
on the following outcomes?

Vertical Growth?
 Bone Mineral Density?
 Ocular Toxicity (posterior subcapsular
cataract and glaucoma)?
 Suppression of adrenal/pituitary axis?
RESULT
The use of corticosteroids at recommended
doses does not have long-term, clinically
significant, or irreversible effects on any of the
outcomes reviewed.
LINEAR GROWTH

Growth reduction my occur from inadequate
control of any chronic disease.
 Although low/medium doses may have the
potential of decreased growth velocity, the effects
are small, nonprogressive and may be reversible.
 When high doses are needed, the use of
adjunctive therapy should be initiated in order
to reduce the steroid dose.
 Children and adolescents taking steroids by any
route should be monitored for growth interference.
BONE MINERAL DENSITY
A small, dose-dependent reduction in BMD may
be associated with inhaled corticosteroid use in
patients older than 18 years of age, but the
clinical significance of these findings is not clear.
CATARACTS / GLAUCOMA
In children, no significant effects are seen with
low-to-medium doses. However, high (>2000
mg) cumulative lifetime doses of inhaled
corticosteroids may increase slightly the
prevalence of cataracts in two studies of adult
and elderly patients.
HPA AXIS FUNCTION
Available evidence indicates that, on average,
children may experience only clinically
insignificant, if any, effects of low-to-medium
dose of inhaled corticosteroids. Rare
individuals may be more susceptible to their
effects even at conventional doses.
OVERALL
RECOMMENDATION
Inhaled corticosteroids are the preferred treatment
for initiating therapy for persistent asthma.
COMBINATION THERAPY:
ADDITION OF OTHER LONGTERM-CONTROL
MEDICATIONS TO INHALED
CORTICOSTEROIDS
QUESTION
In patients with moderate persistent asthma
who are receiving inhaled corticosteroids, does
addition of another long-term-control agent
improve outcomes?
ANSWER

Strong evidence consistently indicates that
long-acting inhaled beta2-agonists added to
low-to-medium inhaled corticosteroids
improve outcomes.
 Adding a leukotriene modifier or
theophylline to inhaled corticosteroids also
improves outcomes, but the evidence is not
as substantial.
RECOMMENDATION
The preferred treatment for adults and
children older than 5 years of age is the
addition of long-acting inhaled beta2-agonists
to low-to-medium doses of inhaled
corticosteroids (not as a substitute).
“JUST DOUBLE THE DOSE”
Studies of adults in which the dose of inhaled
corticosteroids was at least doubled consistently
demonstrate improved outcomes when their asthma
was not controlled with low-to-medium-doses of
inhaled steroids, but these results are consistently
less effective than adding a long-acting inhaled
beta2-agonist.
USE OF ANTIBIOTICS TO
TREAT ASTHMA
EXACERBATIONS
DOES ROUTINELY ADDING
ANTIBIOTICS TO
STANDARD CARE IMPROVE
THE OUTCOMES OF
TREATMENT FOR ACUTE
EXACERBATION OF
ASTHMA?
NOTES ON COMORBID
INFECTION





Most asthma exacerbations are associated with infection by a
respiratory virus, especially rhinovirus.
Only a small percentage of exacerbations are associated with infection
by an atypical bacterium, like Mycoplasma pneumoniae or Chlamydia
pneumoniae.
It is widely believed that coincident bacterial sinusitis contributes to
asthma exacerbations.
Airway obstruction due to mucus plugging possibly predisposes
patients to bacterial infection of non-draining regions of the lungs.
Viral and bacterial infections are both associated with neutrophilic
inflammation of the upper and lower airways.
MORE NOTES ON
COMORBID INFECTION

Low-grade fever may accompany viral
respiratory infections.
 Sputum discoloration (from PMNs) may
accompany viral respiratory infections.
 Sputum of patients with uncomplicated
asthma exacerbations commonly contains
high numbers of PMNs.
UNCHANGED
RECOMMENDATION
(Same as EPR-2)
Therefore, antibiotics are not recommended
for the treatment of acute asthma
exacerbations except as needed for comorbid
conditions – e.g., for the patients with fever
and purulent sputum, evidence of pneumonia,
or suspected bacterial sinusitis.
WRITTEN ACTION PLANS
COMPARED TO MEDICAL
MANAGEMENT ALONE
QUESTION
Compared to medical management alone, does
the use of a written asthma action plan
improve outcomes?
SUMMARY ANSWER TO
THE QUESTION
Data are insufficient to support or
refute the benefits of using written
asthma action plans compared to
medical management alone.
UNCHANGED
RECOMMENDATION
(Same as EPR-2)
Use of written action plans as part of an overall
effort to educate patients in self-management is
recommended, especially for patients with
moderate or severe persistent asthma and
patients with a history of severe exacerbations.
WRITTEN ACTION PLANS
SHOULD:








Enhance clinician-patient communication
Meet the medical needs of the student
Have a format that facilitates the student’s
understanding and ability to take appropriate action
Be explicit
Be an algorithm of procedures to take
Contain steps to take if treatment is ineffective or an
emergency arises
Contain contact information for securing urgent care
Be periodically reviewed and revised as needed
PEAK FLOW-BASED
COMPARED TO
SYMPTOM-BASED
WRITTEN ACTION PLANS
QUESTION
Compared to a written action plan
based on symptoms, does use of a
written action plan based on peak
flow monitoring improve outcomes?
SUMMARY ANSWER TO
THE QUESTION

Evidence neither supports nor refutes the
benefits of written action plans based on
peak flow monitoring compared to
symptom-based plans in improving health
care utilization, symptoms, or lung function.
 However, patient preferences and
circumstances may warrant choosing peak
flow monitoring.
PEAK FLOW MONITORING
TRADITIONAL RECOMMENDATIONS

Peak flow monitoring can be used for short-term
monitoring, managing exacerbations, and daily
long-term monitoring.
 When used in these ways, the patient’s measured
personal best is the most appropriate reference
value.
 Daily long-term monitoring should be limited to
moderate and severe persistent asthma.
MANAGEMENT
SYMPTOM CLASSIFICATION

Severe Persistent
– Day: continual
– Night: frequent

Moderate Persistent
– Day: daily
– Night: >1/week

Mild Persistent
– Day: >2/week (<1/day) [3-6/week]
– Night: >2/month

Mild Intermittent
– Day: 2/week
– Night: 2/month
SYMPTOM CLASSIFICATION

Severe Persistent
Step 4
– Day: continual
– Night: frequent

Moderate Persistent
Step 3
– Day: daily
– Night: >1/week

Mild Persistent
Step 2
– Day: >2/week (<1/day) [3-6/week]
– Night: >2/month

Mild Intermittent
– Day: 2/week
– Night: 2/month
Step 1
SYMPTOM CLASSIFICATION

Severe Persistent
Step 4
PEF/FEV1 <60%
Step 3
PEF/FEV1 60-80%
Step 2
PEF/FEV1 >80%
– Day: continual
– Night: frequent

Moderate Persistent
– Day: daily
– Night: >1/week

Mild Persistent
– Day: >2/week (<1/day) [3-6/week]
– Night: >2/month

Mild Intermittent
– Day: 2/week
– Night: 2/month
Step 1
PEF/FEV1 >80%
SYMPTOM CLASSIFICATION

Severe Persistent
Step 4
– Day: continual
– Night: frequent

Moderate Persistent
Variability >30%
Step 3
– Day: daily
– Night: >1/week

Mild Persistent
Mild Intermittent
– Day: 2/week
– Night: 2/month
PEF/FEV1 60-80%
Variability >30%
Step 2
– Day: >2/week (<1/day) [3-6/week]
– Night: >2/month

PEF/FEV1 <60%
Step 1
PEF/FEV1 >80%
Variability 20-30%
PEF/FEV1 >80%
Variability <20%
DAILY MEDICATIONS
Preferred Treatment:

Step 4
– High-dose inhaled corticosteroids, AND
– Long-acting beta2-agonists

Step 3
– Low-to-medium dose inhaled corticosteroids, AND
– Long-acting beta2-agonists

Step 2
– Low-dose inhaled corticosteroids

Step 1
– No daily medication needed
QUICK RELIEF
TREATMENT

Short-acting bronchodilator inhaler
 Nebulizer treatment with bronchodilator
 Course of systemic corticosteroids
NOTES ON TREATMENT

Classify patients to their most severe step
 Gain control ASAP, then step down to the least
medication needed for control
 Minimize use of short acting inhaled beta2-agonist
 Provide education on self-management and
controlling environment
 Refer to asthma specialist if it is difficult to control
asthma or if step 3 or 4 is required
STEPPING

STEP DOWN: Review treatment every 1
to 6 months; a gradual stepwise reduction in
treatment may be possible.
 STEP UP: If control is not maintained,
consider step up. First, review patient
medication technique, adherence and
environmental control.
2004 PERRY POINT
FIVE ASTHMA MEDICATIONS
www.jobcorpshealth.com

Albuterol inhalation aerosol (albuterol)
 Fluticasone propionate oral inhaler (Flovent)
 Triamcinolone acetonide inhalation aerosol
(Azmacort)
 Salmeterol xinafoate oral inhaler (Serevent)
 Montelukast sodium tablets, 10 mg (Singulair)
2004 PERRY POINT
TWO ORAL STEROIDS

Prednisone tablets, 20 mg (prednisone)

Dexamethasone tablets, 4 mg (Decadron)
PROPELLENTS

CFC: chlorofluorocarbons
– Safe to inhale but damaging to the earth’s ozone
layer
– MDIs with CFC are being phased out

HFA: hydrofluoroalkane
– Safe for the environment and the patient
– Delivers nearly twice as much medication to
the patient
SEVERAL WEBPAGES
REGARDING ASTHMA

www.chestnet.org
– American College of Physicians

www.whatsasthma.org (many links)
– Neomedicus and Merck

www.lungusa.org
– American Lung Association
PERSONAL COMMENTS
ORAL CORTICOSTEROIDS

Only prednisone needed for PO use
 Once per day about equivalent to BID
 May stop med abruptly after ~5 days
 Used almost exclusively for quick relief, not for
supplementing (long term) inhaled steroids or
long acting beta2-agonists in step 4
INHALED STEROIDS
COMMON PRACTICES

Beclomethasone (Beclovent) not in
common use in some medical centers
 Budesonide (Pulmicort) ~20% absorbed,
but used mostly in nebulizer for children
 Flunisolide (Aerobid) not used much
 Fluticasone (Flovent) ~1% absorbed,
commonly used & available in 3 strengths
 Triamcinolone acetonide (Azmacort) not in
common use in some medical centers
LONG ACTING
BETA2-AGONISTS

Salmeterol (Serevent) off market (CFC)
 Fixed dose of salmeterol now only available
in combination with 3 strengths of
fluticasone as Advair (100/50, 250/50 &
500/50)
 Formoterol (Foradil) available
FORMOTEROL

Available as Foradil
 It is both short acting and long acting
 12 mcg of Foradil is equivalent to 50 mcg
of salmeterol (Serevent)
 Provided as 12 mcg capsules to be used in
aerolizer (not PO) every 12 hours
CROMOLYN & NEDOCROMIL

Cromolyn is available as Intal
 Nedocromil is available as Tilade
Not commonly used
LEUKOTRIENE MODIFIERS

Used as adjunctive therapy for asthma
 Oral treatment available
 Simultaneously treats allergic rhinits
LEUKOTRIENE MODIFIERS

Leukotriene Receptor Antagonists (LTRAs)
– Montelukast is available as Singulair prescribed as one 10 mg
tablet per day
– Zafirlukast is available as Accolate prescribed as 20 mg tablet
BID

5-Lipoxygenase Inhibitors
– Zileuton is available as Zyflo prescribed as 600 mg QID
METHYLXANTHINES

Theophylline used very little now and
requires blood level monitoring
QUICK RELIEF

Albuterol inhaler commonly used
 Pirbuterol (Maxair) is also useful and also available as
an Autohaler, a breath activated inhaler, easier and
more reliable to use
 Albuterol nebulizer solution is available, usually given
as 2.5 mg/3ml (0.083%) for teens and young adults

Ipratropium (anticholinergic) (Atrovent) useful for
beta2 receptor resistance to albuterol
 Anticholinergic + albuterol generally used for COPD
 Injectable beta2-agonists too short acting
SUGGESTED MINIMAL STOCK

Albuterol inhaler
 Albuterol nebulizer solution 2.5 mg/3cc
 Prednisone 20 mg tabs
 Advair (fluticasone + salmeterol) DPI in
100/50 & 250/50 doses
 Flovent (fluticasone) MDI 44,110 & 220
mcg/puff OR DPI 50, 100 & 250 mcg/puff
TWO POSSIBLE ADDITIONS

Quick Relief: Pirbuterol (Maxair) is also useful
and also available as an Autohaler, a breath
activated inhaler, easier and more reliable to use
 Quick Relief and Long Acting Beta2-Agonists:
Formoterol (Foradil) can be given BID in place
of Serevent
COMMENTS ABOUT
PEAK FLOW METERS

Comparable to careful monitoring of signs
and symptoms in managing asthma
 Inexpensive / disposable mouthpieces
 Can be used with “personal best” or
predicted average PEF (liters per minute)
 Daily use reserved for most severe patients,
but adherence drops off quickly
 Very subject to effort, in contrast to FEV1
OTHERS
Pulse oximetry – most useful in emergency
rooms
 Spirometry – useful to detect degree of
obstruction and if it can clear with
bronchodilators and or steroids
 Asthma specialists – useful for step 3 and/or
step 4 patients or difficulty with
management
