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Asthma Control: GuidelineBased American Thoracic Society (ATS),

National Asthma Education and PreventionProgram (NAEPP), and Global Initiative for

Asthma (GINA)

Michael P. Pietila, MDPulmonary, Critical Care and InternalMedicine Yankton Medical Clinic, P.C. Assistant Professor Sanford School of

Medicine at USD

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Professional Relationships

I am a contracted speaker for: Merck Pharmaceuticals Dey Pharma L.P. Bureau of COPD Research

and Education to Advance TherapeuticExcellence (BREATHE)

I will not be speaking specifically aboutany of these companies products today.

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Defining and Recognizing Asthma

Netters Anatomy

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Asthma Epidemiology

Estimated > 23 million Americans Prevalence 5-25% of population

Increasing prevalence and severity USA and worldwide Socioeconomics > genetics

$14 Billion direct annual costs in USA

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Epidemiology

More common in males (equal after age20). Atopy Skin test reactivity, elevated IgE

levels, blood eosinophilia.Indoor allergens dust mites, animaldander.

Environmental pollution, occupationalexposure.Respiratory infections.

TOBACCO SMOKE.

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Increasing Asthma Mortality

500,000 hospitalizations per year in U.S.5-6,000 deaths per year

1978 - beginning of increasing mortalityRole of poverty (vs. race) Access to health care, medications, education

Greater environmental exposure Importance of identifying persons with high risk ofdeath

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Definition of Asthma

Obstructive lung disease with characteristicsof: Airway obstruction; reversible in most patients Chronic airway inflammation (eosinophils)

Increased airway responsiveness

Onset of symptoms can occur at any age

NAEP - Guidelines for the Diagnosis and Management of Asthma 1991

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Guidelines for the Diagnosis and Management of Asthma

Key Messages Asthma is an inflammatory diseaseEnvironmental factors are importantObjective measures are neededHealth education is crucialEmphasis on recognition and avoidance oftriggers

Buist & Vollmer. NEJM 331:1584-5;1996

Asthma Guidelines 2007

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Asthma Guidelines 2007

Components of severity: Symptoms and objective testing. FEV1 and FEV1/FVC measurement. Need for short-acting beta-agonist (SABA). Nighttime awakenings. Interference with normal activity.

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Diagnosing AsthmaSymptoms and Medical History Wheezing, cough, difficult breathing and chest

tightnessSymptoms worse at night/on awakeningSeasonal patternEczema, hay fever, family historyTriggers animal fur, chemicals, temperaturechange, dust mites, drugs, exercise, pollen, URI,smokeSymptoms respond to anti-asthma therapyColds go to the chest or last > 10 days.

Pocket Guide for Asthma Management andPrevention 2011

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Asthma Phenotypes

Intermittent/Persistent Mild/Moderate/Severe

Adult onset wheezing Primary asthma and secondary causes Tends to me more severe

Occupational asthmaNeutrophilic inflammation

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Diagnostic Tests

No single test can secure a diagnosis ofasthmaSpirometry is the most helpful, preferredmethod for establishing diagnosis. Increase in FEV1 of > 12% and 200 ml after

inhaled bronchodilator. Many asthma patients are negative and

repeat testing is advised.

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Diagnostic Testing

Peak expiratory flow (PEF) aid indiagnosis and management. Compare to patient's previous best effort

60 L/min improvement after BD or diurnalvariation in PEF of more than 20%

Bronchoprovaction testing.

Methacholine, histamine or inhaled mannitolSkin testing or specific IgE testing forallergens.

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Diagnostic Challenges

Cough variant asthma Chronic cough, often at night

Exercise induced bronchospasm Exercise challenge

Asthma in the elderly COPD vs asthma

Occupational asthma Must correlate symptoms with occupation

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Goals of Therapy

Avoid troublesome symptoms night anddayUse little or no reliever medsHave productive and physically active lifeHave (near) normal lung function

Avoid serious attacks

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Initiating TherapyDetermine level of severity.Consider interval since last exacerbation. Fluctuations in severity and frequency may occur.

Risk assessment: Exacerbations requiring oral corticosteroids:

0-1 per year in intermittent (low risk) patient.> or equal to 2 per year in persistent (higher risk) patient.

Keep in mind the patients baseline FEV1.Initiate treatment in a stepwise fashion. Reevaluate level of control in 2-6 weeks.

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Asthma Care

Patient/doctor relationship Avoid triggers, understand and take meds, recognize

symptoms and seek advice in timely fashion

Identify and reduce exposure to risk Smoke, drugs, dust, fur, pollens, mold

Assess, treat and monitor Stepwise approach, Ongoing monitoring q 3 monthly

when stable, within 2 weeks after exacerbation.

Manage exacerbations

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Stepwise ApproachIf disease is poorly controlled First evaluate for adherence to treatments and

avoidance of triggers Consider a step up treatmentsIf disease is well controlled Step down treatmentsMedications must be adjusted based on

response to treatment and control of underlyingdisease, not on a fixed timetable. If a medicine is not effective after 3 months, it should

be stopped

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Inhaler Technique

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Moderate to Severe Persistent Asthma

Daytime symptoms daily and nighttimesymptoms at least weekly.Using their rescue inhaler at least oncedaily.FEV1 < 80% of predicted.FEV1/FVC ratio reduced by 5% frombaseline.

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Moderate to Severe Persistent Asthma

Moderate to High dose InhaledCorticosteroids (ICS) are the cornerstoneof treatment. Higher potency preparations require fewer

puffs and encourage compliance Under dosing of ICS will result in poorer

control

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Managing Disease Add in a Long Acting Beta Agonist (LABA)

Most pts in the severe category require at least 2 controlleragents

Should NEVER be used as monotherapy

Leukotriene antagonists are also an option: Limited evidence in literature Montelukast, Zafirlukast, ZiluetonTheophylline Limited role, controller agent only, not as efficacious as LABAs

If symptoms are severe add oral corticosteroids. 5-7 days if normal FEV1, 14-21 days if reduced FEV1Consider treatment with IgE antibody.

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Oral Glucocorticoids

Most potent and effective controller agent. Reserve for severe disease and those with

reduced FEV1, use lowest dose possible Should see an improvement in FEV1 of 15%

after 2-3 weeks If requiring oral GCs every 2 -3 months

consider daily low dose (5-10 mg)

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Follow-up

4 to 8 week intervals. Use a questionnaire to evaluate control

Asthma Control Test (ACT)

Consider spirometry if worsening symptomsor a step down in care

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http://www.asthma.com/resources/asthma-control-test.html

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Xolair: What is That?

Xolair (Omalizumab): Is an recombinantmonoclonal anti-IgE antibody designed totreat moderate to severe allergyassociated asthma. Must demonstrate sensitization to an allergen. Inadequate control with inhaled steroids.

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Asthma Guidelines 2007Xolair therapy: Reduce the need for systemic and inhaled

glucocorticoids. Reduce the number of exacerbations, especially

severe exacerbations. No effect on FEV1 values. Given via SubQ route q 2 to 4 weeks. 850 patients radomized

25% reduction in rate of exacerbationOverall response rate 30-50%12 week trial should be offered

Hanania, et al;Ann Intern Med2011;154:573

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Co-Morbid Illness

Allergic rhinitis treat with nasal GCs ifsurgical disease refer to ENTGERD treat with PPI if patient issymptomatic from GERDVocal cord dysfunction (VCD)- referral toqualified speech therapistOSA study in sleep lab and treat asindicated

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Special ConsiderationsPregnancy Variable, safeObesity

Weight loss helpsSurgery PFTs, if < 80% FEV1

steroids help

Chronic sinus/rhinitis Treating these willimprove asthma

OccupationalURIs GER

More common inasthma but treatmentdoesnt reducemorbidity

ASA induced 28%

Anaphylaxis

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Summary

Accurate and complete history andphysical is crucial.Objective testing spirometry,methacholine challenge, peak flows,serum studies.Classify the patient.Step care.Reevaluation/follow-up.

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Summary

Written action planProper inhaler techniqueTrigger avoidanceInhaled GCs are cornerstone of therapy LABAs should be added next LTAs or theophylline follow Consider IgE antibody in proper subsetTreat comorbid illnesses

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