asthma in general practice dec 2010 (1)

Why asthmais goodfor your practice

Dr. Sujeet RajanRespiratory PhysicianBombay Hospital Institute of Medical Sciences

Greatopportunity

Easyopportunity

Asthma is so common….1 in 10 of your patients !

Most patients prefer treatment from their family doctor rather than a Chest Physician

Physicians / GPs can treat asthma just as well as Chest Physicians ( even better )

The 4 keys tosuccessful asthma practice

“Is it asthma?”

Just a few questions in a few minutes

1

The 4 keys tosuccessful asthma practice

Treating the disease2

Not much time

……..and easily.

The 4 keys tosuccessful asthma practice

Making things simple for your patient3

Child’s play

Low cost

The 4 keys tosuccessful asthma practice

Saying the right things

Answering patients’ questions

“Jo bolega, karega”

4

Which secret do you want to unlock?

1. “Is it asthma?”

2. Treating the disease

3. Making things simple

4. Saying the right things

Diagnosis: Why make it ?

The patient has alternatives

(if you don’t, someone else will !)

Excellent prognosis, esp. in children

Treatment is so simple

Do I need a lot of tests?

Nothing usually, besides a sharp history

What questions or statements can suggest asthma?

Do you have a persistent cough ?

Do you wheeze or often feel breathless while

coughing ?

Do your symptoms worsen with climate

change, or dust /other allergens ?

What questions or statements … Do the symptoms get worse at

night ? Do you get chest tightness with

the cough ? Does it all start with a cold ? Do your colds often “go down” into

the chest ?

What questions or statements … Do your symptoms get worse after

extremes of happiness or sadness ?

(emotional swings)

Do heavy meals or late nights worsen

your symptoms ? (GE reflux)

Are your symptoms worse at work than

at home ? (occupational asthma)

What questions or statements …

Does anyone else in your family suffer from any allergies ?

Ask about:skin allergies

eczemafrequent colds

‘bronchitis’

What questions or statements …

“I get relief with this medicine.”

Ask: which medicine?

(always check for bronchodilator)

Diagnosis in children

Commonest cause of a persistent cough is asthma

Cough after exercise, activity, play Vomiting Failure to thrive

( poor sleep, poor growth )

When do you need lung function tests ?

Spirometry ( 250 to 350 rupees )

To re-confirm the diagnosis

When in doubt

Normal Spirometry ( Challenge tests )

Things the patient may not tell you …

Stigma and discrimination from a “word”

Work/school absenteeism

Marital discord

Travel & holidays ‘controlled’

Other ‘advice’ the patient gets

Grandparents/neighbours/ ‘friends’ –

Inhalers ???

Steroids ???

Make the diagnosis but emphasize the prognosis

Instead of asthma controlling your

patient,

the patient can control asthma

Asthma therapy in India today

Completely control symptoms and

fast

Normal life

As good as abroad ( even better )

General practice and physician level

Doesn’t need Chest Physicians !

Asthma Disease:Spasm and swelling

Spasm needs a reliever

Bronchodilator

Swelling needs a contoller

Anti-inflammatory

Two types of drugs:

Reliever & Controller

Reliever

Bronchodilator (beta2 agonist)

Quickly relieves symptoms (within 2-3 minutes)

Not for regular use

Reliever …

Inhaled

Nebulised

Oral

Most of the time

For severe attacks; administer at your clinic/hospital

Rarely needed

Anti-inflammatory

Takes time to act (1-3 hours)

Long-term effect (12-24 hours)

Only for regular use

(whether well or not well)

Controller

If your patient uses reliever

medication every day, or even

more than three or four times a

week, preventive medication

must be added to the treatment

plan.

GINA Workshop Report, December 1995

WHAT HAPPENS WHEN YOU DON’T TREAT ASTHMA WELL

N orm al

Inflam ed(A sthm a)

P artly Treated

Fixed O bstruction(Lead P ipe)

R em odelledA irw ay

What is changing the lives of our asthma patients today?

Inhaled steroid

THE STORY OF ASTHMA TREATMENT

N orm al Inflam ed (untreated)

R egularInha ledS tero id

P artlyTreated

Corticosteroids are the most potent and effective anti-inflammatory medication currently available

for asthma*

*GINA (NHLBI & WHO Workshop Report), December 1995

*Guidelines for the diagnosis and management of Asthma NIH, NHLBI, May 1997

Controller ..

Inhaled corticosteroids Budesonide/ beclomethasone/

fluticasone/ciclesonide – use any Start (400-1000 mcg/day approx. in

2 divided doses) Maintain for 3 months Taper slowly Safe for long-term use (years)

Controllers …

Inhaled corticosteroids: how safe? Even in small children for several

years 30% of Olympic athletes Not anabolic (performance-enhancing)

steroid Even highest ICS dose is safer than

low dose oral steroid Best “Addiction” for asthmatics

Inhaled steroids : safe even for children? 400 mcg/day (budesonide) Over 13 years of continuous use No growth retardation Uncontrolled asthma causes growth

retardation

Pedersen & Agertoft NEJM 2000

Pregnancy and asthma

Don’t x-ray (if possible) All asthma medication is safe Even oral corticosteroids are safe for

exacerbations Uncontrolled asthma during pregnancy

is a serious risk factor for foetal distress and anoxia

Thorax

Inhaled Steroids Not Working ?

Add SRtheophylline

Check Inhaler Technique /

Check Regular UseAdd LABA

Formoterol / Salmeterol

Increase dose of inhaled steroid

Add Leukotriene modifier

Leukotriene Modifiers Oral anti-inflammatory

Not as effective as inhaled steroid

First-line for 2 to 5 yr. olds.

All your ‘regular’ bronchodilator users.

Theophylline

Sustained release for regular use

Inexpensive , but toxic

Not more than 600 mg per day usually

Weak bronchodilator, but A-I effects

Add-on drugs : ICS + ?

1. Long acting Beta²-agonist ( LABA )

2. Montelukast

3. SR Theophylline

ICS + LABA

Which ICS ?

Budesonide: Once daily

Even children < 4 years

Safe for long term use

ICS + LABA

Which LABA ?

Formoterol: Immediate relief (as fast as salbutamol)

12 hours effect

Can be combined with budesonide

Ideal combination

Formoterol ( fast relief and sustained relief ) +

Budesonide ( twice or even once daily use )

Dose: 1- 4 puffs ( OD/BD )

Can be used for relief as well as control

FORACORT

Guidelines for using SMART with FOACORT• SMART means patients take a daily maintenance dose of

FORACORT and in combination take FORACORT as needed in response to symptoms.

The recommended maintenance dosage is 2 inhalations per day

Patients should take 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. Not more than 6 inhalations should be taken on any single occasion.

A total daily dose of up of 12 inhalations could be used for a limited period.

Patients using more than 8 inhalations daily should be strongly recommended to seek medical advice.

Oral Steroid

Prednisolone Acute severe episodes

(20-60 mg/day “burst”along with bronchodilators)

Dispense preferably Steroid-dependent asthma

Steroid-Dependent Asthma

A patient who requires regular

oral corticosteroids for control of

his/her asthma

Why doctors don’t use inhalation therapy

Status quo :“my practice is good or ‘great’”

Oral therapy is easy

Too busy

Cost

Headache to explain

Which inhaler?

Inhalers

MDI DPIs Nebuliser

(acute severeepisodes only)

Scope for Inhalation Therapy highest in a child

< 5 yrs - High incidence of

wheezing

Parents want the best for

their child

The Rotahaler

Has transformed inhalation therapy Child’s play (Insert -Twist - Inhale) Economical (Rs. 74) Acceptable (v/s difficulties with MDI)

Every drug you need

Child below 3, or adult over 85

MDI + Spacer

MDI + Spacer + Baby Mask

When can you not use a Rotahaler ?

Why use a Spacer ?

Ensures correct use of an MDI by correcting co-ordination problems.

Reduces incidence of throat infections with inhaled steroid

As good as nebuliser for acute exacerbations ( with MDI )

Then do we need nebulisers ?

– YES

Acute severe asthma with impending respiratory failure

Intensive care / Hospital / Clinic / Ambulances

Managing asthma in clinic(patient who walks in wheezing quite badly)

Oral prednisolone 20 mg/day x 1 week

Foracort Rotacaps (100/200/400) (Form +

Bud) twice daily x 1 week and also as

rescue

Call patient after 1 week

If much better

Taper or omit Prednisolone

Continue Foracort Rotacaps for 2 months in same dose

Foracort Rotacaps SOS

Call patient after 1 week …

If not much better /still needs salbutamol often

Check Rotahaler Technique

Check whether using Foracort regularly

If still not better at 2-3 months

Consider adding SR theophylline or montelukast

Look for aggravating factors– GE Reflux– Emotions/ stress– Sinusitis– Allergic Rhinitis– Persistent allergens

Always check

Inhaler technique

Regularity of steroid use

What do you tell patients ?

Oh no ! I have asthma ?

Allergic disorder (allergies don’t have cures)

You could call it “allergic bronchitis”

To lead a normal life, accept regular therapy (like DM/ HT/ Epilepsy)

What do you tell patients …

How long do I need this inhaler?

Wont I get addicted ?

Inhalers are a delivery system, not the drug

The drug is in a “homeopathic” dose

The earlier you start steroid, the better. ….. best “addiction”

Untreated asthma will cripple you

What should you keep in your asthma clinic ? Rotahaler/ Revolizer Placebo Rotacaps Placebo MDI/ Spacer/ Baby Mask Nebuliser ( for emergencies only ) Height measure Breathe-o-meter Education material ( available in 9

languages )

The Breathe-o-Meterlike a thermometer for asthma

Inexpensive clinic instrument

Monitoring Builds confidence in

treatment

One ‘hard, fast blow’

The Breathe-o-Meter…

First visit and follow-ups

Improving symptoms

= improving peak flows

= improving confidence

Rarely for home use

What do you tell patients …

Today’s asthmatics are suffering as

they never received regular inhaled

steroids as children.

What costs more is not better (e.g.

nebulisers for home use)

Examples

Myopics Spherical glasses regularly

Everyone Brushing teeth regularly

Obesity Diet & exercise regularly

Asthmatics Inhaled steroid regularly

Asthma management: nothing specialistabout it

Dr. Sujeet RajanRespiratory PhysicianBombay Hospital Institute of Medical Sciences