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New asthma ppp modified 2011 New asthma ppp modified 2011 Presentation Transcript

  • KENYA MEDICAL ASSOCIATION
    CME: SAROVA PANAFRIC HOTEL
    ASTHMA UPDATE
    DR. JOSEPH A ALUOCH F.R.C.P., E.B.S.,
    2nd JUNE 2011
  • ASTHMA
    Less understanding of Aetiology/Pathogenesis
    Genetics complex
    Control of Airway Tone?
    Reversible AWO: variability
    BHR
    Asthma no single aetiology
    Chronic Inflammation
    Dynamic Process
    Healing and Repair (Remodelling)
  • ASTHMA THE DISEASE
    No clear concept of normality
    Disease variation
    Lack of correlation between disease and outcome
    Patient understanding the severity.
    Lack of correlation between FEV and other outcome.
  • Defining asthma can be difficult !
  • Defining Asthma
    Bronchial hyperresponsiveness
    Airway inflammation
    Central features, but not defining for individual characteristics of phenotypes
  • DEFINITION
    Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role
    The ability to synthesize IgE antibody to environmental allergens (i.e., atopy) remains a major risk factor in asthma pathogenesis.
  • INFLAMMATION IN ASTHMA
    MECHANISM:
    CHANGES
    PROCESS
    ASSESSMENT
    HISTOLOGICAL CHANGES
    INFLAMMATORY CELLS
    LOCAL FACTOR
    FACTORS
    :STILL LARGELY UNCLEAR
    : PRIMARY OR SECONDARY
    : INITIATION
    :PERSISTENCE PROGRESS
    E.C.P, N.O, PEFR;
    RELATION TO SEVERITY
    : NON-ALLERGIC
    :ATOPY
    :EXERCISE INDUCED
    :PRIMARY
    :SECONDARY
    :LUNG TRANSPLANT
    :ATOPY
    :ENVIRONMENT
  • INDUCERS
    Allergens,Chemical sensitisers,
    Air pollutants, Virus infections
    INFLAMMATION
    Airway
    Hyper-responsiveness
    Airflow Limitation
    SYMPTOMS
    Cough Wheeze
    Chest tightness
    Dyspnoea
    TRIGGERS
    Allergens,
    Exercise
    Cold Air, SO2
    Particulates
  • ASTHMA UPDATE
    OTHER FACTORS LIMITING AIRFLOW
    Airway edema secondary to eosinophilic inflammation
    Mucus hypersecretion
    Structural changes i.e. hypertrophy and hyperplasia of smooth muscular tissue; tissue fibrosis as part of remodeling.
  • Inflammatary Cells
    Mast Cells
    Eosinophils
    Th2 Cells
    Basophils
    Platelets
    Structural Cells
    Epithelial Cells
    Smooth Muscles Cells
    Fibroblast
    Nerves
    Mediators
    Histamine
    Leukotrienes
    Prostanoids
    PAF
    Kinins
    Adenosine
    Endothelins
    Nitric Oxide
    Cytokines
    Chemokines
    Growth Factors
    Effects
    Bronchospasm
    Plasma exudation
    Mucus secretion
    AHR
    Structural Changes
  • IgE PATHOGENESIS
    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 (pro-inflammatory proteins) including interleukin (IL 1,2,3,4 &5), granulocyte-macrophage colony-stimulating 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
    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.
  • Reversible and variable airflow limitation
    Reversibility of airways’ obstruction
    Increased PEF >15% 15-20 minutes after inhaling ß2-agonist
    Variability of airways’ obstruction
    PEF varies between morning and evening
    >20% in patients taking bronchodilator
    >10% in patients not taking bronchodilator
    Exercise-induced airways’ obstruction
    Decreased PEF >15% after 6 minutes of exercise
    GINA Guidelines 1998
  • ASTHMA UPDATE
    AIRFLOW LIMITATION
    Bronchoconstriction occurs secondary to release of multi-mediators (histamine, leukotrienes, prostaglandins, PAF etc.
    Aeroallergen sensitivity
    Aspirin ( Non-IgE)
    Multi-factorial (exercise and cold air-osmotic; airborne irritants, laughing, GERD & sinusitis via neurogenic reflex; infections)
  • GOAL OF MANAGEMENT
    Minimal (ideally no) chronic (inc. nocturnal) symptoms
    Minimal (infrequent ) exacerbations
    No emergency visits
    Minimal need for prn Beta2-agonists
    No limitations on activities (inc. exercise)
    Near normal PEFR & variability <20%
    Minimal (or no ) adverse effects from medicine
  • Control
    Day time symptoms
    Limitation of activities
    Nocturnal symptoms
    Nocturnal awakenings
    Use of rescue medications
    Objective Ass. Lung F.Test
  • ASTHMA UPDATE
    • NEW DIRECTIONS
    CHANGES IN GUIDELINES
    CONTROL VS. SEVERITY
    HETEROGENEITY REGARDING ETIOLOGY
    DIFFERENT PHENOTYPES
    DIFFERENTIAL DIAGNOSIS- MASQUERADERS
    BETTER MONITORING
    ASTHMA EDUCATION
    BETTER SELF MONITORING
    MEDICAL MONITORING:SPIROMETRY
    NEW THERAPIES
    INHALED STEROIDS WITH NO OR MINIMAL BIOVAILABILITY
    OTHER NEW MOLECULES
    IMPROVED IMMUNOTHERAPIES
    IMPROVED EMPHASIS ON SELF-IMPROVEMENT: NUTRITION; PERSONAL HABITS; HOME ENVIRONMENT
  • ASTHMA UPDATE
    EARLY IDENTIFICATION OF HIGH RISK PATIENTS:
    IMMEDIATE CONCERNS:
    Improve quality of life
    Reduce risk for hospitalizations and death.
    LONG TERM CONCERNS:
    Prevent irreversible changes in airway structure i.e. remodeling with sub-basement fibrosis, mucus hypersecretion, s.m hypertrophy, & injury of lining (epithelium).
  • 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
  • ASTHMA UPDATE
    AIRWAY HYPER-RESPONSIVENESS (TWITCHY LUNGS)
    Exaggerated bronchoconstrictor response to stimuli- triggers such as exercise, cold air, laughing, stress.
    Defined by methacholine/adenosine/mannitol responsiveness
    Rx directed towards reducing inflammation can reduce airway hyper-responsiveness.
  • ASTHMA UPDATE
    HETEROGENOUS PHENOTYPES OF ASTHMA:
    Different patterns of inflammation-targets for eventual treatment
    Many patients have overlapping phenotypes.
    Intermittent; Persistent
    Atopic (extrinsic) vs. Intrinsic
    Exercise induced
    Aspirin sensitive
    Late Onset
    Infection induced (RSV; parainfluenza; adenovirus, rhinovirus)
    Cough variant asthma
    Steroid resistant
  • ASTHMA UPDATE
    ESTABLISH DIAGNOSIS OF ASTHMA:
    History, physical and PFT to establish there are symptoms of airflow obstruction and/or airway hyperresponsiveness;
    At least evidence for reversibility
    Value of history
    What are the triggers in the home?
    Outdoor triggers?-pollens, time of year
    What else triggers asthma- aspirin, NSAIDs, URI’s cold air exercise, forest fires, smoking; positioning, foods,
    Family history
  • ASTHMA UPDATE
    Differential diagnosis:co-morbidities
    GERD;
    vocal cord dysfunction;
    foreign body;
    anatomical abn;
    hypersensitivity bronchopulmonary aspergillosis;
    Chronic sinusitis
    Churg’s syndrome;
    Samter’s syndrome;
    Cystic Fibrosis
    bronchiectasis;
    sleep apnea with aspiration;
    occupation and hobbies (birds);
    wheezing” with COPD
  • ASTHMA UPDATE
    PHYSICAL EXAM:
    Nasal exam- polyps
    Level of wheezing (high, low)
    High level over trachea: consider vocal cord dysfunction
    Hyperexpansion of chest
    Signs of chronicity i.e.(clubbing); consider bronchiectasis, COPD, C.F.
    Signs of hypoxemia (cyanotic nail beds)
    Lymphadenopathy or lack of with history of recurring respiratory infections (consider ID workup)
    Keep in mind undiagnosed adult CF (sweat test is not useful in adults)
  • ASTHMA UPDATE
    LABORATORY EVALUATION:
    r/o Atopy: skin tests properly applied and interpreted;
    Properly performed PFT pre and post BD
    PEF > FEV1; Expiration plateau for at least 6 seconds
    Reproducibility with BD- at least 2 measurements with FEV1 within 0.15 L.
    Reversibility in adults: >250 ml; FEV1> 12% or
    > 10% increase of pred FEV1% for adults. Later may separate COPD from asthma. May need oral steroids for reversibility.
    FEV1/FVC% should be included for children .
  • ASTHMA UPDATE
    Laboratory evaluation:
    • Other PFT:
    • Inspiratory loop for VCD
    • Methacholine challenge
    • Nasal exam/endoscopy- polyps; sinusitis;VCD
    • Chest Xray/ CT of chest on rare occasion
    Sinus CT
    Trial with protonics as a diagnostic tool (pH studies)
    Consider bronchoscopy and lung biopsy for difficult to diagnose and/or treat.
  • ASTHMA UPDATE
    NIH Guidelines: asthma classification
    Initially severity assessment:
    Based on medication usage; history of recent exacerbations, PFT; night time awakenings; persistent or intermittent.
    Initial Rx based on classification of severity
    Manage based on control of symptoms i.e. more functional emphasis:
    Use of rescue meds
    Night time awakenings
    Exacerbation rate
    Objective parameters –PFT; NO measurements
  • ASTHMA UPDATE
    Goals of Therapy
    Reduce impairment (current)
    Prevent troublesome symptoms (cough, breathlessness with exertion and at night)
    Reduce frequent use of SABA to < 2 days a week
    Maintain near normal PFT
    Maintain normal activity
    Reduce risk (future)
    Exacerbations
    Prevent ER visits and hospitalizations
    Prevent loss of lung function; children-prevent reduced lung growth
  • Managing asthma needs brains !
  • UPDATE ON ASTHMA
    Therapeutic Strategies to Improve Control:
    Education: preferably by experienced or certified asthma educator:
    Peak flows- setting parameters of when to call.
    Awareness of questions to ask: nocturnal awakenings, use of rescue meds.
    Asthma treatment plan: what to do when sx develop.
    How to use medications and when- very important
    Compliance checks
  • ASTHMA UPDATE
    Environmental & Personal Health Strategies
    Eliminate tobacco smoke ( in utero and passive)
    Associated with severity and dec. response to steroid Rx.
    Air pollution- forest fires
    Wood burning stoves
    Use of air purifier (HEPA) especially near open windows during pollen seasons
  • UPDATE ON ASTHMA
    Environmental & Personal Health Strategies
    Encourage breast feeding up to 6 months to minimize food allergy induction
    Home environmental control
    Individualize recommendations for aerobics in cold weather and during peak pollen counts.
    Speculative HYGIENE THEORY but worth noting:
    early exposure to daycare; rural environment; early exposure to animals- Favor immune responses away from allergy development;
    antibiotic use; Western lifestyle- Favor immune responses towards allergy responses.
  • UPDATE ON ASTHMA
    Environmental & Personal Health Strategies
    Control co-morbidities that can increase asthma:
    Allergic rhinitis/sinusitis –studies demonstrate that regular use of nasal steroids and/or AH reduce asthma flares and ER visits
    GERD- use of protonics decreases asthma.
    Obesity-dieting is important
    Leptin increases in obesity: inc. IgE sensitization
    Adiponectin decreases in obesity: enhancing remodeling and increased inflammation.
    CPAP for sleep apnea can help control obesity, aspiration
    New concerns: overuse of vitamins, folic acid in pregnancy may be increase incidence of asthma: based on mice studies.
  • ASTHMA UPDATE
    MONITORING ASTHMA TO ASSESS CONTROL:
    Symptom retrieval- ACT
    Spirometrics- frequency
    Other Monitoring Parameters
    Peak flow measurements
    Sputum Eosinophils
    Nitric Oxide and pH Measurements on Exhaled Air
  • ASTHMA UPDATE
    Sputum eosinophils : correlates with inflammatory response but impractical
    NO produced by epithelial and alveoli cells. Correlates with eosinophil bronchial lavage studies
    Many convincing studies that suggest NO can be used to reflect status of eosinophilic inflammation in asthma.
    May be best used as a compliance check with inhaled steroids.
  • ASTHMA UPDATE
    Medications:
    Rescue medications and long term beta agonists:
    Controversy re’ LABA. New data supports use with ICS.
    Xopenex® vs. albuterol
    Inhaled corticosteroids- reduced decline in lung function (FEV1)
    Mometasone and ciclesonide –both have minimal or no bioavailability (absorption)
    Dynamic dosing- use of ICS as a burst to treat exacerbations in well controlled asthma patients and normal lung function
  • ASTHMA UPDATE
    TARGETED THERAPY:
    IgE- anti-IgE (Xolair)
    Leukotrienes (anti-leukotrienes – Singulair; Zyflo
    Trials with Anti-IL-5- reduce eosinophils
    Anti- IL-4 trials-reduce IgE
  • ASTHMA UPDATE
    • Monoclonal anti-IgE (Xolair)
    Must be used for difficult to manage severe and persistent asthmatics
    Resistant to high dose inhaled steroids
    Require oral steroids
    Must have IgE levels in a certain range
    Expensive
    Does it work –in some cases, noticeable reduction in exacerbations
    Side effects-anaphylaxis-very rare but requires close observation for 2 hours after dose.
    Leukotriene modifiers:
    Montelukast ( prevents exercise induction up to 24 hrs- single dose)
    Zyflo ( aspirin sensitive asthmatics)
  • ASTHMA UPDATE
    Approaches Based on Hygiene Theory
    Shifting Th2 to Th1 to modify asthma. The shift to Th1 induces IL-2 and IFN critical in defense against infection
    Alter balance between Th1 and Th2- towards Th1 by immunotherapies
    SLIT vs. SCIT
    Factors favoring Th1:
    Older siblings; early exposure to daycare; rural environment; certain infections (TB, measles, hep A); early exposure to animals;
    Factors favoring Th2:
    Antibiotic use; Western lifestyle; urban environment; diet; house dust mite and cockroach sensitization; RSV
  • Potential Treatments for Acute Asthma
    B-agonists
    Corticosteroids
    Oxygen
    Intubation & Mechanical Ventilation
    Methylxanthines
    Ipratropium Bromide
    BiPAP
    Heliox
    MgSO4 Infusion
    Mucolytics
    Chest Physical Therapy
    Aggressive Hydration
    Antibiotics
    Inhalational Anesthetics
    ECMO
    Inhalational Furosemide
    Inhalational MgSO4
  • Methylxanthines (Theophylline)
    Used for over 50 years to treat asthma
    Poorly understood mechanism of action
    Physiologic effects thought to include bronchodilation, stimulation of diaphragmatic contractility, mucocilliary clearance, and possibly some anti-inflammatory effect.
    Dose related toxicities include nausea, vomiting, headache, CNS stimulation, seizure, hematemasis, hyperglycemia, and hypokalemia
  • Bottom Line on Methylxanthines
    "theophylline/aminophylline is not recommended because it appears to provide no additional benefit to optimal inhaled B2-agonist therapy and may increase adverse effects.”
    Use after admission remains controversial
  • Ipratropium Bromide
    A synthetic anticholinergic compound
    Anticholinergic compounds are known to cause bronchodilation
    Atropine has been used, but often limited due to side effects such as tachycardia, dry mouth, disturbances of visual accommodation, etc.
    Ipratropium thought to be relatively free of side effects, but with preservation of bronchodilatory properties
  • Ipratropium Bromide Bottom Line
    Small, early studies tend to favor its use
    More recent, larger studies fail to find benefit
    Given ipratropium’s relative lack of toxicity, one “safely” can use it
  • Noninvasive Positive-Pressure Ventilation (BiPAP)
    Literature is extensive in treatment of COPD, but sparse in treatment of acute asthma
    Studies using CPAP in asthma have shown it to improve symptoms, but not gas exchange
  • BiPAP
    BiPAP theoretical benefits:
    Decreased work of breathing (and CO2 production)
    Ameliorating large negative intrapleural pressures and accompanying potential for hemodynamic compromise
    Bronchodilation with decreased airway resistance (due to “splinting” airways open with air pressure)
    Improved delivery of inhalational medication
    Problems include:
    Discomfort with facemask and pressure apparatus
    Requires very close observation by trained personnel
  • BiPAP Bottom Line
    Little evidence to guide us
    Existing evidence seems to support its use
    Given few known risks with an attempt, would consider BiPAP in patients refractory to conventional therapy (B-agonists and corticosteroids), or facing impending intubation
  • Magnesium Sulfate (Infused)
    Mechanism of action not well understood but may inhibit bronchial smooth muscle contraction by inhibiting intracellular influx of calcium
    Side effects are dose and rate related:
    facial warmth, flushing, decrease in BP, sweating, nausea, emesis, CNS effects (including coma)
  • Bottom Line on MgSO4
    Lower doses (2g in 20 min) well tolerated but probably only helpful in severe asthma if at all
    Weak evidence that higher doses (2g in 2 min or 10-20 g in 1 hour) more effective, but side effects may be more of a problem
    Doses on the order of 2g in 2 min shown to be safe in obstetrical literature
  • Heliox
    As described by Gluck: “Helium-oxygen mixtures improve ventilation by reducing the Reynolds number and reducing density dependent resistance. Helium’s beneficial effects are due to its high kinematic viscosity, high binary diffusion coefficient for CO2, and high diffusivity.”
    In English: Helium flows through airways more “easily” that nitrogen, decreasing work of breathing
    Not thought to directly promote bronchodilation
  • Heliox: an Ethereal Treatment
    Few clinical trials mostly consisting of case series, uncontrolled studies, and some pediatric literature
    No “definitive” study, but seems to be a consensus in the literature supporting its use in some cases - particularly severe asthma
  • Heliox Bottom Line
    Little available evidence
    May be helpful (at least in very severe asthma) in “buying time” until other treatments become effective
    Use unlikely to cause harm unless it delays other necessary treatment such as B-agonists or necessary intubation
  • The Bottom, Bottom Line
    B-agonists and corticosteroids remain the mainstay treatments for asthma exacerbation
    Methylxanthines not helpful acutely, but may play a role subacutely and/or in chronic management
    Ipratropium Bromide not harmful, may help
    BiPAP and Heliox may spare a patient from more morbid treatments such as intubation
    MgSO4 is without good evidence of benefit, but high doses may be helpful in severe asthma
  • ASTHMA MEDICATIONS
    Beta2-Agonists
    • Injected
    • Short-acting inhaled
    • Long-acting inhaled
    Corticosteroids
    • Inhaled
    • Systemic (oral)
    Leukotriene Modifiers
    Methyl Xanthines
    Cromolyn and Nedocromil
    Anticholinergics
  • COMORBID INFECTIONS
    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.
  • RECOMMENDATION
    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.
  • 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
  • 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 STEROIDSCOMMON 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
  • Keep asthma medicine cool !
  • Ciclesonide
    Newest ICS (About 5 years in use)
    Small airways effect
    High level of efficacy of available ICS
    Safety profile
    Does not affect circadian rhythm
    High degree of serum protein binding
    Rapid clearance rate; reduced systemic effect
  • CIC
    • OPTIMAL EFFICACY
    • MINIMAL SYTEMIC ABSORPTION
    • LOW SIDE EFFECTS
    • RETENTION IN LUNG
    • DISTRIBUTION IN LYPOPHILLIC TISSUE OF THE LUNG, SLOW ABSORPTION , PROLONGED HALF LIFE
  • LONG ACTINGBETA2-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
  • Children and allergy in asthma
  • METHYLXANTHINES
    Theophylline used very little now and requires blood level monitoring
  • 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
  • Other Drugs
    Surfactant Replacement Therapy
    New anti-inflammatory Agents
    Inhaled antibiotics
    Anticytokine Agents
    Protease inhibitors immunomodulators
  • Anti-IgE
    Recombinant humanized monoclonal antibody to treat persons over 12 years with moderate to severe asthma
    -Omalizumab - Xolair
    -Inhibits binding of IgE to receptors on mast cells and basophils
    -Prevents the release of mediators of allergic response that cause bronchospasm
    -Given subcutaneously q 2-4 weeks, very expensive but effective in reducing hospital visits and steroids use.
  • Special AdministrationTechniques
    Devices used to deliver aerosol medication
    -MDI
    -Jet Nebulizer
    -UItrasonic Nebulizer
    -Dry powder inhaler
    -Spacer
  • Inhalation devices
  • CONSEQUENCES OF POOR ASTHMA CONTROL
    Social economic waste that is preventable
    Loss in school/job absenteeism
    High morbidity
    Marginalization of Asthmatics in life
    Family life disruption (divorces and single mother hood)
    All ADDS up to poor quality of life and early demise
  • Barriers to asthma medication
  • BARRIERS IN ASTHMA
    Patient
    Healthcare system
    Health care provider
    environmental
  • BARRIERS IN ASTHMA
    Patient
    Varying cultural issues
    Complex treatment regimen
    Fear of medication
    Poor adherence – side effects of mediation – poor coping
    Embarrassment over asthma
    Low – income – lack of resources
    Lack of appreciation of severity of asthma
  • BARRIERS IN ASTHMA
    Health care provider
    Busy with other respiratory disease
    Attitude: misdiagnosis and under diagnosis
    Training and knowledge
    Managing acute attacks rather than long term control
    Limited time to give asthma education
    Lack of awareness of existence of clinical guidelines
  • BARRIERS IN ASTHMA CONT’
    Health care system
    Geographical
    Poor infrastructure
    Availability of drugs
    Low public health
    Priorities (TB/HIV malaria
    Private versus public
    Cost of hospital visits
  • BARRIERS IN ASTHMA CONT’D
    Environmental factors
    School
    Home
    Workplace
    Tobacco – smoke
    Urbanization - pollution
  • BARRIERS IN ASTHMA CONT’D
    Effects of barriers
    Socio-economic
    Frequent symptoms
    Severe symptoms
    More emergency room visits
    More absenteeism
    Frequent hospitalization
    Higher mortality
  • The challenges of asthma management
    Over-reliance on rescue medication1
    Suboptimal control1
    Poor adherence to maintenance therapy1
    Complexity of current treatments1
    Lack of education and understanding among patients1
    1FitzGerald JM, et al. Can Resp J 2006;13:253–259;2Harrison TW, et al. Lancet 2004;363:271–275.
  • THANK YOU FOR YOUR KIND ATTENTION