New therapies for asthma 2013 Edward Omron MD, MPH

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A simple discussion of asthma for those individuals newly diagnosed, pregnancy and asthma, and difficult to treat asthmatics with new therapies 2013. This presentation is for non-health care professionals.

Edward Omron MD, MPH, FCCP
Pulmonary Medicine Specialist
Morgan Hill, CA 95037
www.docomron.com

Published in: Health & Medicine
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New therapies for asthma 2013 Edward Omron MD, MPH

  1. 1. Edward Omron MD, MPH, FCCPPulmonary, Critical Care, and Internal MedicineMorgan Hill, CA 95037408-778-0022deepbreath@docmron.comwww.docomron.com
  2. 2.  Reversible inflammatory lung disease The airways of the lung are swollen andnarrowed resulting in “wheezing” Recurrent cough, chest tightness, shortnessof breath, and exercise limitation Symptoms worsen withexercise, infection, changes in weather, orat night. Can occur at any age or gender
  3. 3. Beta2 receptors lie within airway smooth muscleAlbuterol causes the muscle to relax and the airway to dilate
  4. 4.  In 2009, 25 million Americans had asthma◦ Of these 13 million have had an asthma attack In 2007 there were 3500 deaths fromasthma◦ 63% of these deaths occurred in women The prevalence of adult asthma in CA 2009is 8% Asthma accounts for 50 billion health caredollars yearly
  5. 5.  Evidence of airway disease and an objectivemeasure of airway function i.e. spirometry Wheezing, cough, tightness, shortness ofbreath are commonly reported Just because you wheeze doesn’t mean youhave asthma!◦ A diagnosis of asthma may last a lifetime and mayhave unintended consequences!◦ May sure the clinician verifies the diagnosis beforeinitiating therapy
  6. 6.  Pattern of symptoms◦ Episodic vs continual; seasonal◦ Onset, duration and frequency (weekly)◦ Diurnal variations (Nocturnal) Aggravating Factors◦ Environmental allergens(mold, dust-mite, cockroach)◦ Occupational chemicals Family History Nasal Polyps Runny nose/congestion/heartburn
  7. 7.  Blood Tests◦ CBC with differential◦ IGE level in some patients Region 14 Respiratory Allergy Profile fornorthern California Allergic Asthma◦ Diagnose suspected IgE antibody-mediatedrespiratory reactions◦ This test includes total IgE and 23 ImmunoCapspecific IgE allergens◦ Bermuda grass, birch, cat epithelium anddander, cockroach, common ragweed, dustmite, dog dander, and mold (Alternariaalternata, Aspergillus fumigatus)
  8. 8.  Asthma◦ Clinical Suspicion◦ Airway muscle spasm “hyperreactivity” All patients should undergo spirometry◦ Be careful of office based spirometry in primarycare offices!◦ Normal Spirometry does not exclude the diagnosis◦ Methacholine bronchoprovocation to confirm◦ Exercise challenge and testing in some cases
  9. 9.  Not using medications correctly or unmotivated Diagnosis wrong or secondary diagnosis Secondary Gain steroid resistant Asthma phenotypes STOP SMOKING Approach◦ Repeat spirometry and peak flow log◦ Cardiopulmonary exercise testing◦ Bronchoscopy◦ High resolution CT of chest◦ Immunologic markers
  10. 10.  Pulmonary Specialist Referral◦ Initially to confirm the diagnosis◦ ALWAYS after life threatening asthmatic attack◦ Exercise limitation not improving therapies◦ Pregnant patients with asthma◦ Other conditions complicate asthma(e.g., sinusitis, severe rhinitis, VCD, GERD)◦ Patient is being considered for immunotherapy◦ Occupational asthma evaluation
  11. 11.  Most common potentially serious medicalproblem in pregnancy: 8% of pregnantwomen Higher risk of complications to includepreterm birth, low birth weight, congenitalmalformations, and perinatal death Pregnancy may affect the course of asthma Treatment reduces risk to both mother andinfant Choice of medications is key to preventadverse effects on the fetus
  12. 12.  Shortness of breath in pregnancy◦ Normal as gestation evolves◦ Asthma, reflux, postnasaldrip, bronchitis, pulmonaryembolism, cardiomyopathy◦ NO smoking◦ Pregnancy class B medications Budesonide (inhaled steroid) Montelukast (leukotriene antagonist) Cromolyn puffer◦ Necessary pregnancy class C medication Albuterol inhaler or nebulized therapy
  13. 13.  There is no cure of asthma thus far in 2013 CONFIRM the diagnosis before anyaugmentation of treatment of regimens◦ Rule out vocal cord dysfunction◦ Cystic fibrosis◦ Pertussis infection◦ Reflux disease◦ Interstitial Lung Diseases Severe persistent asthma is a great challengeto both the patient and the physician
  14. 14.  Severe persistent asthmatics with allergiesand an elevated IgE antibody level IgE is an allergy antibody◦ It binds to allergens and causes the release ofinflammatory mediators which makes asthmaworse Xolair binds to IgE antibody and turns it off Reduced medication use, symptoms, andimproved quality of life Cost about $1500.00 monthly Monthly subcutaneous injections
  15. 15.  Severe asthmatics have excessive smoothmuscle in the airways BT is a non-drug procedure that reducesairway smooth muscle by applying heat tothe airways◦ This reduces the frequency of asthma attacks Three outpatient procedures performedthree weeks apart under sedation
  16. 16.  Severe exacerbations: 32% reduction Emergency Department Visits: 84%reduction Days missed from work or school: 1.3 vs3.9 days Asthma Quality of Life Score: BT 1.35 vs1.16 No significant adverse effects for up to 5years
  17. 17.  FDA Indication: approved for the treatmentof severe persistent asthma in patients 18years or older whose asthma is not wellcontrolled on inhaled corticosteroids andlong acting beta agonists Exercise limitation persists despiteaggressive inhalational and oral therapeuticagents.
  18. 18.  http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm http://www.thoracic.org/education/breathing-in-america/resources/chapter-3-asthma.pdf NEJM 2006;35:2689-2695 NEJM 2009; 360: 1002-1014 Am J Respir Crit Care Med 2012; 185: 709–714 Lancet 2012; 380: 651-659 NEJM 2009; 360: 1862-1869

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