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Pharmacological Management of Asthma

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Pharmacological Management of Asthma

  1. 1. Pharmacological Management of Asthma Ellen Nicholson Queens Nurse City & Hackney GP Confederation November 2016 DISCLAIMER: The views and opinions expressed in this presentation are those of the authors and do not necessarily represent the views and policy of PLAN(Pan London Airways Network).
  2. 2. WHAT THIS PRESENTATION COVERS Background Key priorities Discussion
  3. 3. DECLARATIONS OF INTEREST Received education for professional advisory boards/speaking from Teva, Boehringer Ingelheim and Novartis Committee member of NICE Asthma Management Guidelines consultation publication 19/12/2016 Member of Association of Respiratory Nurse Specialists and Primary Care Respiratory Society
  4. 4. NATIONAL REVIEW OF ASTHMA DEATHS (NRAD) C O N F I D E N T I A L E N Q U I R Y I N T O > 2 0 0 A S T H M A - R E L A T E D D E A T H S K E Y F I N D I N G S I N C L U D E D : F R E Q U E N T S U B - O P T I M A L I C S / P O S T E R O I D T R E A T M E N T E X C E S S I V E U S E O F S A B A L A C K O F R E F E R R A L T O S P E C I A L I S T S E R V I C E S P O O R L Y R E C O R D E D P U L M O N A R Y F U N C T I O N T E S T S W I T H I N T H E C O M M U N I T Y G E N E R A L L A C K O F P A A P U S E Levy et al., 2014
  5. 5. Presentation with respiratory symptoms: wheeze, cough, breathlessness, chest tightness 1 High probability of asthma Code as: suspected asthma Initiation of treatment Assess response objectively lung function/( validated symptom score) Good response Asthma Adjust maintenance dose. Provide self- management Arrange on-going review Intermediate probability of asthma Test for airway obstruction spirometry + bronchodilator reversibility Suspected asthma: Watchful waiting (if asymptomatic) or Commence treatment assess response objectively Good response Other diagnosis confirmed Investigate/treat for other more likely diagnosis Other diagnosis unlikely Low probability of asthma Poor response Poor response Options for investigations are: Test for variability: • reversibility • PEF charting • challenge tests Test for eosinophilic inflammation or atopy: • FeNO • blood eosinophils, • skin-prick test, IgE Structured clinical assessment (from history and examination of previous medical records) Look for:  recurrent episodes of symptoms  recorded observation of wheeze  symptom variability  personal history of atopy  absence of symptoms of alternative diagnosis  historical record of variable PEF or FEV 1
  6. 6. Pharmacological Management
  7. 7. APPROACH TO MANAGEMENT Start treatment at the level most appropriate to initial severity. Achieve early control. Maintain control by: increasing treatment as necessary decreasing treatment when control is good.
  8. 8. NEW BTS GUIDELINES Stepwise approach replaced by regular preventer and add on approach. This highlights short acting beta2 agonists are key ‘rescue therapy’ from symptoms or asthma attacks but should rarely be used on their own
  9. 9. BTS GUIDELINES High probability of asthma: start initiation of treatment (typically 6 weeks of inhaled corticosteroids) Reasses with a validated symptom questionnaire and/or lung function tests (FEV1 or home serial peak flows Good symptomatic response to treatment - confirm diagnosis of asthma Record how the diagnosis was made Poor response or equivocal, check inhaler technique and adherence, arrange further tests and consider alternative diagnoses.
  10. 10. INTERMEDIATE PROBABILITY OF ASTHMA Spirometry, with bronchodilator reversibility is preferred test Initiate treatment and assess the response by repeating lung function tests and objective measures of asthma control. In adults and children with an intermediate probability of asthma and normal spirometry results; Challenge tests FeNO to identify eosinophilic inflammation.
  11. 11. E O S I N O P H I L S Elevated sputum eosinophil predict asthma exacerbations and responsiveness to ICS. Patients with blood eosinophil counts greater than 400 cells per μL experience have more severe exacerbations and have poorer asthma control. Price et al (2016) UK Cohort Study F E N O Raised eosinophil counts and exhaled nitric oxide (FeNO) are biomarkers of Th2 immune responses FeNo value in patient >12 years Low <20 ppb Intermediate 20-50 ppb High > 50 ppb In case of >40 ppb increase from previous stable levels interpret as high Schneider (2015) et al
  12. 12. LOW PROBABILITY If there is a low probability of asthma and/or an alternative diagnosis is more likely, investigate for the alternative diagnosis and/or undertake or refer for further tests of asthma. BTS 2016
  13. 13. SHORT ACTING ß2 AGONISTS  Side Effects: Fine tremor Tachycardia Hypokalaemia Restlessness Hypoxaemia  Cautions: Hyperthyroidism Cardiovascular disease Arrhythmias Susceptibility to QT-interval prolongation Hypertension Alleviate breathlessness by their direct affect on the airway by relaxing smooth muscle But they also: ↓ pulmonary hyperinflation ↑ mucociliary clearance Improve respiratory muscle function
  14. 14. BTS 2016
  15. 15. CHOICE Choice of drug (s) should take into account person’s - Preference to device - Symptomatic response - Ability to use the inhaler device effectively - Drugs potential to reduce exacerbations - Minimise side effects - Cost
  16. 16. INHALER TECHNIQUE  Optimal inhaled particle deposition  requires a forceful inhalation for DPIs and a gentle inhalation for pMDI inhalers Bud60 Bud35 0 10 20 30 40 50 % Lung Deposition Insp Flow l/min Lung deposition of budesonide inhaled via Turbuhaler®: a comparison with terbutaline sulphate in normal subjects. Borgstrom et al. 1994 Acknowledgement Paul Pfeffer
  18. 18. Supress inflammatory/immunological responses & mitigate against airway hyper- responsiveness It takes 1-4 weeks before the benefit of Introducing/up-titrating ICS is apparent A high level of drug deposits within the mouth and throat Oral candidiasis occurs as a consequence of this. Rinsing the mouth after may reduce the risk of oral opportunistic infection Battaglia et al., 2014
  19. 19. BTS emphasise preventer medication to minimise future asthma attacks Add on therapy recommend combination inhaler (ICS/LABA) If a patient has poor control of their asthma, it is essential to check whether they are using their current drug treatment correctly and regularly, before stepping up treatment
  20. 20. LEUKOTRIENE RECEPTOR AGONISTS Leukotrienes are inflammatory mediators produced by leukocytes which contribute to bronchospasm and airway hyper-responsiveness BTS recommend as add on therapy after Combination inhaler Example drugs include: Montelukast, Zafirlukast
  22. 22. MAINTENANCE AND RELIEVER THERAPIES (MART) Maintenance and Reliever Therapies are designed for adults (aged 18 or over). Evidence suggests MART reduces exacerbations, hospitalisation and SABA use Symbicort SMART Regime Fostair MART Regime DuoResp Spiromax MART Regime.
  23. 23. pMDI DPI OD MART Step 1 Step 2/3 Step 3/4 ‘Inhaler Tree’ – Acknowledgement to Dr. Paul Pfeffer
  24. 24. MULTIPLE INHALERS CONFUSE ASTHMA PATIENTS Study of 208 patients with a single inhaler type and 113 with multiple inhaler types. 29% error rate in patients with a single inhaler type 39% of patients with multiple inhaler types made significant errors. 32% error rate in patients with multiple DPI types. 46% error rate in patients with a pMDI and a DPI van der Palen et al. ERJ 1999
  25. 25. Theophylline family of drugs e.g. Aminophylline, Theophylline, Phyllocontin Continus (SR) Inhibits the phosphodiesterase enzyme causing relaxation of the bronchial smooth muscle and bronchodilation Narrow therapeutic window – readily toxic (requires monitoring). Slow release drugs may be prescribed to treat poorly controlled asthma (step 4) Can be administered intravenously to terminate acute bronchospasms refractory to nebulised bronchodilators METHYLAXANTHINES
  26. 26. MUSCARINIC ANTAGONIST Onset of action is slower than ß2 agonists  Approx 30mins Bronchodilator effects longer Side effects:  Dry mouth  Blurred vision  Paradoxical bronchospasm  Glaucoma – care with nebulisers T I O T R O P I U M R E S P I M A T ( S P I R I V A ® )Once daily LAMA Indication: maintenance bronchodilator in adult patients with asthma Dose: 2.5mcg TT puffs BD
  27. 27. Omalizumab Indicated as an add on therapy to improve asthma control in adult and adolescent patients (12 years and above) with severe persistent allergic asthma which is not controlled on optimised BTS step 5 therapy NICE Technology appraisal (TA278) April 2013 Mepilizumab A targeted anti IL-5 therapy for adult patients with severe refractory eosinophilic asthma Humanised monoclonal antibody which inhibits the bioactivity of the cytokine interleukin (IL-5)
  28. 28. FEVIPIPRANT Between 2012 and 2013, study carried out by University of Leicester/University of Oxford in the UK, and Novartis in Switzerland. RCT 61 participants received either fevipiprant tablets 225mg bd or a placebo for 12 weeks. Fevipiprant gave greater reduction in eosinophil count compared with placebo. Mean percentage of eosinophils in sputum decreased from 5.4% to 1.1%. It decreased in the placebo group from 4.6% to 3.9%. Gonem et al 2016. Lancet Volume 4. No 9, p699–707, September 2016
  29. 29. MONITORING AND FOLLOW UP Flo-tone device In-check dial
  31. 31. PAAP & ASTHMA REVIEW Triggers should be documented in patient notes and on asthma action plan Each review should review asthma control (asthma control test etc.) Ring et al., 2011 Gibson & Powell, 2004 Newell et al. 2015 Inhaler techniques should be routinely undertaken Non-adherence should be identified and monitored Urgent review for all with more than 12 short-acting beta agonist inhalers in previous 12 months
  32. 32. WEIGHT LOSS Weight loss initiatives – including dietary and exercise programmes – can be offered for overweight or obese adults and children with asthma and may improve their asthma control
  33. 33. PREGNANCY Women with asthma who are pregnant should be informed of the importance of continuing their asthma medication during pregnancy for the health of both mother and baby
  34. 34. LONG ACTING ß2 AGONISTS The Asthma UK report published in June 2015 ‘Patient safety failures in asthma: the scale of unsafe prescribing in the UK’ identified 22,840 people prescribed a LABA or LAMA without ICS 106,742 people prescribed more than 12 short-acting bronchodilators a year Representing 0.4% and 2% respectively of the total 5.4 million people receiving treatment for asthma. It is dangerous to use a long-acting reliever inhaler without a steroid preventer inhaler
  36. 36. SUMMARY Use inhaler device that patient is able to use Try to avoid generic prescribing Consider if diagnosis is correct if treatment is not reducing side effects or onwards referral Everyone with an asthma diagnosis should have a PAAP