Asthma in general practices

1. Why asthma
is good
for your practice
Dr. Sujeet Rajan
Respiratory Physician
Bombay Hospital Institute of Medical Sciences

2. Great
opportunity
Easy
opportunity

3. 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 )

4. The 4 keys to
successful asthma practice
“Is it asthma?”
Just a few questions in
a few minutes
1

5. The 4 keys to
successful asthma practice
Treating the disease
2
Not much time
……..and easily.

6. The 4 keys to
successful asthma practice
Making things simple for
your patient
3
Child’s play
Low cost

7. The 4 keys to
successful asthma practice
Saying the right things
Answering patients’
questions
“Jo bolega, karega”
4

8. Which secret do you
want to unlock?
1. “Is it asthma?”
2. Treating the disease
3. Making things simple
4. Saying the right things

9. Diagnosis:
Why make it ?
 The patient has alternatives
(if you don’t, someone else will !)
 Excellent prognosis, esp. in children
 Treatment is so simple

10. Do I need a lot of tests?
Nothing usually, besides a
sharp history

11. 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 ?

12. 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 ?

13. 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)

14. What questions or
statements …
 Does anyone else in your family
suffer from any allergies ?
Ask about:
skin allergies
eczema
frequent colds
‘bronchitis’

15. What questions or
statements …
“I get relief with this medicine.”
Ask: which medicine?
(always check for bronchodilator)

16. Diagnosis in children
 Commonest cause of a persistent
cough is asthma
 Cough after exercise, activity, play
 Vomiting
 Failure to thrive
( poor sleep, poor growth )

17. When do you need lung
function tests ?
 Spirometry ( 250 to 350 rupees )
 To re-confirm the diagnosis
 When in doubt
 Normal Spirometry ( Challenge tests )

18. Things the patient may
not tell you …
Stigma and discrimination
from a “word”
Work/school absenteeism
Marital discord
Travel & holidays ‘controlled’

19. Other ‘advice’ the patient gets
Grandparents/neighbours/ ‘friends’ –
Inhalers ???
Steroids ???

20. Make the diagnosis but
emphasize the prognosis
Instead of asthma controlling your
patient,
the patient can control asthma

21. 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 !

22. Asthma Disease:
Spasm and swelling
 Spasm needs a reliever
Bronchodilator
 Swelling needs a contoller
Anti-inflammatory

23. Two types of drugs:
Reliever & Controller
Reliever
Bronchodilator (beta2 agonist)
Quickly relieves symptoms
(within 2-3 minutes)
Not for regular use

24. Reliever …
Inhaled
Nebulised
Oral
Most of the time
For severe attacks;
administer at your
clinic/hospital
Rarely needed

25. 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

26. 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

27. WHAT HAPPENS WHEN YOU
DON’T TREAT ASTHMA WELL
Normal
Inflamed
(Asthma)
Partly Treated
Fixed Obstruction
(Lead Pipe)
Remodelled
Airway

28. What is changing the lives
of our asthma patients
today?
Inhaled steroid

29. THE STORY OF ASTHMA
TREATMENT
Normal Inflamed (untreated)
Regular
Inhaled
Steroid
Partly
Treated

30. 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

31. 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)

32. 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

33. 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

34. 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

35. Inhaled Steroids Not
Working ?
Add SR
theophylline
Check Inhaler
Technique /
Check Regular Use
Add LABA
Formoterol /
Salmeterol
Increase dose
of inhaled
steroid
Add Leukotriene
modifier

36. Leukotriene Modifiers
 Oral anti-inflammatory
 Not as effective as inhaled steroid
 First-line for 2 to 5 yr. olds.
 All your ‘regular’ bronchodilator users.

37. Theophylline
 Sustained release for regular use
 Inexpensive , but toxic
 Not more than 600 mg per day usually
 Weak bronchodilator, but A-I effects

38. Add-on drugs : ICS + ?
1. Long acting Beta²-agonist ( LABA )
2. Montelukast
3. SR Theophylline

39. ICS + LABA
 Which ICS ?
Budesonide: Once daily
Even children < 4 years
Safe for long term use

40. ICS + LABA
Which LABA ?
Formoterol: Immediate relief (as fast as
salbutamol)
12 hours effect
Can be combined with
budesonide

41. Ideal combination
Formoterol ( fast relief and
sustained relief ) +
Budesonide ( twice or even
once daily use )
Dose: 1- 4 puffs ( OD/BD )

42. Can be used for relief as
well as control
FORACORT

43. 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.

44. Oral Steroid
 Prednisolone
 Acute severe episodes
(20-60 mg/day “burst”
along with bronchodilators)
 Dispense preferably
 Steroid-dependent asthma

45. Steroid-Dependent Asthma
A patient who requires regular
oral corticosteroids for control of
his/her asthma

47. 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

48. Which inhaler?
Inhalers
MDI DPIs Nebuliser
(acute severe
episodes only)

49. Scope for Inhalation
Therapy highest in a child
 < 5 yrs - High incidence of
wheezing
 Parents want the best for
their child

50. 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

51. Child below 3, or adult over 85
 MDI + Spacer
 MDI + Spacer + Baby Mask
When can you not use a
Rotahaler ?

53. 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 )

54. Then do we need nebulisers ?
– YES
 Acute severe asthma with impending
respiratory failure
 Intensive care / Hospital / Clinic /
Ambulances

55. 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

56. Call patient after 1 week
If much better
Taper or omit Prednisolone
Continue Foracort Rotacaps
for 2 months in same dose
Foracort Rotacaps SOS

57. Call patient after 1 week …
If not much better /
still needs salbutamol often
Check Rotahaler Technique
Check whether using Foracort
regularly

58. 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

59. Always check
 Inhaler technique
 Regularity of steroid use

60. 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)

61. 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

62. 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 )

63. The Breathe-o-Meter
like a thermometer for asthma
 Inexpensive clinic
instrument
 Monitoring
 Builds confidence in
treatment
 One ‘hard, fast blow’

64. The Breathe-o-Meter…
 First visit and follow-ups
 Improving symptoms
= improving peak flows
= improving confidence
 Rarely for home use

65. 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)

66. Examples
Myopics Spherical glasses regularly
Everyone Brushing teeth regularly
Obesity Diet & exercise regularly
Asthmatics Inhaled steroid regularly

67. Asthma management:
nothing specialist
about it
Dr. Sujeet Rajan
Respiratory Physician
Bombay Hospital Institute of Medical Sciences