Amr Badreldin Hamdy,MD FCCPProf of Pulmonary MedicineBanha University, EGYPTPulmonary ConsultantNEW CAPITAL MEDICAL CENTRE, ABU DHABI6/26/2013 3Amr Badreldin Hamdy MD FCCP
Is There A Cure For Asthma?Asthma cannot be cured, but it can beControlled“We should expect nothing less”!
In lay usage, “control” conveys thesense of being reined in or keptwithin certain boundaries.
The patient’s level of asthma controlrepresents the extent to which theclinical manifestations of asthmahave been removed or reduced bytreatment.
The goals of asthma treatment arerelating not only to the control ofpatient’s current symptoms, but alsoto the prevention of future adverseoutcomes, such as exacerbations, arapid decline in lung function andside-effects of treatment.
The assessment of asthma control fallsinto two broad categories:assessment of the current level ofclinical control and assessment offuture risk to the patient.
Asthma is a chronic inflammatory disorderof the airways.This causes an increase in airway hyper-responsivenessleading too Wheezingo Breathlessnesso Chest tightnesso CoughingGINA, 2002
Amr Badreldin Hamdy MD FCCPAsthma is one of thecommonest chronic diseasesworldwide and is increasing inchildren and probably also inadults.
Burden of Asthma The WHO has reported the annualcosts of BA exceed those of TB andHIV combined due to poor asthmacontrol and disease management.6/26/2013 Amr Badreldin Hamdy MD FCCP 12
Burden of Asthma-cont’dThe evaluation of asthma costsconsiders both direct costs(medication and treatment) andindirect costs (loss of school orworking days and decrease inproductivity).6/26/2013 Amr Badreldin Hamdy MD FCCP 13
Asthma: limits daily-life activities02040%ofpatients60Asia Pacific Europe USRabe et al. 2000; Fulbrigge et al. 2002; Lai et al. 2002
Amr Badreldin Hamdy MD FCCPWhile it is a worldwideproblem, the prevalence of thecondition seems to be higher inaffluent than non-affluentpopulations.
Amr Badreldin Hamdy MD FCCPUnder-diagnosis and under-treatment are major contributors toasthma morbidity and mortality.Long term preventive treatment isthe cornerstone of good asthmacontrol.
Amr Badreldin Hamdy MD FCCPPutting primary emphasis oncontrolling bronchial spasmrather than chronic airwayinflammation looks like “puttingthe cart before the horse”.
Amr Badreldin Hamdy MD FCCPEven following administration of oneof the many forms of asthmatreatment, up to 40% of adultsremain symptomatic, and up to 5%of cases are difficult to managedespite multiple forms of treatment.
Amr Badreldin Hamdy MD FCCPWhat Are Benefits Of LongTerm Preventive TreatmentOf Asthma?
Achieving asthma control is the focusof all recently developed asthmatreatment guidelines.
Amr Badreldin Hamdy MD FCCPThe goal is effective controlof asthma, which strives toensure that the asthmatic isable to lead a normal andphysically active life.
Current clinical control is assessed bydirect observation of the patient’scurrent or recent clinical status ontreatment.
Amr Badreldin Hamdy MD FCCPRemember!One must always considerthat the goal of total control ofasthma must be balancedagainst the cost and potentialadverse effects of asthmacontrol.
The assessment of asthma control has twocomponents: current clinical control(including symptoms, reliever use and simple“bedside” measures of lung function) andfuture risk of adverse outcomes (e.g.exacerbations, rapid decline in lung function,and side effects).
What is asthma control?As defined by the Global Initiative for Asthma (GINA), 2007oMinimal to no daytime asthma symptomsoNo limitations on activitiesoNo nocturnal symptoms or awakeningsoMinimal to no need for reliever or rescuetherapyoNormal lung function (FEV1 or PEF)oNo exacerbationswww.ginasthma.org
Exacerbations, by definition andclinical practice, are identified by achange from and return to previousstatus, i.e. by their time trend.
Exacerbations are events that aremore common in poorly controlledasthma but may occur at any level ofclinical asthma control.
What are the Key elements ofan Asthma Program?
Amr Badreldin Hamdy MD FCCPoEducation-motivation.oSelf assessment management.oEnvironmental management.oPharmacological management.
Amr Badreldin Hamdy MD FCCPIn the assessment ofasthma control, there areseveral important activitiesthat should be accomplishedduring the periodic visit forasthma:
Amr Badreldin Hamdy MD FCCP1. Assessment of psychosocialstatus.2. Assessment of adherence-compliance.3. Assessment of medicationuse and its side effects.
Amr Badreldin Hamdy MD FCCP4. Assessment of asthmatriggers.5. Review of written asthmaaction plan (as appropriate).6. Confirmation of asthmadiagnosis.
Amr Badreldin Hamdy MD FCCPA common misconception is thatasthma severity is considered“static”; namely, that once a patientis classified with a given severitylevel, it remains constant.Asthma symptoms are a dynamicand often a changing parameter.
Amr Badreldin Hamdy MD FCCPAsthma control can be expected tochange over time. It should beassessed at every clinical encounterfor asthma, and managementdecisions should be based on thelevel of asthma control.
Amr Badreldin Hamdy MD FCCPIf a patient has been stable on anasthma treatment program for aperiod of time, consideration shouldbe given to try “stepping down”therapy to a less intense level oftreatment plan.
Amr Badreldin Hamdy MD FCCPoFailure to agree to set a commongoal with the patients.oPatient resistance/objection toinhalation therapy.oPoor inhalation technique.oSteroid phobia.oWorry about excessive cost.
Key Goals in Patient EducationWith the help of the health-care team, patientscan learn to do the following:o Avoid risk factors.o Understand the difference between “reliever” and“controller” medications.o Monitor status using symptoms or PEFRo Recognize signs that asthma is worsening and takeaction.6/26/2013 Amr Badreldin Hamdy MD FCCP 39
Aims of asthma management, which if achieved,indicate overall asthma controloMinimal (ideally no) symptomsoMinimal (infrequent) exacerbationsoNo emergency visitsoMinimal (ideally no)PRN ß2-agonist useoNo activity restriction, including exerciseoPEF circadian variation less than 20%o(Near) normal PEFoMinimal (or no) adverse effects from medicinesGINA, 2002
Patients currently achievingcontrolNot Well-ControlledWell-ControlledOnly 5% of patientsachieve asthmacontrolRabe et al. Eur Respir J, 2000
CAUSES OF NONRESPONSIVEASTHMA6/26/2013 Amr Badreldin Hamdy MD FCCP 42
1. Wrong diagnosiso COPDo Bronchiectasis, Cystic fibrosis,o Inhaled FBo Recurrent aspiration.o Obliterative bronchitis.o Tumors involving the central airway.o Tracheobronchomalacia.o Vocal cord dysfunction.6/26/2013 Amr Badreldin Hamdy MD FCCP 43
2. Poor Adherence To Therapyo Patient related.o Drug related.6/26/2013 Amr Badreldin Hamdy MD FCCP 44
Do we really avoid the triggers?6/26/2013 Amr Badreldin Hamdy MD FCCP 51
Can We Control His Asthma?6/26/2013 Amr Badreldin Hamdy MD FCCP 52
How to Avoid Pollution?6/26/2013 Amr Badreldin Hamdy MD FCCP 53
Pest Elimination6/26/2013 Amr Badreldin Hamdy MD FCCP 54
Pollen Elimination6/26/2013 Amr Badreldin Hamdy MD FCCP 55
Asthma and Exercise6/26/2013 Amr Badreldin Hamdy MD FCCP 56
Asthma and Fumes, Odors andStrong Scents6/26/2013 Amr Badreldin Hamdy MD FCCP 57
Adherence6/26/2013 Amr Badreldin Hamdy MD FCCP 58
Adherence DefinitionIt is a the extent to which a person’sbehavior-taking medication, followinga diet, and/or executing lifestylechanges, corresponds with agreedrecommendations from a health careprovider.Rand CS. AJ Cardiology; 1993,72.6/26/2013 Amr Badreldin Hamdy MD FCCP 59
Adherence IncidenceIn developed countries, adherenceto long-term therapies in thegeneral population is around 50%and is much lower in developingcountries.6/26/2013 Amr Badreldin Hamdy MD FCCP 60
Evidence shows that adherencerates for the regular taking ofpreventive therapies are as low as28% in developed countries.Reid D et al., Respirology, 2000,5.6/26/2013 Amr Badreldin Hamdy MD FCCP 61
Rates of non-adherence amongpatients with asthma range from 30%to 70%, whether adherence ismeasured as percentage of prescribedmedication taken, serum theophyllinelevels, days of medicationadherence, or percentage of patientswho failed to reach a clinicallyestimated adherence minimum.Bender B et al, Ann Allergy, Asthma, & Immunology, 1997,79.6/26/2013 Amr Badreldin Hamdy MD FCCP 62
Types of Non-compliance6/26/2013 Amr Badreldin Hamdy MD FCCP 63
oReceiving a prescription but not filling it.oTaking an incorrect dose.oTaking medication at the wrong times.oIncreasing or decreasing the frequencyof doses.oStopping the treatment too soon.oNon-participation in clinic visits.oFailure to follow doctor’s instructions.6/26/2013 Amr Badreldin Hamdy MD FCCP 64
o“Drug holidays”, which meansthe patient stops the therapy fora while and then restarts thetherapy.o“White-coat compliance”, whichmeans patients are compliant tothe medication regimen aroundthe time of clinic appointments.6/26/2013 Amr Badreldin Hamdy MD FCCP 65
Asthma Compliance Score6/26/2013 Amr Badreldin Hamdy MD FCCP 66
Categories of Factors IdentifiedFrom the Literature Review6/26/2013 Amr Badreldin Hamdy MD FCCP 67
(2) Therapy-related FactorsoRoute of administration.oTreatment complexity.oMedication side effects.oDuration of the treatment period.oDegree of behavioral change required.oTaste of the medication.oRequirements for drug storage.6/26/2013 Amr Badreldin Hamdy MD FCCP 69
(3) Healthcare System FactorsoLack of accessibility.oLong waiting time.oDifficulty in getting prescriptionsfilled.oUnhappy clinic visits.6/26/2013 Amr Badreldin Hamdy MD FCCP 70
(4) Social and Economic FactorsoInability to take time off work.oCost and income.oSocial support.6/26/2013 Amr Badreldin Hamdy MD FCCP 71
(5) Disease FactorsoDisease symptoms.oSeverity of the disease.6/26/2013 Amr Badreldin Hamdy MD FCCP 72
How to Recognize AsthmaDeterioration?oIncreasing frequency of severity ofsymptoms, especially waking at night.oIncreasing use of reliever medication.oFailure of medication to completelyrelieve symptoms.oFalling peak flow and /or increasing peakflow variability.6/26/2013 Amr Badreldin Hamdy MD FCCP 73
continuedoPhysical difficulties.oTobacco smoking or alcohol intake.oForgetfulness.oHistory of good compliance.6/26/2013 Amr Badreldin Hamdy MD FCCP 74
Amr Badreldin Hamdy MD FCCPIf a patient with asthma is notresponding as we think theyshould, it’s time to “think newthoughts” and see if we aremissing something that isundermining our treatmentplan.
Incorrect inhaler choice or poor techniqueo There is no clinical difference between inhaler deviceswhen used correctly, but each type requires a differentpattern of inhalation for optimal drug delivery to the lungso Problems with inhaler technique are common in clinicalpractice & can lead to poor asthma controlo Asthma control worsens as the number of mistakes ininhaler technique increaseso All patients should be trained in technique, and trainersshould be competent with the inhalation technique
Inhaler choice and techniqueo Take patient preference into account whenchoosing the inhaler deviceo Simplify the regimen and do not mix inhaler devicetypeso The choice of steroid inhaler is most importantbecause of the narrower therapeutic windowo Invest the time to train each patient in properinhaler technique:• Observe technique & let patient observe self (using video demonstrations)• Devices to check technique & maintain trained technique are available (eg, 2ToneTrainer & Aerochamber Plus spacer for metered dose inhalers; In-Check Dial,Turbuhaler whistle, Novolizer for dry powder inhalers)o Recheck inhaler technique on each revisitHaughney J et al. Respir Med. 2008;102:1681–93.
Evidence linking asthma & rhinitiso >50% of patients with asthma have rhinitiso Similar epidemiologyo Common triggerso Similar pattern of inflammation:T helper type 2 cells, mast cells, eosinophilso Nasal challenge results in asthmaticinflammation & vice versao Rhinitis predicts development of asthmaThomas M. BMC Pulm Med. 2006;6:S4.
Unintentional versus intentional nonadherencePerceptual–Practical Model of Adherence(can’t take, won’t take)UNINTENTIONALnonadherenceINTENTIONALnonadherenceCapacity & resourcesPractical barriersMotivationalBeliefs/preferencesPerceptual barriersHorne R et al. 2005. National Co-ordinating Centre for NHS Service Delivery and Organisation R&D, London.Intentional non adherence derives from the balance between the patient’s beliefs about thepersonal necessity of taking a given medication relative to any concerns about taking it
The terms severity and control should notbe regarded as synonymous, as patientswith severe asthma may be wellcontrolled on high doses of treatmentand patients with mild asthma may becurrently poorly controlled, e.g. owing topoor compliance.
Severity is described by the intensityof the treatment required to achievegood control.
The probability of a patient becomingwell controlled is independent oftheir baseline severity (their baselinedose of ICS).
The level of asthma control resultsfrom the interaction of theunderlying phenotype, theenvironment (genetic and external)and the response to treatment.
Amr Badreldin Hamdy MD FCCPPoor Controlled AsthmaoThe occurrence of prior near fatalepisode.oRecent hospitalization.oRecent emergency room visit.oNight time symptoms.oLimitation of daily activities.
Amr Badreldin Hamdy MD FCCPNeed for inhaled beta2-agonistsseveral times per day or at night.FEV1 or PEFR less than 60%predicted.
Amr Badreldin Hamdy MD FCCPWell Controlled AsthmaoAsthma symptoms are twice a weekor less.oRescue bronchodilator medication isused twice a week or less.oThere is no nocturnal or earlymorning awakening.oThere are no limitations ofwork, school, or exercise.
Amr Badreldin Hamdy MD FCCPoThe patient and physician considertheir asthma well controlled.oThe patient’s PEF or FEV1 is normalor his/her personal best.
Amr Badreldin Hamdy MD FCCPComplete (Total) Controlled AsthmaoNo asthma symptoms.oNo rescue bronchodilator use.oNo night or early morning awakening.oNo limitations on exercise, work, school.oComplete control of asthma by patientassessment and normal best PEF or FEV1.
In 1995, the GINA guidelinesintroduced the concept of themedication required to maintaincontrol.
Amr Badreldin Hamdy MD FCCPPreventersThese have anti-inflammatoryactions (ICS, Cromones).
Amr Badreldin Hamdy MD FCCPControllersDrugs which have a sustainedbronchial dilatation action, butunproven anti-inflammatory action (LABA, SR xanthines, Leukotrienereceptor antagonists).
Amr Badreldin Hamdy MD FCCPRelieversFor acute relief from symptoms.
Referenceso Hess DR: Aerosol delivery devices in thetreatment of asthma. Respiratory Care, 2008;53(6):699.o Castro M & Kraft M: Clinical Asthma. Mosby ElServier, 2008.o Bush RK & Georgitis J.W.: Handbook of Asthmaand Allergic Rhinitis. Blackwell Publ. Ltd.,1977.6/26/2013 Amr Badreldin Hamdy MD FCCP 97
o Lavorini F. & Corbetta L.: Achieving AsthmaControl: The Key Role of Inhalers.Breathe, 2008; 5(2):121.o Bateman ED et al.: Achieving Guideline-basedAsthma control: Does the Patient Benefit?. EurRespir J 2002; 20:588.o Soubra S & Guntupalli KK: Acute RespiratoryFailure In Asthma. Indian J Crit Care Med2005; 9(4):225.6/26/2013 Amr Badreldin Hamdy MD FCCP 98
o Kankaanranta H et al: Add-on Therapy Optionsin Asthma not Adequately Controlled by ICS: Acomprehensive Review. Respiratory Research2004; 5:17.o WHO: adherence to Long-term therapies.Evidence for Action 2003.o Kristin Casler: Asthma. Questions youhave…Answers you need. People’s MedicalSociety 1998.6/26/2013 Amr Badreldin Hamdy MD FCCP 99