Asthma Control: Guideline Based American Thoracic Society (ATS), National Asthma Education and Prevention Program (NAEPP), and Global Initiative for Asthma (GINA)

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Asthma Control Guideline BasedAmerican Thoracic
Society (ATS), National Asthma Education and
Prevention Program (NAEPP), and Global Initiative
for Asthma (GINA)

• Michael P. Pietila, MD
• Pulmonary, Critical Care and Internal Medicine
  Yankton Medical Clinic, P.C.
• Assistant Professor Sanford School of Medicine at
  USD

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Professional Relationships

• I am a contracted speaker for
• Merck Pharmaceuticals
• Dey Pharma L.P. Bureau of COPD Research and
  Education to Advance Therapeutic Excellence
  (BREATHE)
• I will not be speaking specifically about any of
  these companies products today.

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Defining and Recognizing Asthma
Netters Anatomy
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Asthma Epidemiology

• Estimated gt 23 million Americans
• Prevalence 5-25 of population
• Increasing prevalence and severity
• USA and worldwide
• Socioeconomics gt genetics
• 14 Billion direct annual costs in USA

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Epidemiology

• More common in males (equal after age 20).
• Atopy Skin test reactivity, elevated IgE
  levels, blood eosinophilia.
• Indoor allergens dust mites, animal dander.
• Environmental pollution, occupational exposure.
• Respiratory infections.
• TOBACCO SMOKE.

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Increasing Asthma Mortality

• 500,000 hospitalizations per year in U.S.
• 5-6,000 deaths per year
• 1978 - beginning of increasing mortality
• Role of poverty (vs. race)
• Access to health care, medications, education
• Greater environmental exposure
• Importance of identifying persons with high risk
  of death

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Definition of Asthma

• Obstructive lung disease with characteristics
  of
• Airway obstruction reversible in most patients
• Chronic airway inflammation (eosinophils)
• Increased airway responsiveness
• Onset of symptoms can occur at any age
• NAEP - Guidelines for the Diagnosis and
  Management of Asthma 1991

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Guidelines for the Diagnosis and Management of
Asthma

• Key Messages
• Asthma is an inflammatory disease
• Environmental factors are important
• Objective measures are needed
• Health education is crucial
• Emphasis on recognition and avoidance of triggers
• Buist Vollmer. NEJM 3311584-51996
• Asthma Guidelines 2007

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Asthma Guidelines 2007

• Components of severity
• Symptoms and objective testing.
• FEV1 and FEV1/FVC measurement.
• Need for short-acting beta-agonist (SABA).
• Nighttime awakenings.
• Interference with normal activity.

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Diagnosing Asthma

• Symptoms and Medical History
• Wheezing, cough, difficult breathing and chest
  tightness
• Symptoms worse at night/on awakening
• Seasonal pattern
• Eczema, hay fever, family history
• Triggers animal fur, chemicals, temperature
  change, dust mites, drugs, exercise, pollen, URI,
  smoke
• Symptoms respond to anti-asthma therapy
• Colds go to the chest or last gt 10 days.

Pocket Guide for Asthma Management and Prevention
2011
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Asthma Phenotypes

• Intermittent/Persistent
• Mild/Moderate/Severe
• Adult onset wheezing
• Primary asthma and secondary causes
• Tends to me more severe
• Occupational asthma
• Neutrophilic inflammation

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Diagnostic Tests

• No single test can secure a diagnosis of asthma
• Spirometry is the most helpful, preferred method
  for establishing diagnosis.
• Increase in FEV1 of gt 12 and 200 ml after
  inhaled bronchodilator.
• Many asthma patients are negative and repeat
  testing is advised.

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Diagnostic Testing

• Peak expiratory flow (PEF) aid in diagnosis and
  management.
• Compare to patient's previous best effort
• 60 L/min improvement after BD or diurnal
  variation in PEF of more than 20
• Bronchoprovaction testing.
• Methacholine, histamine or inhaled mannitol
• Skin testing or specific IgE testing for
  allergens.

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Diagnostic Challenges

• Cough variant asthma
• Chronic cough, often at night
• Exercise induced bronchospasm
• Exercise challenge
• Asthma in the elderly
• COPD vs asthma
• Occupational asthma
• Must correlate symptoms with occupation

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Goals of Therapy

• Avoid troublesome symptoms night and day
• Use little or no reliever meds
• Have productive and physically active life
• Have (near) normal lung function
• Avoid serious attacks

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Initiating Therapy

• Determine level of severity.
• Consider interval since last exacerbation.
• Fluctuations in severity and frequency may occur.
• Risk assessment
• Exacerbations requiring oral corticosteroids
• 0-1 per year in intermittent (low risk) patient.
• gt or equal to 2 per year in persistent (higher
  risk) patient.
• Keep in mind the patients baseline FEV1.
• Initiate treatment in a stepwise fashion.
• Reevaluate level of control in 2-6 weeks.

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Asthma Care

• Patient/doctor relationship
• Avoid triggers, understand and take meds,
  recognize symptoms and seek advice in timely
  fashion
• Identify and reduce exposure to risk
• Smoke, drugs, dust, fur, pollens, mold
• Assess, treat and monitor
• Stepwise approach, Ongoing monitoring q 3 monthly
  when stable, within 2 weeks after exacerbation.
• Manage exacerbations

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Stepwise Approach

• If disease is poorly controlled
• First evaluate for adherence to treatments and
  avoidance of triggers
• Consider a step up treatments
• If disease is well controlled
• Step down treatments
• Medications must be adjusted based on response to
  treatment and control of underlying disease, not
  on a fixed timetable.
• If a medicine is not effective after 3 months, it
  should be stopped

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Inhaler Technique
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Moderate to Severe Persistent Asthma

• Daytime symptoms daily and nighttime symptoms at
  least weekly.
• Using their rescue inhaler at least once daily.
• FEV1 lt 80 of predicted.
• FEV1/FVC ratio reduced by 5 from baseline.

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Moderate to Severe Persistent Asthma

• Moderate to High dose Inhaled Corticosteroids
  (ICS) are the cornerstone of treatment.
• Higher potency preparations require fewer puffs
  and encourage compliance
• Under dosing of ICS will result in poorer control

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Managing Disease

• Add in a Long Acting Beta Agonist (LABA)
• Most pts in the severe category require at least
  2 controller agents
• Should NEVER be used as monotherapy
• Leukotriene antagonists are also an option
• Limited evidence in literature
• Montelukast, Zafirlukast, Zilueton
• Theophylline
• Limited role, controller agent only, not as
  efficacious as LABAs
• If symptoms are severe add oral corticosteroids.
• 5-7 days if normal FEV1, 14-21 days if reduced
  FEV1
• Consider treatment with IgE antibody.

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Oral Glucocorticoids

• Most potent and effective controller agent.
• Reserve for severe disease and those with reduced
  FEV1, use lowest dose possible
• Should see an improvement in FEV1 of 15 after
  2-3 weeks
• If requiring oral GCs every 2-3 months consider
  daily low dose (5-10 mg)

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Follow-up

• 4 to 8 week intervals.
• Use a questionnaire to evaluate control
• Asthma Control Test (ACT)
• Consider spirometry if worsening symptoms or a
  step down in care

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http//www.asthma.com/resources/asthma-control-tes
t.html
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Xolair What is That?

• Xolair (Omalizumab) Is an recombinant
  monoclonal anti-IgE antibody designed to treat
  moderate to severe allergy associated asthma.
• Must demonstrate sensitization to an allergen.
• Inadequate control with inhaled steroids.

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Asthma Guidelines 2007

• Xolair therapy
• Reduce the need for systemic and inhaled
  glucocorticoids.
• Reduce the number of exacerbations, especially
  severe exacerbations.
• No effect on FEV1 values.
• Given via SubQ route q 2 to 4 weeks.
• 850 patients radomized
• 25 reduction in rate of exacerbation
• Overall response rate 30-50
• 12 week trial should be offered

Hanania, et alAnn Intern Med 2011154573
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Co-Morbid Illness

• Allergic rhinitis treat with nasal GCs if
  surgical disease refer to ENT
• GERD treat with PPI if patient is symptomatic
  from GERD
• Vocal cord dysfunction (VCD)- referral to
  qualified speech therapist
• OSA study in sleep lab and treat as indicated

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Special Considerations

• Pregnancy
• Variable, safe
• Obesity
• Weight loss helps
• Surgery
• PFTs, if lt 80 FEV1 steroids help
• Chronic sinus/rhinitis
• Treating these will improve asthma

• Occupational
• URIs
• GER
• More common in asthma but treatment doesnt
  reduce morbidity
• ASA induced
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• Anaphylaxis

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Summary

• Accurate and complete history and physical is
  crucial.
• Objective testing spirometry, methacholine
  challenge, peak flows, serum studies.
• Classify the patient.
• Step care.
• Reevaluation/follow-up.

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Summary

• Written action plan
• Proper inhaler technique
• Trigger avoidance
• Inhaled GCs are cornerstone of therapy
• LABAs should be added next
• LTAs or theophylline follow
• Consider IgE antibody in proper subset
• Treat comorbid illnesses

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