Update on the Latest Asthma Guidelines

1
Section 2

• Update on the Latest Asthma Guidelines

2
Asthma Assessment and MonitoringKey Differences
From 1997 and 2002Expert Panel Reports

• 3 age categories defined (0?4, 5?11, and 12
  years) with different management recommendations
• Key elements of assessment and monitoring
• Severity
• Control
• Responsiveness to treatment
• Severity emphasized for initiating therapy
• Control emphasized for monitoring and adjusting
  therapy
• Severity and control defined in terms of 2
  domains
• Impairment
• Risk
• Stepwise management approach expanded

Adapted from 2007 NHLBI Expert Panel Guidelines
(EPR-3).
3
NHLBI Asthma Goals

• Reduce impairment
• Prevent symptoms
• Reduce SABA use to 2 d/week
• Maintain normal pulmonary function
• Maintain normal activity levels
• Provide satisfactory care
• Reduce risk
• Prevent exacerbations, ED visits, and
  hospitalization
• Prevent loss of lung function
• Minimize adverse effects of drug therapy

Adapted from 2007 NHLBI Expert Panel Guidelines
(EPR-3).
4
Asthma Severity and ControlImpairment Domain
Impairment Frequency and Intensity of Symptoms
and Functional Limitations
Symptoms
Lung Function

• Nighttime awakenings
• Need for short-acting ß2-agonists (SABAs) for
  quick relief of symptoms
• Work/school days missed
• Ability to engage in normal daily activities or
  desired activities
• Quality-of-life assessments

• Spirometry
• Peak flow

Adapted from 2007 NHLBI Expert Panel Guidelines
(EPR-3).
5
Asthma Severity and ControlRisk Domain

• Likelihood of asthma exacerbations, progressive
  decline in lung function, or risk of adverse
  effects from medications
• Assessment
• Frequency and severity of exacerbations
• Oral corticosteroid use
• Urgent-care visits
• Lung function
• Noninvasive biomarkers may play an increased role
  in future

Adapted from 2007 NHLBI Expert Panel Guidelines
(EPR-3).
6
Classification of Asthma Severity
Adapted from 2007 NHLBI Expert Panel Guidelines
(EPR-3).
7
Impairment Assessing Control
Patients 12 years of age
Adapted from 2007 NHLBI Expert Panel Guidelines
(EPR-3).
8
Assessing Control Via Validated Questionnaires to
Determine Impairment

• Asthma Therapy Assessment Questionnaire (ATAQ)
• 0 well-controlled, 1?2 not well-controlled,
• 3?4 very poorly controlled
• Asthma Control Questionnaire (ACQ)
• 0.75 well-controlled, 1.5 not
  well-controlled
• Asthma Control Test (ACT)
• 20 well-controlled, 16?19 not
  well-controlled,
• 15 very poorly controlled

Adapted from 2007 NHLBI Expert Panel Guidelines
(EPR-3).
9
Assessing Control ATAQ Questionnaire

• Self administered
• Identifies level of control and barriers to
  disease management
• Probes health care utilization and QOL
• Questions cover
• Provider communication
• Nocturnal awakenings
• Missed activities
• Medication use
• Relationship with provider
• Attitudes about treatment
• Perception of control
• Health care utilization

Vollmer WM, et al. Am J Respir Crit Care Med.
19991601647-1652.
10
Assessing Control ACQ Questionnaire

• Brief (7 items)
• Question composition
• 5 on symptoms to assess control
• 1 on ?2-agonist (SABA) use
• 1 FEV1 measurement
• Probes prior week
• Sleep interruption
• Symptoms upon waking
• Activity limitation
• Extent of SOB
• Extent of wheezing
• Daily SABA use
• Staff administered FEV1 test

Juniper EF, et al. Eur Respir J. 199914902-907.
11
Assessing Control ACT Questionnaire

• Brief (5 items)
• Question composition
• 3 on symptoms to assess control
• 1 on ?2-agonist (SABA) use
• 1 on self assessment
• Probes prior 4 weeks
• Loss of productivity
• Frequency of SOB
• Sleep interruption
• Frequency of SABA use
• Assessment of control

Asthma Control Test. Available at
http//www.asthmacontrol.com. Accessed May
2007. Nathan RA, et al. J Allergy Clin Immunol.
200411359-65.
12
Risk Assessing Control

Adapted from 2007 NHLBI Expert Panel Guidelines
(EPR-3).
13
Assessing Control Biomarkers

• Airway hyperresponsiveness
• Eosinophils (blood or sputum)
• Eosinophilic cationic protein (ECP)
• Serum IgE
• Skin tests
• pH
• Inflammatory mediators
• Exhaled markers

These tests have not been validated as predictors
of clinical outcomes
Adapted from 2007 NHLBI Expert Panel Guidelines
(EPR-3).
14
Assessing Control Exhaled Biomarkers

• Fractional Exhaled NO (FENO)
• gt 90 specific for asthma diagnosis
• Correlates with eosinophilic inflammation
• Rise in FENO precedes symptoms
• Rapid Response marker reflects ICS Tx or
  withdrawal in days
• PGE2 and PGF2 markers for COPD, not asthma
• Leukotriene E4 increased in asthma, not COPD
• Reduced pH
• Breath temperature may reflect inflammation
• Yet-to-be identified small molecules
• Combinations of markers (profile)

Kharitonov SA, et al. Chest. 20061301541-1546.
15
Components of Asthma Management

• Assessment of severity and control
• Environmental control
• Asthma education
• Patient
• Physician
• Medication
• SABA, LABA
• Corticosteroids
• Leukotriene modifiers
• Fixed-dose combinations

• Theophylline
• Cromolyn
• Nedocromil
• Omalizumab

Adapted from 2007 NHLBI Expert Panel Guidelines
(EPR-3).