Tip and trick in asthma management 2021

Ultimate asthgmoal oaf management Nutchanart Tomaun

หญิงไทยคูอ* ายุ 42 ป2 มาadmit ด*วย ไอ เหนื่อย 3 วัน lung – wheezing both lung ไดร* ับการวินจิ ฉยั เปHน acute asthmatic attack Treatment >> dexamethasone + berodual NB Clinical improvement Asthma ? Initiate management ?

การวนิ จิ ฉยั Asthma • History and physical examination • Exclude other diseases: CXR should be done • Evidence of variable airflow obstruction > Spirometry: Typical-variability, responsibility (but not all) > PEF variability >10%

History and physical examination 01 - หอบ ไอ มีเสียงวีด๊ เมอ่ื มีสิ่งกระตน*ุ เช_น เปนH หวดั อากาศเยน็ ฝนcุ ออกกำลงั กาย - หายไดเ* ม่ือพ_นยาขยายหลอดลม หรือ ไม_มีตวั กระตุ*นแลว* - สว_ นใหญ_อายุน*อยกว_า 40 ปmหรอื มีประวตั ิเคยเปนH เม่ือยังเดก็ , แตก_ พ็ บ late onset ได* - มีประวัติสูบบุหร่ีหรอื ไม_กไ็ ด* - อาจมปี ระวัติครอบครวั หรอื ประวตั ิ atopy - ตรวจรา_ งกายขณะมีอาการได* generalized wheezing

Evidence of variable airflow limitation Post BD FEV1 เพิม่ มากกว4า Spirometry FEV1 เพิ่มมากกวา4 200 ml 200 ml หรอื 12% หรือ 12% หลงั ไดS anti-inflammation drug 4 wk. . Peak flow limitation Peak flow variability >10% False negative result . - normal spirometry - viral infection, severe AE may absent variable - 10% of COPD BD response

Limitation of spirometry/peak flow False negative result - May be normal spirometry in pt. with anti-inflamatory drug False positive result - Exacerbation of respiratory disease can contribute BD response - viral infection, bronchitis, bronchiectesis - 10% of COPD BD response

“History and physical examination is the key for diagnosis of asthma”

Exclude other disease History and 2 4 examnination Try of treatment 13 and assessment of symptom and spirometry / PEFR Spirometry or PEFR variability If doubt in diagnosis

Cardiac asthma Differential Bronchial obstruction diagnosis Vocal cord dysfunction Pneumonia ,TB COPD Bronchiectasis

01 CO0P1D 02 Asthma • หอบ ไอ มีเสมหะ • หอบ ไอ มีเสียงวดี๊ เมื่อมีสิ่งกระตน*ุ • อาการ progressive เชน_ เปHนหวดั อากาศเยน็ ฝcนุ • มีเสียงวีด๊ เคยพ_นยา • เหนื่อยเวลาออกแรง • หายไดเ* มอื่ พน_ ยาขยายหลอดลม หรือ • อายุ >40ปm ไมม_ ตี ัวกระตน*ุ แล*ว • สูบบุหร่ี >10 PY หรอื passive smoker • อายุเท_าไหร_กไ็ ด* • มีประวตั ิสบู บหุ รหี่ รอื ไม_กไ็ ด*

หญงิ ไทย มา ER ดว* ย ไอ เหนอื่ ย 3 วนั lung – wheezing both lung อายุ 42 ป2 ไดร* บั การวินจิ ฉัยเปนH acute asthmatic attack Treatment >> Prednisolone 30 mg /d 5 day + Ventolin MDI >>>>> Clinical improvement ค-ำเถคายมมีไอ เหนอ่ื ยวดี๊ ตอนกลางคนื 1 คร้งั ต:อ 3-4 เดือน หายเองบางครง้ั 1-. เคยยไไอปเคหนลื่อินยิกหไรดือ@ยมาเี เสมยี ็ดงวสด๊ี ีชมตอพนูมไหากนินเวลดาีข/ท้ึนำหอลย;าังงกไรนิ ถถงึ ห@าอายาการมาก 423--... CเเปเคคปรXยยIนะRมใวชมีปัตA –ายริ sนะาmnพวาัตoน;oนิเk/rปเmin4คIนgย-หa5ไอlปบปคหลK ืดไนิ มิกภ:เูมคริแพยพส/A บูปรบะุหวัตรคิ ่ี รอบครวั

How to initiate treatment A Low dose ICS in this patient ? B Medium dose ICS C High dose ICS D Low dose ICS/LABA E Medium dose ICS/LABA

- ใหค* วามรู*แก_ผูป* cวย asthma ควบคุมได* หรือ ควบคุม - การควบคุมสิ่งแวดล*อม ไมไ_ ด* - ยา: Controller, >> GINA >> Score- ACT, ACQ Reliever ประเมนิ การรกั ษา การรักษา

Initial asthma treatment - where to start ? Should all patients start at Step1 ?

≥2/mo. ≥1/ wk. and Low PFT or exacerbation ≥1/ wk. <2/mo. Preferred controller is ICS/LABA for initial maintenance therapy: If pts have Symptoms most days or waking with asthma ≥ 1/wk, ≥ 1/wk and FEV1 < 60% If pts have Symptoms most days or waking with asthma GINA 2020, Box 3-4A © Global Initiative for Asthma, www.ginasthma.org

Low, medium and high ICS doses: adults/adolescents This is NOT a table of equivalence. These are suggested total daily doses for the ‘low’, ‘medium’ and ‘high’ dose treatment options with different ICS. DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant; pMDI: pressurized metered dose inhaler (non-CFC); * see product information GINA 2020, Box 3-6A

How to initiate treatment A Low dose ICS in this patient ? B Medium dose ICS C High dose ICS Salmateral /fluticasone (50/250) D Low dose ICS/LABA 1 puff bid E Medium dose ICS/LABA

GOAL of treatment No exacerbation ASSESSMENT Symptom control GINA No airway inflammation No BHR ACT score Normal pulmonary function PEFR No airway remodeling FENO No side effect

GOAL of Asthma Management Asthma control = symptom control + risk Treatment issue Co-morbid

Asthma Control = Symptom Control + Future risk

GINA Assessment of asthma control Daytime asthma Any night waking Need for reliever for Any activity limitation symptoms more due to asthma? symptoms more than caused by asthma? than twice/week twice a week

Risk factor of poor asthma outcome ใช4 reliver > 1 canister/mo. FEV1< 60% predicted, high BD reversibility Pregnancy, GERD, Rhinosinusitis ,obesity Smoking Exacerbate >/1 in past year High blood Eo, FENO เคยใส& ET-T

Partly Controlled… Is it enough ? Health care service Limitation of activities * Reference category is well-controlled asthma Partly controlled = Uncontrolled Gold LS at al. Ann Allergy Asthma Immunol 2012; 109: 260-265.

เปาE หมาย..ผูKปวL ยควบคมุ โรคไดK PEFR > 80% predicted แนวทางการวินิจฉยั และรักษาโรคหืดในประเทศไทยสําหรับผ้ใู หญ่ พ.ศ. 2562

Importance of regular controller medication No night symptoms am PEF No SABA use AHR FEV1 (Histamine) % improvement 0 Weeks Months Years Days Adapted from Woolcock AJ. Clin Exp Allergy Rev 2001; 1: 62-4

With FP/Salmeterol, 80% asthma control – Steroid naïve % Well-controlled Daily Daily ICS ICS/LABA PRN FP/Salm Irusen EM. GINA 2019 for mild asthma A Critique. S Afr Fam Pract. 2020;62(1), a5104

ICS and LABAs improve asthma control via complementary mechanisms ICS LABAs receptors Bronchoconstriction Inflammation Effect structural Mast cell changes Cytokine release Endothelial cells Cytokines Mucus glands Plasma leak Mucus secretion Endothelial cells Plasma leak Sensory nerve activation 1. Barnes P. Pharmaceuticals 2010; 3:514-540; 2. Barnes P. Eur Respir J 2002;19:182-191

Time to achieve Well-Controlled asthma - ICS/LABA help to achieve earlier - Increased Compliance & Trust ICS/LABA ICS Week 2 Week 7 FP SFC 0 1 2 3 4 5 6 7 8 9 10 The week by which 50% of patients achieved their first WELL-CONTROLLED week Patients previously on low-dose ICS (stratum 2) *Well controlled defined as achieving at least 2 of the following 3 criteria every week; daytime symptoms < 2 days/week with symptom score >1, use of rescue beta2 agonist for < 2 days/week and < 4 occasions/week or morning PEF>80% predicted every day plus achieving all other criteria from GINA and NIH guidelines for at least 7 out of 8 weeks Bateman E. et al, Am J Respir Crit Care Med 2004 ; 170 : 836-844

When to step down ? 4 Step 1 Well control > 3-6 mo. Step 2 No exacerbation > 3-6 mo. STEPS CONCEPT Step 3 PEFR > Step (or best) 80% predicted > 3-6 mo. How to step down ? 4 No pregnancy, no travel, no respiratory infection …step down ICS คร้ังละ 50% q 3-6 เดอื น until step1

How to step down ? …step down ICS คร้งั ละ 50% q 3-6 เดอื น until step1 ตวั อยา* ง SFC 1x2 …>> SFC 1x1 …>>>> Budesonide 1x2 …>>>>>>> Budesonide 1x1

Most common problem in uncontrolled asthma • Poor inhaler technique • Poor medication adherence • Incorrect diagnosis • Comobidities condition • Ongoing exposure to allergen

Accuhaler less critical error than MDI and Turbuhaler Proportion of COPD and asthma patients making a critical error 40 31–64 years <30 years 35 30 ≥65 years Patients (%) 25 20 15 Autohaler Accuhaler pMDI Turbuhaler 10 5 0 Aerolizer Assessment of Handling of Inhaler Devices in Real Life: 3811 Patients in Primary Care Errors were considered critical if they could have substantially affected dose delivery to the lung. Adapted from Molimard M, et al. J Aer Med 2003;16:249–254.

Ellipta and Accuhaler have the same minimum required inspiratory flow rate values (in L/min) and Flow-resistance Minimun required inspiratory flow rate values (in L/min) Device System Acceptable inhalation Good inhalation Flow resistance Diskus® DPI-blister 30 30 Medium Ellipta® DPI-blister 30 30 Medium Handihaler® DPI-capsule 20 30 Breezhaler® DPI-capsule 50 50 High low Haidl, R. 2016, Inhalation device requirements for patients' inhalation maneuvers, Respiratory Medicine 118 (2016) 65e75

Accuhaler is a low-medium resistance inhaler, suitable for patientswith mild asthma through to very severe COPD1 Mean (95% CI) PIFR (L/min) 120 Accuhaler need >30 L/min 110 Mild Moderate Severe Mild Moderate Severe Very severe 100 Asthma COPD 90 (n=45) (n=60) 80 70 60 50 40 Healthy volunteers (n=15) COPD, Chronic Obstructive Pulmonary Disease, PIFR, Peak Inspiratory Flow Rate 1. Prime D et al. J Aerosol Med Pulm Drug Deliv. 2015 Dec 1; 28(6): 486–497. 2. . Hamilton M et al. Poster presented at the Annual Congress of the American Thoracic Society (ATS), San Francisco, California, USA, May 18–23, 2012 . For Health Care Professionals Only

Asthma in special condition 01 COUGH VARIANT 04 PREGNANT ASTHMA ASTHMA 05 ELDERLY ( ASTHMA , 02 OCCUPATIONAL ASTHMA-COPD ASTHMA (5-20% overlapping syndrome) ADULT ONSET ASTHMA) 03 WORK AGGRAVATED ASTHMA

Medication concerning Aspirin , NSAIDS Not contraindication if no previous history of drug induced attack Beta-blocker Contraindication: - If needed : use only selective beta1 blocker

Pregnancy DO’S DON’TS Controller ใชSไดSทุกตวั Not need to stepdown Must have controller Avoid : oral beta agonist รบี ทำใหS controll 1/3 ดีข้ึน , 1/3 แยKลง, 1/3 คงเดิม

Aspirin-exacerbated respiratory disease Chronic rhinosinusitis Nasal polyp Hypersensitivity to ASA and NSAIDS Acute attack in minute to1-2 hours Rhinorrhea, nasal obstruction, conjuctival irritation, scarlet flush at head and neck

Adverse effects with montelukast • FDA boxed warning in March 2020 about risk of serious neuropsychiatric events, including suicidality, with montelukast • Includes suicidality in adults and adolescents • Nightmares and behavioral problems in children • Before prescribing montelukast, health professionals should consider its benefits and risks, and patients should be counselled about the risk of neuropsychiatric events

Initial treatment of COPD

ICS/LABA in COPD © 2020 Global Initiative for Chronic Obstructive Lung Disease

NICE guideline: initial treatment

Patients with features of asthma and COPD GINA 2020, Box 5-2

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