Asthma control (2)

6/26/2013 amr badreldin hamdy MD 1

Asthma Control
Clinical Pearls

Amr Badreldin Hamdy,
MD FCCP
Prof of Pulmonary Medicine
Banha University, EGYPT
Pulmonary Consultant
NEW CAPITAL MEDICAL CENTRE, ABU DHABI
6/26/2013 3
Amr Badreldin Hamdy MD FCCP

Is There A Cure For Asthma?
Asthma cannot be cured, but it can be
Controlled
“We should expect nothing less”!

In lay usage, “control” conveys the
sense of being reined in or kept
within certain boundaries.

The patient’s level of asthma control
represents the extent to which the
clinical manifestations of asthma
have been removed or reduced by
treatment.

The goals of asthma treatment are
relating not only to the control of
patient’s current symptoms, but also
to the prevention of future adverse
outcomes, such as exacerbations, a
rapid decline in lung function and
side-effects of treatment.

The assessment of asthma control falls
into two broad categories:
assessment of the current level of
clinical control and assessment of
future risk to the patient.

Asthma is a chronic inflammatory disorder
of the airways.
This causes an increase in airway hyper-responsiveness
leading to
o Wheezing
o Breathlessness
o Chest tightness
o Coughing
GINA, 2002

6/26/2013 Amr Badreldin Hamdy MD FCCP 10

Asthma is one of the
commonest chronic diseases
worldwide and is increasing in
children and probably also in
adults.

Burden of Asthma
 The WHO has reported the annual
costs of BA exceed those of TB and
HIV combined due to poor asthma
control and disease management.

Burden of Asthma-cont’d
The evaluation of asthma costs
considers both direct costs
(medication and treatment) and
indirect costs (loss of school or
working days and decrease in
productivity).

Asthma: limits daily-life activities
0
20
40
%ofpatients
60
Asia Pacific Europe US
Rabe et al. 2000; Fulbrigge et al. 2002; Lai et al. 2002

While it is a worldwide
problem, the prevalence of the
condition seems to be higher in
affluent than non-affluent
populations.

Under-diagnosis and under-
treatment are major contributors to
asthma morbidity and mortality.
Long term preventive treatment is
the cornerstone of good asthma
control.

Putting primary emphasis on
controlling bronchial spasm
rather than chronic airway
inflammation looks like “putting
the cart before the horse”.

Even following administration of one
of the many forms of asthma
treatment, up to 40% of adults
remain symptomatic, and up to 5%
of cases are difficult to manage
despite multiple forms of treatment.

What Are Benefits Of Long
Term Preventive Treatment
Of Asthma?

Achieving asthma control is the focus
of all recently developed asthma
treatment guidelines.

The goal is effective control
of asthma, which strives to
ensure that the asthmatic is
able to lead a normal and
physically active life.

Current clinical control is assessed by
direct observation of the patient’s
current or recent clinical status on
treatment.

Remember!
One must always consider
that the goal of total control of
asthma must be balanced
against the cost and potential
adverse effects of asthma
control.

The assessment of asthma control has two
components: current clinical control
(including symptoms, reliever use and simple
“bedside” measures of lung function) and
future 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), 2007
oMinimal to no daytime asthma symptoms
oNo limitations on activities
oNo nocturnal symptoms or awakenings
oMinimal to no need for reliever or rescue
therapy
oNormal lung function (FEV1 or PEF)
oNo exacerbations
www.ginasthma.org

Exacerbations, by definition and
clinical practice, are identified by a
change from and return to previous
status, i.e. by their time trend.

Exacerbations are events that are
more common in poorly controlled
asthma but may occur at any level of
clinical asthma control.

What are the Key elements of
an Asthma Program?

oEducation-motivation.
oSelf assessment management.
oEnvironmental management.
oPharmacological management.

In the assessment of
asthma control, there are
several important activities
that should be accomplished
during the periodic visit for
asthma:

1. Assessment of psychosocial
status.
2. Assessment of adherence-
compliance.
3. Assessment of medication
use and its side effects.

4. Assessment of asthma
triggers.
5. Review of written asthma
action plan (as appropriate).
6. Confirmation of asthma
diagnosis.

A common misconception is that
asthma severity is considered
“static”; namely, that once a patient
is classified with a given severity
level, it remains constant.
Asthma symptoms are a dynamic
and often a changing parameter.

Asthma control can be expected to
change over time. It should be
assessed at every clinical encounter
for asthma, and management
decisions should be based on the
level of asthma control.

If a patient has been stable on an
asthma treatment program for a
period of time, consideration should
be given to try “stepping down”
therapy to a less intense level of
treatment plan.

Barriers of Effective
Treatment

oFailure to agree to set a common
goal with the patients.
oPatient resistance/objection to
inhalation therapy.
oPoor inhalation technique.
oSteroid phobia.
oWorry about excessive cost.

Key Goals in Patient Education
With the help of the health-care team, patients
can learn to do the following:
o Avoid risk factors.
o Understand the difference between “reliever” and
“controller” medications.
o Monitor status using symptoms or PEFR
o Recognize signs that asthma is worsening and take
action.

Aims of asthma management, which if achieved,
indicate overall asthma control
oMinimal (ideally no) symptoms
oMinimal (infrequent) exacerbations
oNo emergency visits
oMinimal (ideally no)PRN ß2-agonist use
oNo activity restriction, including exercise
oPEF circadian variation less than 20%
o(Near) normal PEF
oMinimal (or no) adverse effects from medicines
GINA, 2002

Patients currently achieving
control
Not Well-Controlled
Well-Controlled
Only 5% of patients
achieve asthma
control
Rabe et al. Eur Respir J, 2000

CAUSES OF NONRESPONSIVE
ASTHMA

1. Wrong diagnosis
o COPD
o Bronchiectasis, Cystic fibrosis,
o Inhaled FB
o Recurrent aspiration.
o Obliterative bronchitis.
o Tumors involving the central airway.
o Tracheobronchomalacia.
o Vocal cord dysfunction.

2. Poor Adherence To Therapy
o Patient related.
o Drug related.

3. Unidentified Exacerbation Factors
o Unidentified allergies
o Occupational exposure
o GERD
o Systemic diseases (thyrotoxicosis,
carcinoid syndrome, Churg-Strauss
Syndrome)
o Drugs (Beta-blockers, ACE-inhibitors)
o Rhinitis/sinusitis/sleep apnea
o Psychological factors6/26/2013 Amr Badreldin Hamdy MD FCCP 45

4. Unstable Asthma
o Nocturnal asthma
o Pre-menstrual asthma
o Brittle asthma

5. Corticosteroid Dependant/Resistant
Asthma.

Asthma Phenotypes
oIntermittent/Persistent
– Mild/Moderate/Severe
oAdult onset wheezing
– Primary asthma and secondary causes
– Tends to me more severe
oOccupational asthma
oNeutrophilic inflammation

The asthma phenotypes may alter the
intensity of treatment required
(severity) and, in turn, contribute to
the patient’s level of asthma control.

6/26/2013
50

Do we really avoid the triggers?

Can We Control His Asthma?

How to Avoid Pollution?

Pest Elimination

Pollen Elimination

Asthma and Exercise

Asthma and Fumes, Odors and
Strong Scents

Adherence

Adherence Definition
It is a the extent to which a person’s
behavior-taking medication, following
a diet, and/or executing lifestyle
changes, corresponds with agreed
recommendations from a health care
provider.
Rand CS. AJ Cardiology; 1993,72.

Adherence Incidence
In developed countries, adherence
to long-term therapies in the
general population is around 50%
and is much lower in developing
countries.

Evidence shows that adherence
rates for the regular taking of
preventive therapies are as low as
28% in developed countries.
Reid D et al., Respirology, 2000,5.

Rates of non-adherence among
patients with asthma range from 30%
to 70%, whether adherence is
measured as percentage of prescribed
medication taken, serum theophylline
levels, days of medication
adherence, or percentage of patients
who failed to reach a clinically
estimated adherence minimum.
Bender B et al, Ann Allergy, Asthma, & Immunology, 1997,79.

Types of Non-compliance

oReceiving a prescription but not filling it.
oTaking an incorrect dose.
oTaking medication at the wrong times.
oIncreasing or decreasing the frequency
of doses.
oStopping the treatment too soon.
oNon-participation in clinic visits.
oFailure to follow doctor’s instructions.

o“Drug holidays”, which means
the patient stops the therapy for
a while and then restarts the
therapy.
o“White-coat compliance”, which
means patients are compliant to
the medication regimen around
the time of clinic appointments.

Asthma Compliance Score

Categories of Factors Identified
From the Literature Review

(1) Patient –centered Factors
oDemographic factors: age, ethnicity,
gender, education, marriage status.
oPsychosocial factors: beliefs,
motivation, attitude.
oPatient-prescriber relationship.
oHealth literacy.
oPatient knowledge.

(2) Therapy-related Factors
oRoute 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.

(3) Healthcare System Factors
oLack of accessibility.
oLong waiting time.
oDifficulty in getting prescriptions
filled.
oUnhappy clinic visits.

(4) Social and Economic Factors
oInability to take time off work.
oCost and income.
oSocial support.

(5) Disease Factors
oDisease symptoms.
oSeverity of the disease.

How to Recognize Asthma
Deterioration?
oIncreasing frequency of severity of
symptoms, especially waking at night.
oIncreasing use of reliever medication.
oFailure of medication to completely
relieve symptoms.
oFalling peak flow and /or increasing peak
flow variability.

continued
oPhysical difficulties.
oTobacco smoking or alcohol intake.
oForgetfulness.
oHistory of good compliance.

How to Deal with a Non-
responding Patient?

If a patient with asthma is not
responding as we think they
should, it’s time to “think new
thoughts” and see if we are
missing something that is
undermining our treatment
plan.

Incorrect inhaler choice or poor technique
o There is no clinical difference between inhaler devices
when used correctly, but each type requires a different
pattern of inhalation for optimal drug delivery to the lungs
o Problems with inhaler technique are common in clinical
practice & can lead to poor asthma control
o Asthma control worsens as the number of mistakes in
inhaler technique increases
o All patients should be trained in technique, and trainers
should be competent with the inhalation technique

Inhaler choice and technique
o Take patient preference into account when
choosing the inhaler device
o Simplify the regimen and do not mix inhaler device
types
o The choice of steroid inhaler is most important
because of the narrower therapeutic window
o Invest the time to train each patient in proper
inhaler technique:
• Observe technique & let patient observe self (using video demonstrations)
• Devices to check technique & maintain trained technique are available (eg, 2Tone
Trainer & Aerochamber Plus spacer for metered dose inhalers; In-Check Dial,
Turbuhaler whistle, Novolizer for dry powder inhalers)
o Recheck inhaler technique on each revisit
Haughney J et al. Respir Med. 2008;102:1681–93.

Evidence linking asthma & rhinitis
o >50% of patients with asthma have rhinitis
o Similar epidemiology
o Common triggers
o Similar pattern of inflammation:
T helper type 2 cells, mast cells, eosinophils
o Nasal challenge results in asthmatic
inflammation & vice versa
o Rhinitis predicts development of asthma
Thomas M. BMC Pulm Med. 2006;6:S4.

Unintentional versus intentional nonadherence
Perceptual–Practical Model of Adherence
(can’t take, won’t take)
UNINTENTIONAL
nonadherence
INTENTIONAL
nonadherence
Capacity & resources
Practical barriers
Motivational
Beliefs/preferences
Perceptual barriers
Horne 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 the
personal necessity of taking a given medication relative to any concerns about taking it

The terms severity and control should not
be regarded as synonymous, as patients
with severe asthma may be well
controlled on high doses of treatment
and patients with mild asthma may be
currently poorly controlled, e.g. owing to
poor compliance.

Severity is described by the intensity
of the treatment required to achieve
good control.

The probability of a patient becoming
well controlled is independent of
their baseline severity (their baseline
dose of ICS).

The level of asthma control results
from the interaction of the
underlying phenotype, the
environment (genetic and external)
and the response to treatment.

Poor Controlled Asthma
oThe occurrence of prior near fatal
episode.
oRecent hospitalization.
oRecent emergency room visit.
oNight time symptoms.
oLimitation of daily activities.

Need for inhaled beta2-agonists
several times per day or at night.
FEV1 or PEFR less than 60%
predicted.

Well Controlled Asthma
oAsthma symptoms are twice a week
or less.
oRescue bronchodilator medication is
used twice a week or less.
oThere is no nocturnal or early
morning awakening.
oThere are no limitations of
work, school, or exercise.

oThe patient and physician consider
their asthma well controlled.
oThe patient’s PEF or FEV1 is normal
or his/her personal best.

Complete (Total) Controlled Asthma
oNo asthma symptoms.
oNo rescue bronchodilator use.
oNo night or early morning awakening.
oNo limitations on exercise, work, school.
oComplete control of asthma by patient
assessment and normal best PEF or FEV1.

Patients Physicians
Healthcare
system
TOTAL CONTROL
Raising expectations…
Researchers

In 1995, the GINA guidelines
introduced the concept of the
medication required to maintain
control.

Preventers
These have anti-inflammatory
actions (ICS, Cromones).

Controllers
Drugs which have a sustained
bronchial dilatation action, but
unproven anti-inflammatory action (
LABA, SR xanthines, Leukotriene
receptor antagonists).

Relievers
For acute relief from symptoms.

References
o Hess DR: Aerosol delivery devices in the
treatment of asthma. Respiratory Care, 2008;
53(6):699.
o Castro M & Kraft M: Clinical Asthma. Mosby El
Servier, 2008.
o Bush RK & Georgitis J.W.: Handbook of Asthma
and Allergic Rhinitis. Blackwell Publ. Ltd.,
1977.

o Lavorini F. & Corbetta L.: Achieving Asthma
Control: The Key Role of Inhalers.
Breathe, 2008; 5(2):121.
o Bateman ED et al.: Achieving Guideline-based
Asthma control: Does the Patient Benefit?. Eur
Respir J 2002; 20:588.
o Soubra S & Guntupalli KK: Acute Respiratory
Failure In Asthma. Indian J Crit Care Med
2005; 9(4):225.

o Kankaanranta H et al: Add-on Therapy Options
in Asthma not Adequately Controlled by ICS: A
comprehensive Review. Respiratory Research
2004; 5:17.
o WHO: adherence to Long-term therapies.
Evidence for Action 2003.
o Kristin Casler: Asthma. Questions you
have…Answers you need. People’s Medical
Society 1998.

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