Asthma Control: Guideline

Based
American 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
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.
Defining and Recognizing Asthma

Netters Anatomy
Asthma Epidemiology
Estimated > 23 million Americans
Prevalence 5-25% of population
Increasing prevalence and severity
USA and worldwide
Socioeconomics > genetics
$14 Billion direct annual costs in USA

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.
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
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
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 331:1584-5;1996
Asthma Guidelines 2007
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.
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 > 10 days.
Pocket Guide for Asthma Management and
Prevention 2011
Asthma Phenotypes
Intermittent/Persistent
Mild/Moderate/Severe
Adult onset wheezing
Primary asthma and secondary causes
Tends to me more severe
Occupational asthma
Neutrophilic inflammation
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 > 12% and 200 ml after
inhaled bronchodilator.
Many asthma patients are negative and
repeat testing is advised.
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.
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
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
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.
> 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.
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
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

Inhaler Technique
Moderate to Severe Persistent
Asthma
Daytime symptoms daily and nighttime
symptoms at least weekly.
Using their rescue inhaler at least once
daily.
FEV1 < 80% of predicted.
FEV1/FVC ratio reduced by 5% from
baseline.
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

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.

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)
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

http://www.asthma.com/resources/asthma-control-test.html
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.
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 al;Ann Intern Med
2011;154:573
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

Special Considerations
Pregnancy
Variable, safe
Obesity
Weight loss helps
Surgery
PFTs, if < 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
28%
Anaphylaxis
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.
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