Bronchial Asthma Presentation

7/29/2019 Bronchial Asthma Presentation

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AsthmaA Global Healthcare Issue


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AsthmaA GLOBAL HEALTHCARE ISSUE

Asthma is a worldwide problem

Approximately 300 million individuals are affected1

Over the last 40 years there has been a sharp increase in theglobal prevalence, morbidity, mortality, and economic burden

associated with asthma2

Asthma prevalence is expected to increase by 50% every

decade2

Hence, 150 million more people will become asthma sufferers

1. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention. Revised Edition 2007.

2. Braman SS. Chest2006; 130: 4S12S.


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Too many patients still die from theirasthma

There are an estimated 250,000 annual worldwide

deaths from asthma1

Most asthma deaths occur in those >45 years old and

are largely preventable2


2. Braman SS. Chest2006; 130: 4S12S.


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Asthma prevalence in children

Asthma is the most common

disease among children1,2

Children living in poverty:3

Suffer the largest burdenof childhood asthma

morbidity

Are more likely to receive

inadequate therapy

1. ISAAC Steering Committee. Lancet1998; 351: 12251232. 2. Bibi HS et al. Respir Med2006; 100: 458462.

3. Halterman JS et al.Ambulatory Paed2003; 3: 102105.

PeruNew Zealand

AustraliaUruguay

KuwaitCanada

USAKenyaChile

JapanParaguay

Hong KongSingapore

PhilippinesMalta

France

PakistanSpainMorocco

ArgentinaThailand

South AfricaPortugalMalaysiaAustriaSweden

GermanyItaly

FinlandLebanon

South KoreaPoland

IranIndiaChina

EstoniaTaiwan

IndonesiaUzbekistan

LatviaRussia

Albania

0 5 10 15 20 25 30Prevalence of asthma symptoms (%)3

Country


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Asthma Insights & Reality in Pakistan Survey(AIRIP)1

Presence of patients Asthma symptoms in the last 4 weeks

Moderate

symptoms

Mild to no

symptoms

Severe

symptoms

1. Jones, P.W, et al., Survey of Asthma Insights and Reality In Pakistan (AIRIP), Journal of Respirology, 2006

47%


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Asthma Insights & Reality in Pakistan

Survey(AIRIP)

Frequency of asthma in past 12 months(sudden severe episodes of cough, wheeze tightness, or breathlessness)1


32%

51%

0% 10% 20% 30% 40% 50% 60%

Adults

Children

Adults 51%

Children 32%


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Asthma emergencies in thelast 12 months (AIRIP)1

50% admitted to emergency ward

overnight

Almost 50% saw doctor as an

emergency



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Asthma Insights and Reality in Europe (AIRE)

Majority of patients overestimate their level of

asthma control1

1. Rabe KF et al.Eur Resp J2000; 16: 802807.

SP: severe persistent; MOP: moderate persistent; MP: mild persistent; MI: mild intermittent;

Well/completely controlled Somewhat controlled Poorly/not controlled

100

75

50

25

0

Patient

s%

SP MOP MP MI

Children

SP MOP MP MI

Adults

However, only 5.3% of all patients (5.1% of adults and 5.8% ofchildren) met all the criteria for asthma control


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Parents underestimate the level of theirchildrens asthma1

Not

daily

Daily 2x/wk Freq Not

daily

Daily < 3 3 0 1 Yes No

Daytime asthma

symptoms

Night time asthma

symptoms

Rescue medication

use

Office/

emergency room

visits

Hospitalisations Preventative

medication use

1. Halterman JS et al.Ambulatory Paed2003; 3: 102105.

8078

8284

78

73

64

76

65

70

76

81

0

10

20

30

40

50

60

70

80

90

Parentsreportinggoodcontrol(%)

Parents reporting good control Actual level of asthma control


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Physician assessment of control in thePrimary Practice Audit study1

58%

42%

Controlled

Uncontrolled

1. Chapman KR et al. Eur Respir J. 2008; 31: 320325.

n=10,428

59%

41%

Controlled

Uncontrolled

Physician Guideline


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PhysicianAcceptance of a certain level of

symptoms for their asthmatic patients

As patients do not complain,

assumption that patients are well

enough controlled

PatientAcceptance of asthma symptoms as

part of their usual life: under-report

Trust in their physicians to accurately

assess their condition and give them

the best treatment

Current status of asthma control:a vicious circle


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Patients want to avoid asthmasymptoms1

1. Lloyd A et al. Prim Care Resp J2007; 16: 241248.

35

109

94

0

20

40

60

80

100

120

Avoid a day with

symptoms

Avoid asthma attacks

that required emergency

visits to GP/ER

To achieve total

avoidance

of asthma symptoms

Willingnesstopay

(Eurospermonth)


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What do you think?

According to the AIRIP survey what percentage of

asthmatic patients in Pakistan had ever been

administered a lung function test?1

1. 15%

2. 48%

3. 30%

4. 58%

Asthmaticpatients notadministered lungfunction test

85%

Asthmatic patientsadministered lungfunction test

15%

1. Jones, P.W, et al., Survey of Asthma Insights and Control In Pakistan (AIRIP), Journal of Respirology, 2006


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AsthmaThe Financial Burden of theDisease


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The cost of asthma: a financial burden onthe healthcare system

Asthma Insights & Reality in Latin America survey (AIRLA)1

5255

31

69

6158

0

10

20

30

40

50

60

70

80

Use of emergency care in the

past 12 months

Current use of quick relief

bronchodilators

School/work absence

Patients(%

)

Adults Children

1. Neffen H et al.Pan American J Public Health2005; 17: 191197.


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AsthmaA FINANCIAL BURDEN

Direct and Indirect costs associated with uncontrolled asthma1:

According to a UK study, the total cost per patient is 3.5 times higher inthe uncontrolled (attack) group than in the controlled (non-attack) group1

This highlights the importance of controller medication to prevent attacks /

exacerbations and keep asthma under control, resulting in significant cost

saving and improved quality of life1

Rescuemedication

use

Hospitalization/

Emergencyroom visits

Indirect costs(lost time at

work, school,etc)

Impaired

Quality of Life

RepeatedGP

consultations

1. Hoskins, G., et al., Risk factors and costs associated with an asthma attack, Thorax; 55:19-24 (2000).


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Asthma care can be improved: inhaledsteroids and asthma

Ministry of Social Affairs and Health in Finland National Action Programme1

1. Haahtela T et al.Thorax2001; 56; 806814.

400

350

300

250

200

150

100

50

0

1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Year

Index(1981=100)

Proportion of asthmatic patients

in the population

Death rate due to asthma

among asthmatic patients

Days in hospital due to asthmaamong asthmatic patients


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Knowledge of Inhaled Corticosteroids(AIRIP)1

86.5 87 87.5 88 88.5

Not at all

familiar

% of respondents

Adults

Children

In Pakistan, over

80% of individuals

(adults andchildren) were not

familiar with

inhaled

corticosteroids

(ICS)

1. Jones, P.W, et al., Survey of Asthma Insights and Control In Pakistan (AIRIP), Journal of Respirology, 2006


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AsthmaA Two-Component Disease


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Asthma symptoms:the tip of the iceberg1

Airway inflammation

Bronchial hyperresponsiveness

ASTHMA SYMPTOMS

Airway obstruction

1. Warner O. Am J Resp Crit Care Med2003; 167: 14651466.

Bronchoconstriction

Bronchial oedema

Mucous hypersecretion

Inflammatory cell recruitment eosinophils


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Any symptoms of asthma are a sign ofinflammation

Inflammation in asthma patients can be present during

symptom-free periods:1

Symptoms resolve quickly. Inflammation, however, as measured byairway hyperresponsiveness, takes far longer1

As chronic inflammation causes an increase in airway

hyperresponsiveness, if the inflammation is notcontrolled, symptoms are likely to reoccur

1. Woolcock AJ. Clin Exp AllergyRev2001; 1: 6264.


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Chronic inflammation is associated withairway hyperresponsiveness

AHR is defined as the ability of the airways to narrow too easily and

by too much in response to provoking stimuli, leading to:1

Recurrent episodes of wheezing2

Breathlessness2

Chest tightness and coughing2

Airway narrowing leads to variable airflow limitation and intermittent

symptoms2

Airway remodelling is even apparent in children with mild,

intermittent asthma3,4

Seretide (SFC) treats the two main components of asthma:

inflammation and bronchoconstriction

1. Downie SR et al.Thorax2007; 62: 684689. 2. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention.Revised Edition 2007. 3. Bibi HS et al.Respir Med2006; 100: 458462. 4. Jeffery P. Pediatric Pulmonol2001; (Suppl. 21): 316.


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Asthma:A two-part problem of

Inflammation and bronchoconstriction1

Normal airway Airway inflammation

and bronchoconstriction

InflammationDamaged airway passage wall

1. Bousquet J et al. Am J Resp Crit Care Med2000; 161: 17201745.


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Symptoms / exacerbations

LABA ICS

Inflammatory cell infiltration/

activation

Mucosal oedema

Cellular proliferation Epithelial damage

Basement-membrane thickening

Bronchoconstriction

Bronchial hyper-reactivity

Hyperplasia Inflammatory-mediator release

Smoothmuscle

dysfunction

Airwayinflammation/remodelling

Asthma is a two component disease:complementary effects of long-acting 2-agonist &

corticosteroid combination therapy1

1. Johnson M. Proc Am Thorac Soc2004; 1: 200206.


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FP and salmeterol have synergistic

properties when used together

The combination of LABA and ICS is now the most effective

treatment for patients with persistent asthma1

Specifically, the combination of FP and salmeterol has been

shown to be an effective treatment for patients with persistent

asthma, previously uncontrolled on either FP or salmeterol alone2

1. Barnes PJ. Eur Respir J2002; 19:182191. 2. Shapiro G et al.Am J Respir Crit Care Med2000; 161:527534.


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Asthma Controlas per Guidelines


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GINA 2006:Assess, Treat and Monitor

This cycle involves:

ASSESSING CURRENT LEVEL OF ASTHMA CONTROLGINA Guidelines help to identify what level of control your patient is currently on

(Controlled / Partly Controlled / Uncontrolled)1

TREATING TO ACHIEVE CONTROLGINA Guidelines highlight that the aim of asthma treatment is to achieve control2.

GOAL (Gaining Optimal Asthma ControL) study proves that this is achieved with

2

MONITORING TO MAINTAIN CONTROLGOAL study shows that daily treatment with Seretide helps maintain control of

asthma symptoms2

The use of the ACT questionnaire to facilitate in monitoring patient progress2

1. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention. Revised Edition 2007.2. Bateman, E D., Can Guideline-defined Asthma Control be Achieved? The Gaining Optimal Asthma ControL Study, Am J Respir Crit Care Med, Vol. 170, pg.

836-844 2004


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Assessing Current Level of Asthma ControlGINA 2006: Levels of asthma control1

CharacteristicControlled

(All of the following)

Partly controlled(Any measure present

in any week)Uncontrolled

Daytime symptomsNone

(Twice or less / week)

More thantwice / week

3 or more

features

of partly

controlled asthmapresent in

any week

Limitations of activities None Any

Nocturnal symptoms /awakening

None Any

Need for reliever / rescuetreatment

None (Twice or less /week)

More thantwice / week

Lung function(PEF or FEV1)*

Normal< 80% predicted or personal

best (if known)

Exacerbations None One or more/ year** One in any week***

*Lung function is not a reliable test for children 5 years and younger

**Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate

***By definition, an exacerbation in any week makes that an uncontrolled asthma week

.

The Aimof AsthmaTreatment



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Treating to Achieve ControlMedications to treat asthma can be classified as controllers or

relievers1

Controllers Relievers

Are medications taken daily

on a long-term basis to keepasthma under clinical controle.g: long acting inhaled beta-2 agonists in combination with

inhaled glucocorticosteroids

Also known as rescue

medication is used only on anas-needed / SOS basis at thetime of an acute attack. These

act quickly to reversebronchoconstriction & should

not substitute the use of a

controllere.g: rapid-acting inhaled beta-2 agonists (salbutamol)


Increased use, especially daily use, of reliever medication is a warning ofdeteroriation of asthma control and indicates the need to re-assess

treatment


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Step 1 Step 2 Step 3 Step 4 Step 5Asthma education

Environmental Control

As needed rapid-acting Beta-2 agonist

ControllerOptions

Select one Select one Add one or more Add one or both

Low doseinhaled ICS*

Low-dose ICSplus long actingBeta 2 agonist

Medium or high doseICS plus long actingBeta 2 agonist

Oral

Glucocorticosteroid

(lowest dose)

Leukotriene modifier** Medium or high dose ICS Leukotriene Modifier Anti-IgE treatment

Low dose ICS plusLeukotriene modifier

Sustained release theophylline

Low dose ICS plus sustained

release theophylline

Recommended Treatment Alternative Treatment *ICS = Inhaled Glucocorticosteroids** = Receptor antagonist or synthesis inhibitors

Alternative reliever treatments include inhaled anticholinergics, short acting oral beta 2 agonists, some long acting beta 2 agonists and short acting

theophylline. Regular dosing with short and long acting beta 2 agonist is not advised unless accompanied by regular use of an inhaled

glucocorticosteroid

REDUCE INCREASE

Management Approach To Achieve ControlAsthma control rather than severity1



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What do you think?

A 26 year old asthmatic, normally controlled onbeclomethasone 400 mcg daily and salbutamol 100mcg prn, presents to your surgery with worseningwheeze for the past 2 months. She is having daily

nocturnal attacks Her peak flow is 150 l/min.How would you describe her asthma control?

1. Totally Controlled OR

Well Controlled2. Partially Controlled

3. Un-controlled


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What do you think?

A 20 year old lady complains of intermittent

shortness of breath and wheeze. This occurs twice aweek at the most. You correctly diagnose asthma.What is the best advice for her?

1). Start oral Ventolin

2). Start anti-histamines

3). Start leukoterine receptor antagonist

4). Take inhaled short acting B2 agonist on an as-

needed basis


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?

Can Guideline defined

Asthma Control beAchieved?

YES NO


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Such stringent and sustained measures of asthma controlhave never previously been assessed in a clinical trial

1

>5001000 mcgbeclomethasone

equivalent(moderate to

high dose ICS)

500 mcgbeclomethason

e equivalent(low dose ICS)

Steroid-nave(no ICS)

FluticasonePropionate 250 b.d.

FluticasonePropionate100 b.d.

3

2

1

Study treatment*Study strata based on previous total daily dose of ICS

4weekrun-in

3416uncontrolled

asthmapatients

1

1. Bateman et al. Am J Respir Crit Care Med2004. 2. Adams et al. The Cochrane Library, 2002. Oxford.

250 b.d.

100 b.d.


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This study demonstrated the advantage of

over inhaled fluticasone inachieving comprehensive sustainedasthma control1

Bringing a new paradigm toAsthma Control

This is the 1st landmark study to-date to assess whether guideline-defined asthma control canbe achieved7


41%


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uncontrolled asthmatics were TOTALLY controlledwith

Total Controlmeant that an uncontrolled asthmatic achieved all of the following in each assessment week:

Totally controlled asthmawas achieved if the patient

during the 8 consecutive

assessment weeks recorded

7 totally controlled weeks

and had no exacerbations,

emergency room criteria, or

medication-related adverse

events criteria 4

*Predicted PEF was calculated based on the European Community for Steel and Coal standards (40) for patients 18

years and older and on the Polgar standards (41) for patients 12-17 years old.

**Exacerbations were defined as deterioration in asthma requiring treatment with an oral corticosteroid or an emergency

department visit or hospitalization

Day timeSymptoms

Rescue Beta 2agonist use

Night-timeawakening

Morning PEF

Exacerbations**

Emergencyvisits

Treatment relatedadverse events

None

None

80% predicted * every day

None

None

None

None enforcing change inasthma therapy

41%


1

75%


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uncontrolled asthmatics, not controlled on low-dose ICS, were WELL-CONTROLLED with

Well Controlledmeant that an uncontrolled asthmatic experienced

Daytime Symptoms 2 days with symptom score > 1**

Rapid-acting Beta 2agonist use Use on 2 days and 4 occasions/week

Morning PEF 80% predicted *** every day

Night-time awakening None

Exacerbations* None

Emergency visits None

Treatment-related adverse events None enforcing change in asthma therapy

2 or more of the following in each

assessment week

ALL of the following in each assessment week:

*Exacerbations were defined as deterioration in asthma requiring treatment with an oral corticosteroid or an emergency

department visit or hospitalization

**Symtpom score: 1 was defined as symptoms for one short period during the day. Overall scale: 0 (none) 5 (severe)

***Predicted PEF was calculated based on the European Community for Steel and Coal standards (40) for patients 18 years andolder and on the Polgar standards (41) for patients 12-17 years old.

75%


1


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7 out of 10 patients can achieve guidelinedefined control of their asthma with

Patientswitha

w

ell-controlledwe

ek(%)

Week of study

80

60

40

20

0-4 0 4 8 12 10 20 24 28 32 36 40 44 48 52

(n=1709)FP (n=1707)

Run-in

Phase I

Phase II

p


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Adding a LABA vs. higher-dose ICS in patientswith uncontrolled asthma on ICS alone1

n=162

n=159

n=208

***

**

***

**

**

n=144

n=142

n=126

n=135

n=136

n=149n=156

n=195

n=137

35

30

25

20

15

10

5

0

Higher-dose ICS

Weeks of treatment

C

hangeinmeanm

orning

PEF(L/min

)

2117139510

1. Greening AP et al. Lancet1994; 344: 219224.

*

*p


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SFC provides similar control of asthmasymptoms with less steroid1

%

patientsachie

ving

TotalContro

l

0

10

20

30

40

FP

500

n=577 n=583

p


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A Cochrane database review has shown that the use of FP leads

to fewer symptoms and less rescue medication use compared with

beclometasone and budesonide, at half the dose

FP given at half the daily dose of beclometasone or budesonidewas also shown to lead to small improvements in measures of

airway calibre

FP produced a significantly greater end of treatment FEV1 (0.04

litres (95% CI: 0.0 to 0.07 litres), end of treatment and change in

morning PEF, but not change in FEV1 or evening PEF compared

with budesonide and beclometasone, at half the dose

FP = Fluticasone Propionate

Adams N et al. Cochrane Database Syst Rev2008;2: CD002310.

FP leads to fewer symptoms and less rescue medication

use when given at half the dose of beclometasone andbudesonide1


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SFCreduces the need for patients totake their rescue inhaler1

Woodcock1

Median use of salbutamol in the SFC group

was significantly lower than in the ICS-only

group (p


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SFC increases the number of symptom-freedays experienced by asthma patients1

SFC = Salmeterol/Fluticasone PropionateFP = Fluticasone Propionate

1. Woodcock AA et al. Primary Care Respir J2007; 16: 155161.

0

10

20

30

40

50

60

70

80

90

Stratum 1(steroid nave)

Stratum 2(low dose ICS)

Stratum 3(moderatedose ICS)

Pooled strata data

SFC

FP

W

eeks152adjusted

meanchange(%

)

81.5

76.6 74.2

51.055.9

29.9

72.5

54.5


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Asthma control is maintained and

sustained with SFC1

With sustained treatment, asthma control stability is maintained over

months and is positively associated with the initial level of asthma

control and SFC use

SFC = Salmeterol/Fluticasone Propionate

1. Bateman ED et al.Am J Respir Crit Care Med2004; 170: 836844.

0

10

20

30

40

50

60

70

8090

100

Total control Well controlled

%

weekscontrolmaintaine

d

81%86%


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SFC compared with LTRAstudy design1


1. Calhoun WJ et al. Am J Respir Crit Care Med2001; 164: 759763.

SFC 50/100g BID

Montelukast 10mg BID

Screening

period Randomisation

12-weektreatment period

0

Weeks

SFC treatment group

MON treatment group

814

Days

2 4 6 8 10 12


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p


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p


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1. Ringdal N et al. Respir Med2003; 97: 234241.

SFC 50/100 g

FP 100g BID + montelukast 10 mg QD

Treatment week

MeanmorningPEF

(L/min) 420

400

380

360

0

Run-in 12 34 56 78 910 1112

SFC is more effective than FP +oral montelukast in asthma 1

Endpoint

p


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SFC compared with FP +montelukast: exacerbations 1

0

20

40

60

80

FP 100 g BID

+ MON 10 mg QD

SFC

50/100g BID

Numberofpa

tients

p < 0.05


1. Gold M et al. Eur Respir J2001; 18 (Suppl 33): 262s.

The number of

patients with at

least one

exacerbation and

the time to the first

exacerbation was

significantly lower in

the Seretide group

Treatment ith


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p


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SFC vs. Montelukast (LTRA)

Higher increase in mean morning FEV11

Greater number of symptom-free days2

Produced better lung function & asthma control; hence moreeffective than montelukast + fluticasone propionate3

Lower rate of exacerbations4

More effective initial management strategy than montelukast1

Treatment with SFC resulted in:


1. Calhoun WJ et al. Am J Respir Crit Care Med2001; 164: 759763.

2. Data on File, GlaxoSmithKline. SAS40021. 2. Calhoun WJ et al. Am J Respir Crit Care Med2001; 164: 759763.3. Ringdal N et al. Respir Med2003; 97: 234241.4. Gold M et al. Eur Res ir J 2001 18 Su l 33 : 262s.

SFC t l k t ti t


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*Patients responded that they were satisfied or very satisfied with their therapy in each of

these categories

SFC versus montelukast: patientsatisfaction1

SFC = Salmeterol/Fluticasone Propionate1. Data on File. GlaxoSmithKline. SAS40020

p


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Response to the use of LTRA is independent of the use of

ICS

Response to LTRA has been shown to be the same

regardless of ongoing use of ICS

The effect of LTRAs appears to be additive to that of ICSs

There is no evidence of a synergisticeffect when LTRA is added to ICS in

patients with asthma

1

1. Beckeret al. CMAJ2005; 173(6 Suppl): S37S38.


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Asthma Management

Options

P ti t li ith th


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Patient compliance with asthmamedication

Compliance with asthma medicationdecreases over time

In one study, only 40% of asthma patients were compliant with their

medication over 5 weeks1

In another study, compliance with asthma medication decreased

from 51% during the first week to less than 30% after 10 weeks2

1. Chmelik F et al. Ann Allergy1994; 73: 527532. 2. Onyirimba F et al. Ann Allerg Asthma Immunol2003; 90: 411415.

P ti t li ith th


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Patient compliance with asthmamedication1

1. Horne R. Chest2006; 130; 6572

PoorCompliance

Concern about side effects

Patients negative attitude towards

medicines in general

Past experience

Views of others

Cultural influencesPractical difficulties

Patients perceived need

R li M di ti Mi


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Reliever Medication Misuse

In Pakistan, in the indication of Asthma, there is a large use of relievermedication1indicating that patients asthma is uncontrolled and theyexperience frequent attacks.

According to GINA, this is a warning of deterioration of ones asthma

condition2

This highlights misunderstandings of the disease and the low level ofpatient compliance

Aiming for Total Control with results in the virtualelimination of exacerbations and hence, reliever medication use3

1. IMS Data, MIS Qtr 3/2008 & PKPI 1S/2008

2. Global Initiative for Asthma (GINA): Global Strategy for Asthma Management & Prevention, Revised Edition 20073. Bateman et al. Am J Respir Crit Care Med2004. 2. Adams et al. The Cochrane Library, 2002. Oxford.4. Hoskins 2000

According to a UK study, the average total cost of asthma per patient was 2.1times higher in the attack (exacerbation) group than the non-attack (no

exacerbation) group, excluding cost of hospitalization4

I i ti t li


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Improving patient compliance

Simple, regular dosing

Simple dose regimens are generally

easier for patients to follow1

Compliance rates are most highly

correlated with the number of doses

rather than the number of medications or

tablets that must be taken daily1

The core issue for patients is: How

many times a day must I remember totake a dose?1

1. Cramer J.A. Heart2002; 88: 203206.


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Regular, twice-daily SFCgives control of asthma:what does this mean for the patient?

Well controlled asthma control is achieved1

SFC leads to more symptom-free days and

virtual elimination of exacerbations2

The twice-daily dosing may facilitate improvedpatient compliance3

1. Bateman ED et al. Am J Respir Crit Care Med2004; 170: 836844. 2. Woodcock AA et al. Primary Care Respir J2007; 16: 155161. 3. CramerJA. Heart2002; 88: 203206.


i T t l C t l f


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gives Total Control ofasthma

Patients can experience improvements in quality of life (QoL)to levels where there is little or no impact of asthma onQoL for patients1

The patients perspective of how well their asthma is being treated is

best represented by QoL1 Well controlled asthma can result in little or no impact of asthma symptoms

on QoL for many patients1

At least 7 out of 10 asthma patients are well controlled taking1


1. Bateman ED et al. Eur Respir J2002; 20: 588595.


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Monitoring Asthma Control inClinical Practice

A th C t l T t (ACT)


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Asthma Control Test (ACT)

ACT is an effective, validated andindependent method of assessingasthma control in clinical practice

Asthma treatment target previously

not defined

Despite the availability of effective

treatments and comprehensive

guidelines, outcomes of asthma

management are frequently sub-optimal

Clear targets are needed to guide treatment andfacilitate assessment of CONTROL

1,2

1

1


2. ACT: The Asthma Control Test, GSK Data on File

A th C t l T t (ACT)


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Clear therapeutic targets exist

for many chronic diseases

Philosophy of treat to targetHypertension BP


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2002, by QualityMetric Incorporated.Asthma Control Test is a trademark of QualityMetric Incorporated.

Whats Yo r Score?


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Whats Your Score?

A score20 indicates that asthma iswell controlled.

A score 19 indicates that asthma

may not be well controlled

With TOTAL CONTROL of asthma now a reality, ACT can beused to raise expectations of asthma management and help

make TOTAL CONTROL the aim for all patients.

Maximum score of 25 indicates

TOTAL asthma control.



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Is endorsed by severalinternational societies including:

Pakistan -Pakistan Chest SocietyCanada -Canadian Thoracic Society (CTS)Canadian Lung Association (CLA)Australia -Asthma Foundation Australia (AFA)National Asthma Council (NAC)Turkey -

Turkish Thoracic Society (TTS)Korea -Korea Asthma Allergy FoundationAnd many more

Conclusions


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ConclusionsNew Concepts in Asthma Control

TOTAL CONTROLof asthma is achievable

NO Daily Symptoms

NO Rescue salbutamol useNO Days at 80% AM PEF*NO Night-time awakeningNO Exacerbations**NO Adverse Events leading to treatment change

With the right treatment approach, anasthmatic can have a better Quality of Life

1

1. Bateman ED et al.Am J Respir Crit Care Med2004; 170: 836844.


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Full Prescribing Information is available on request

GlaxoSmithKline Pakistan Limited

35 - Dockyard Road, West Wharf, Karachi - 74000

Seretide is a trademark of GlaxoSmithKline group of companies.

GlaxoSmithKline Pakistan Limited is a member of

GlaxoSmithKline group of companies.

GlaxoSmithKline Pakistan Limited


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CASESTUDIES

CASE - A


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CASE A

Patient name: Maryam AhmedAge: 51

Maryam is a 51-year old woman with a history of asthma. She has beenexperiencing a gradual increase in symptoms over the recent years.These include daily symptoms as well as night waking once a weekdespite being treated with inhaled steroids. Her early morningexercise routine is triggering symptoms leading to an over-use of

relief inhalers.As part of the treatment long-acting B2 agonists were added to inhaled

corticosteroids which seemed to bring about relief.However on one occasion, she was exposed to a trigger for an acute

exacerbation which resulted in an attack. Her previous practice oftaking oral corticosteroids was not acted upon due to confusion.When she was presented at a surgery, the receptionist recognized theneed of immediate assessment. When tested, her Peak flow wasmeasured to be 45% and the respiratory rate was 27 breaths/minute.Although Maryam was breathless she was able to speak and explainabout the whole situation to the nurse on duty.

CASE A


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CASE A

Questions

Q1). How will you tackle the problems presented by Maryam?

Q2). What should the doctor do now?

Q3). How should Maryams response be monitored?

Q4). Should Maryam be admitted to the hospital?

?? ?

CASE - B


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CASE B

Name: Maimoona NaseemAge: 40

A 40-year old woman has had increasingly difficult to control asthmasince the birth of her third child at the age of 30 years. She has beenunder the care of another physician, but requests a second opinion.

You confirm that she has been on beclomethasone 1000g twice dailyfrom a pMDI with a spacer device, and that her inhaler technique is

good. In spite of this she has night waking at least 4 times per week,has difficulty completing household chores like sweeping andwashing clothes, and seldom goes out, fearing that she will have anasthma attack.

She has required emergency treatment at your rooms on 4 occasions inthe last year, and on each occasion has required a burst of oralprednisone 40mg daily for 7 days. She has gained weight to 85 kgover the last 2 or 3 years. Previous treatment with theophylline syrup

has provided temporary relief. On examination she has a prominentwheeze, and her FEV1 is 65% of predicted at best. Values as low as28% of predicted have been recorded at emergency visits to the clinic.

CASE B


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CASE B

Questions

Q1) How would you define this patients asthma?

Q2) What should the management/treatment goals be for thiscase?

Q3) For how long should the treatment be continued? When

would you consider stopping treatment?

Q4) What is/ are the most practical method/s for establishingwhether a patients asthma is controlled?

Q5) Which patients should be targeted for use of an AsthmaControl Test?

??

?

CASE - C


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CASE C

Patient name:Uzma KhanAge: 18

Uzma is a 18-year-old female who was referred by her family physician to anallergist, Dr.Raffay. She has moderate persistent asthma and chronicallyuses inhaled corticosteroids. Her chief complaint is of frequent asthmaexacerbations, which have had a significant impact on her quality of lifeand have taken significant time from her studies and other social activities.

These exacerbations often require urgent care visits and treatment withsystemic corticosteroids but is not fully compliant to her medication. Shealso suffers from atopic dermatitis, is allergic to nuts, and is on animmunotherapy regimen.

Uzmas parents are also concerned that shes of marriageable age and howthis problem is going to affect her marriage prospects. Thus they tend toconceal this problem rather than actively seeking out treatment.

Expert Commentaries: Dr. Usman Rafi:The take home message with this patient is that youre dealing with a 18-year-old teenager who will now most likely have life-long asthma andwhose asthma is interfering significantly with her life and the life of herfamily.

CASE C


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CASE C

Questions

Q). Identify key areas where the patient isexperiencing problems in life and explain

how you would help this patient managethe challenges of having asthma.

?

?

?


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TOTAL ASTHMA CONTROL

WHEN?For all uncontrolled asthmatics (4 years & above)

HOW?Daily use of 2 puffs, twice daily

WHY?

Seretideprovides TOTAL ASTHMA CONTROLallowing patients to live life to the fullest

1

1

2

1. Bateman ED et al.Am J Respir Crit Care Med2004; 170: 8368442. Seretide Evohaler Data sheet. Version No. GDS24/IPI12. Date of issue: 31st Jan 2008.


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Bronchial Asthma Presentation

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