Asthma Guidelines and
Improving Patient Care
Learning Objectives
Upon completion of this activity,
participants should be able to:
• Describe the role of inflammation in persistent asthma
• Explain how to incorporate new recommendations
offered in the NAEPP EPR-3 asthma guidelines into
patient care
• Describe the importance and clinical relevance of
impairment and risk as components of severity and
asthma control
• Cite ways to apply guidelines-based recommendations
for identifying and managing difficult-to-control patients
NAEEP EPR-3=National Asthma Education and Prevention Program Expert Panel Report 3.
2
What Is RAD?
RAD is the Respiratory & Allergic
Disease Foundation, a 501(c)(3)
not-for-profit organization:
– Dedicated to providing quality education for
clinicians by clinicians
– Physician leadership
– Funded by multiple industry supporters
– Science-based
3
4
What Is ARC?
• National network of respiratory disease educators
• Outreach Centers across the country are local
hubs for respiratory education and outreach
• Programs developed with funding from multiple
industry supporters
• Focused on practical topics for advancing
respiratory care
• Programs are non-promotional and educational
in nature
Clinical Action Steps
5
Our goal: Upon completion of this program, you will consider…
• Reviewing current asthma treatment practices vs
those in the new EPR-3 asthma guidelines
• Providing allergy testing to all patients with persistent
asthma
• Monitoring asthma disease control in your patients’
routinely scheduled follow-up visits
• Co-managing or consulting with an asthma specialist
when patients require step 4 therapy or above
• Using written action plans and patient education to
improve asthma outcomes
New Guidelines and
An Evolved View of Asthma
Definition, Pathophysiology, and Diagnosis
Asthma Defined
7
“Chronic inflammatory disorder of the airways”
• Inflammatory cell infiltrates: eosinophils, lymphocytes,
neutrophils
• Mast cell activation, epithelial cell injury
• Abnormal smooth muscle function and
neovascularization
Inflammation contributes to:
•
•
•
•
Respiratory symptoms
Airflow limitation/partial airway obstruction
Airway hyperresponsiveness
Disease chronicity
Adapted from National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma
(EPR-3) 2007. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August
2007. NIH publication no. 08-4051.
8
Our Understanding of Asthma Has Evolved
• Role of inflammation as the major feature of
asthma as a chronic disease substantiated
• Variability of asthma is evidenced by different
phenotypes and changes over time within the
individual
• Atopy (IgE-mediated disease) increasingly
recognized as major predisposing factor for asthma
• Current asthma treatment with anti-inflammatory
therapy does not appear to alter disease
progression in infants/children
• Potential for a nonreversible component to asthma
is increasingly recognized
9
Asthma Pathophysiology
Individual
• Genetic predisposition
• Intrinsic vulnerability
• Atopy/allergy
• Environmental triggers
Inflammation
• Inflammation underlies
disease processes
• Phenotype varies by
Impact
Clinical symptoms also
vary by individual
and over time
individual and over time
AHR=airway hyperresponsiveness.
Predictive Index for
Development of Asthma
One or more of the following
– Parental history of asthma
– Physician’s diagnosis of atopic dermatitis
– Sensitization to aeroallergens
OR
Two of the following
– Sensitization to foods
– ≥4% peripheral blood eosinophilia
– Wheezing apart from colds
National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3)
2007. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August 2007.
NIH publication no. 08-4051.
10
Confirm Diagnosis
• Especially when symptoms are atypical or
response to treatment is poor
• When reversible airways are obstructed
– ≥12% increase in FEV1 (≥200 cc)
– Inhaled or oral corticosteroids may be
required to demonstrate reversibility
• Methacholine challenge can confirm
diagnosis
FEV1=forced expiratory volume at 1 second.
11
Important Asthma “Masqueraders”
• Cough
– Postnasal drip
– Reflux
– ACE inhibitor
– Vocal cord dysfunction
• Hyperventilation
• Panic attacks
May coexist and complicate therapy
unless recognized and treated
12
Initial Asthma Assessment:
Assessing Asthma Severity
Impairment and Risk
14
Four Components of Initial Assessment
1. Classification of asthma severity;
measures of pulmonary function using
spirometry are recommended
2. Identification of precipitating factors
3. Identification of comorbid conditions
that may aggravate asthma
4. Assessment of patient knowledge and
skills for self-management
Documenting each of these steps will aid in the
long-term management of asthma
Identify Precipitating Factors
and Comorbid Conditions
Precipitating
Factors
• Allergens
• Irritants (eg,
environmental,
tobacco smoke)
• Respiratory viruses
• Medications
Comorbid
Conditions
• GERD
• Rhinosinusitis
• Rhinitis
• OSA
• Obesity
• ABPA
GERD=gastroesophageal reflux disease.
OSA=obstructive sleep apnea.
ABPA=allergic bronchopulmonary aspergillosis.
15
New in EPR-3: Allergy Testing for All
Patients With Persistent Asthma
• All patients with persistent asthma are
recommended for evaluation of allergens as
possible contributing factors
– Especially perennial allergens
– Can be done through skin or in vitro testing
• Allergies are significant triggers for asthma in
≥80% of children and 50%-60% of adults
National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of
Asthma (EPR-3) 2007. Bethesda, MD: US Department of Health and Human Services, National
Institutes of Health; August 2007. NIH publication no. 08-4051.
16
Immunological Mechanisms in
Respiratory Diseases
17
Relationship Between Asthma
and Serum IgE Level
Odds Ratio for Presence
of Asthma
40
18
N = 2657
20
10
5.0
ULN
2.5
1.0
0.32
1
3.2
10
32
100 320 1000 3200
Serum IgE (IU/ml)
ULN=upper limit of normal.
Burrows B, et al. N Engl J Med. 1989;320:271-277.
19
Asthma Severity
Where Does It Fit?
New in EPR-3: Differentiating Severity,
Control, and Responsiveness
• Severity
– The intrinsic intensity of the disease process
– Measured before receiving long-term control therapy
• Control
– The degree to which asthma’s manifestations are minimized
and the goals of therapy are met
– Guide decisions to maintain or adjust therapy
• Responsiveness
– The ease with which asthma control is achieved by therapy
• Both severity and control have 2 domains:
– Impairment: immediate manifestations of the disease
– Risk: potential for exacerbations or decreased lung function
National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3) 2007. Bethesda, MD: US
Department of Health and Human Services, National Institutes of Health; August 2007. NIH publication no. 08-4051.
20
21
Severity: Impairment and Risk Domains
Severity, Control, and
Responsiveness Are Related
Select Appropriate
Therapy Step
Step therapy
up or down
22
Severity Table: EPR-3
How Is it Organized?
Component
of
Severity
23
Classification of Asthma Severity >12 yrs of age
Intermittent
Persistent
Mild
Moderate
Severity Classification
Severe
Severity Table: EPR-3
Impairment Domain
Impairment
Component
of
Severity
24
Classification of Asthma Severity >12 yrs of age
Intermittent
Persistent
Mild
Moderate
Severe
Symptoms
Nighttime
awakening
SABA use
IMPAIRMENT DOMAIN
Interference
with activity
Lung function
SABA=short-acting β-agonist.
Severity Table: EPR-3
Risk Domain
Component
of
Severity
25
Classification of Asthma Severity >12 yrs of age
Intermittent
Persistent
Mild
Moderate
Severe
Impairment
Symptoms
RISK
Nighttime
awakening
SABA use
Interference
with activity
Lung function
Exacerbations
requiring
oral steroids
RISK DOMAIN
Considers exacerbation severity, frequency,
interval since last exacerbation, and potential link
between FEV1 and relative annual risk
Severity Table: EPR-3
Initial Treatment Step
Component
of
Severity
26
Classification of Asthma Severity >12 yrs of age
Intermittent
Persistent
Mild
Moderate
Severe
Impairment
Symptoms
RISK
Nighttime
awakening
SABA use
Interference
with activity
Lung function
Exacerbations
requiring
oral steroids
Recommended
Treatment
Step
0-1/yr
≥2/yr
Treatment Step
Step of treatment recommended for initial therapy,
with follow-up in 2-6 wks
Impairment
Component
of
Severity
Intermittent
Persistent
Mild
Moderate
Severe
Symptoms
<2 d/wk
>2 d/wk
but not daily
Daily
Throughout the
day
Nighttime
awakening
<2 d/mo
3-4x/mo
>1x/wk but not
nightly
Often 7x/wk
<2 d/wk
>2 d/wk
but not daily &
not >1x on any day
Daily
Several times
per day
NONE
Minor limitation
Some limitation
Extremely
limited
SABA use
Interference
with activity
Lung function
RISK
Classification of Asthma Severity (>12 yrs) 27
• Normal FEV1
between
exacerbations
• FEV1: >80%
predicted
• FEV1/FVC:
normal
Exacerbations
requiring
oral steroids
0-1/yr
Recommended
Treatment Step
Step 1
• FEV1 : >80%
predicted
• FEV1/FVC: normal
• FEV1: >60% but
<80% predicted
• FEV1/FVC:
reduced 5%
• FEV1: <60%
• FEV1/FVC:
reduced 5%
≥2/yr
Consider severity and interval since last exacerbation as
they may fluctuate over time in any severity category
Step 2
Step 3
Step 4 or 5
& consider short OS burst
Asthma Treatment Steps
New Treatment
Recommendations in EPR-3
New in EPR-3: Pharmacologic Therapy
• New data on the safety of LABAs are discussed
 The Expert Panel concluded that LABAs should not
be used as monotherapy for long-term control of
persistent asthma
 LABAs should continue to be considered
adjunctive therapy to inhaled corticosteroids
• New medication choice: Immunomodulators
(omalizumab)
National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of
Asthma (EPR-3) 2007. Bethesda, MD: US Department of Health and Human Services, National
Institutes of Health; August 2007. NIH publication no. 08-4051.
29
Pharmacologic Therapy (cont’d)
• For patients not adequately controlled on
low-dose inhaled corticosteroids, the option to
increase the ICS dose should be given equal
weight to the addition of an LABA
• The Expert Panel continues to endorse the use
of a combination of LABAs and ICS as the most
effective therapy for the patient who has more
severe persistent asthma
LABA=long-acting beta2-agonist.
National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of
Asthma (EPR-3) 2007. Bethesda, MD: US Department of Health and Human Services, National
Institutes of Health; August 2007. NIH publication no. 08-4051.
30
New in EPR-3:
IgE Immunomodulation
• Current therapy is not fully effective for all
patients; many patients on higher-step therapy
are still uncontrolled
• New and investigational compounds aimed at
modulating the effects of IgE offer promise for
controlling symptoms and preventing
progression
• Suppression of IgE and/or IgE synthesis is an
important strategy
Adapted from National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of
Asthma (EPR-3) 2007. Bethesda, MD: US Department of Health and Human Services, National Institutes of
Health; August 2007. NIH publication no. 08-4051.
31
Anti-IgE Therapy
• Omalizumab, a monoclonal anti-IgE antibody, is
currently the only approved anti-IgE therapy licensed in
the United States for:
the prophylaxis of asthma exacerbations and
control of symptoms in moderate to severe allergic
asthma in patients ≥12 years of age
• Given as an add-on therapy to ICS in moderate to
severe allergic asthma, it significantly reduces asthma
exacerbations and allows doses of ICS to be reduced
National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma
(EPR-3) 2007. Bethesda, MD: US Department of Health and Human Services, National Institutes of
Health; August 2007. NIH publication no. 08-4051.
32
Appropriate Candidates for
Anti-IgE Therapy
Adolescent (≥12 yrs) and adult patients:
• with moderate to severe persistent asthma
• who demonstrate a positive skin or in vitro
reactivity to a perennial aeroallergen
– with IgE between 30-700 IU/mL
– whose symptoms are inadequately controlled
with ICS or ICS+LABA
– who are not eligible for immunotherapy
– who have adequate coverage or resources for
cost of therapy
33
Anti-IgE Therapy Considerations
34
BLACK BOX WARNING FOR OMALIZUMAB:
Anaphylaxis, presenting as bronchospasm, hypotension, syncope,
urticaria, and/or angioedema of the throat or tongue, has been
reported to occur after administration of Xolair. Anaphylaxis has
occurred as early as after the first dose of Xolair, but also has
occurred beyond 1 year after beginning regularly administered
treatment. Because of the risk of anaphylaxis, patients should be
closely observed for an appropriate period of time after Xolair
administration, and health care providers administering Xolair
should be prepared to manage anaphylaxis that can be lifethreatening. Patients should also be informed of the signs and
symptoms of anaphylaxis and instructed to seek immediate
medical care should symptoms occur (see WARNINGS, and
PRECAUTIONS, Information for Patients).
Xolair [package insert]. South San Francisco, CA: Genentech, Inc; 2007.
Overview of Asthma Medications
Daily: Long-term Control
–
–
–
–
–
Corticosteroids (inhaled and systemic)
Cromolyn/nedocromil
LABAs
Methylxanthines (theophylline)
Leukotriene modifiers
As-needed: Quick Relief
– SABAs
– Anticholinergics
– Systemic corticosteroids
Immunomodulators
– Omalizumab
– Allergen-specific immunotherapy
35
Steps of Therapy
36
Preferred medications:
• Best balance of efficacy and safety in clinical
trials for patients at that level of severity
All medications:
• Must be tailored to individual patient’s needs,
circumstances, and responsiveness
37
Steps of Therapy: Age ≥12 Years
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Step 6
Step 5
Step 4
Step 3
Step 2
Preferred:
Step 1
Preferred:
SABA PRN
Low-dose ICS
Alternative:
Cromolyn, LTRA,
Nedocromil, or
Theophylline
Preferred:
Low-dose
ICS + LABA
OR
Medium-dose ICS
Alternative:
Low-dose ICS +
either LTRA,
Theophylline, or
Zileuton
Preferred:
Medium-dose ICS
+ LABA
Alternative:
Medium-dose ICS
+ either LTRA,
Theophylline, or
Zileuton
Preferred:
High-dose
ICS + LABA
Preferred:
High-dose
ICS + LABA + oral
corticosteroid
AND
AND
Consider
Omalizumab for
patients who have
allergies
Consider
Omalizumab for
patients who have
allergies
Each step: Patient education, environmental control, and management of comorbidities.
Steps 24:
Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).
Quick-Relief Medication for All Patients
•
•
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals
as needed. Short course of oral systemic corticosteroids may be needed.
Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step
up treatment.
Step up if
needed
(first, check
adherence,
environmental
control, and
comorbid
conditions)
Assess
control
Step down if
possible
(and asthma is
well controlled
at least
3 months)
38
Steps of Therapy: Age ≥12 Years
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Step 6
Step 5
Step 4
Step 3
Step 2
Preferred:
Step 1
Preferred:
SABA PRN
Low-dose ICS
Alternative:
Cromolyn, LTRA,
Nedocromil, or
Theophylline
Preferred:
Low-dose
ICS + LABA
OR
Medium-dose ICS
Alternative:
Low-dose ICS +
either LTRA,
Theophylline, or
Zileuton
Preferred:
Medium-dose ICS
+ LABA
Alternative:
Medium-dose ICS
+ either LTRA,
Theophylline, or
Zileuton
Preferred:
High-dose
ICS + LABA
Preferred:
High-dose
ICS + LABA + oral
corticosteroid
AND
AND
Consider
Omalizumab for
patients who have
allergies
Consider
Omalizumab for
patients who have
allergies
Each step: Patient education, environmental control, and management of comorbidities.
Steps 24:
Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).
Quick-Relief Medication for All Patients
•
•
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals
as needed. Short course of oral systemic corticosteroids may be needed.
Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step
up treatment.
Step up if
needed
(first, check
adherence,
environmental
control, and
comorbid
conditions)
Assess
control
Step down if
possible
(and asthma is
well controlled
at least
3 months)
39
Steps of Therapy: Age ≥12 Years
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Step 6
Step 5
Step 4
Step 3
Step 2
Preferred:
Step 1
Preferred:
SABA PRN
Low-dose ICS
Alternative:
Cromolyn, LTRA,
Nedocromil, or
Theophylline
Preferred:
Low-dose
ICS + LABA
OR
Medium-dose ICS
Alternative:
Low-dose ICS +
either LTRA,
Theophylline, or
Zileuton
Preferred:
Medium-dose ICS
+ LABA
Alternative:
Medium-dose ICS
+ either LTRA,
Theophylline, or
Zileuton
Preferred:
High-dose
ICS + LABA
Preferred:
High-dose
ICS + LABA + oral
corticosteroid
AND
AND
Consider
Omalizumab for
patients who have
allergies
Consider
Omalizumab for
patients who have
allergies
Each step: Patient education, environmental control, and management of comorbidities.
Steps 24:
Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).
Quick-Relief Medication for All Patients
•
•
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals
as needed. Short course of oral systemic corticosteroids may be needed.
Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step
up treatment.
Step up if
needed
(first, check
adherence,
environmental
control, and
comorbid
conditions)
Assess
control
Step down if
possible
(and asthma is
well controlled
at least
3 months)
40
Steps of Therapy: Age ≥12 Years
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Step 6
Step 5
Step 4
Step 3
Step 2
Preferred:
Step 1
Preferred:
SABA PRN
Low-dose ICS
Alternative:
Cromolyn, LTRA,
Nedocromil, or
Theophylline
Preferred:
Low-dose
ICS + LABA
OR
Medium-dose ICS
Alternative:
Low-dose ICS +
either LTRA,
Theophylline, or
Zileuton
Preferred:
Medium-dose ICS
+ LABA
Alternative:
Medium-dose ICS
+ either LTRA,
Theophylline, or
Zileuton
Preferred:
High-dose
ICS + LABA
Preferred:
High-dose
ICS + LABA + oral
corticosteroid
AND
AND
Consider
Omalizumab for
patients who have
allergies
Consider
Omalizumab for
patients who have
allergies
Each step: Patient education, environmental control, and management of comorbidities.
Steps 24:
Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).
Quick-Relief Medication for All Patients
•
•
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals
as needed. Short course of oral systemic corticosteroids may be needed.
Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step
up treatment.
Step up if
needed
(first, check
adherence,
environmental
control, and
comorbid
conditions)
Assess
control
Step down if
possible
(and asthma is
well controlled
at least
3 months)
41
Steps of Therapy: Age ≥12 Years
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Step 6
Step 5
Step 4
Step 3
Step 2
Preferred:
Step 1
Preferred:
SABA PRN
Low-dose ICS
Alternative:
Cromolyn, LTRA,
Nedocromil, or
Theophylline
Preferred:
Low-dose
ICS + LABA
OR
Medium-dose ICS
Alternative:
Low-dose ICS +
either LTRA,
Theophylline, or
Zileuton
Preferred:
Medium-dose ICS
+ LABA
Alternative:
Medium-dose ICS
+ either LTRA,
Theophylline, or
Zileuton
Preferred:
High-dose
ICS + LABA
Preferred:
High-dose
ICS + LABA + oral
corticosteroid
AND
AND
Consider
Omalizumab for
patients who have
allergies
Consider
Omalizumab for
patients who have
allergies
Each step: Patient education, environmental control, and management of comorbidities.
Steps 24:
Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).
Quick-Relief Medication for All Patients
•
•
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals
as needed. Short course of oral systemic corticosteroids may be needed.
Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step
up treatment.
Step up if
needed
(first, check
adherence,
environmental
control, and
comorbid
conditions)
Assess
control
Step down if
possible
(and asthma is
well controlled
at least
3 months)
42
Steps of Therapy: Age ≥12 Years
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Step 6
Step 5
Step 4
Step 3
Step 2
Preferred:
Step 1
Preferred:
SABA PRN
Low-dose ICS
Alternative:
Cromolyn, LTRA,
Nedocromil, or
Theophylline
Preferred:
Low-dose
ICS + LABA
OR
Medium-dose ICS
Alternative:
Low-dose ICS +
either LTRA,
Theophylline, or
Zileuton
Preferred:
Medium-dose ICS
+ LABA
Alternative:
Medium-dose ICS
+ either LTRA,
Theophylline, or
Zileuton
Preferred:
High-dose
ICS + LABA
Preferred:
High-dose
ICS + LABA + oral
corticosteroid
AND
AND
Consider
Omalizumab for
patients who have
allergies
Consider
Omalizumab for
patients who have
allergies
Each step: Patient education, environmental control, and management of comorbidities.
Steps 24:
Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).
Quick-Relief Medication for All Patients
•
•
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals
as needed. Short course of oral systemic corticosteroids may be needed.
Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step
up treatment.
Step up if
needed
(first, check
adherence,
environmental
control, and
comorbid
conditions)
Assess
control
Step down if
possible
(and asthma is
well controlled
at least
3 months)
43
Steps of Therapy: Age ≥12 Years
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Step 6
Step 5
Step 4
Step 3
Step 2
Preferred:
Step 1
Preferred:
SABA PRN
Low-dose ICS
Alternative:
Cromolyn, LTRA,
Nedocromil, or
Theophylline
Preferred:
Low-dose
ICS + LABA
OR
Medium-dose ICS
Alternative:
Low-dose ICS +
either LTRA,
Theophylline, or
Zileuton
Preferred:
Medium-dose ICS
+ LABA
Alternative:
Medium-dose ICS
+ either LTRA,
Theophylline, or
Zileuton
Preferred:
High-dose
ICS + LABA
Preferred:
High-dose
ICS + LABA + oral
corticosteroid
AND
AND
Consider
Omalizumab for
patients who have
allergies
Consider
Omalizumab for
patients who have
allergies
Each step: Patient education, environmental control, and management of comorbidities.
Steps 24:
Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).
Quick-Relief Medication for All Patients
•
•
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals
as needed. Short course of oral systemic corticosteroids may be needed.
Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step
up treatment.
Step up if
needed
(first, check
adherence,
environmental
control, and
comorbid
conditions)
Assess
control
Step down if
possible
(and asthma is
well controlled
at least
3 months)
Referral to an Asthma Specialist
44
Consider consultation or co-management with an
asthma specialist if patient:
• is receiving step 3 care but is recommended for step 4 or higher
• has a history that includes life-threatening asthma exacerbation
• is not meeting therapy goals after 3 to 6 months of treatment
• has signs and symptoms that are atypical, or there are problems
in differential diagnosis
• has other conditions that complicate asthma (eg, COPD, VCD,
GERD)
• requires additional diagnostic testing
• needs additional education/guidance on complications of
therapy, problems with adherence, or allergen avoidance
• is being considered for immunotherapy or omalizumab
Education for a Partnership in Asthma Care
• Patients should be educated at multiple points
of care (eg, home, office, pharmacy)
• Self-management education includes:
– Asthma information and training in asthma
management
– Self-monitoring (symptoms or peak flow)
– Written asthma action plans
• Involve patients in decision-making process to
foster partnership
45
Asthma Action Plans
for ALL Patients
• Why daily treatment to control asthma is often
needed
• How to recognize and handle signs and symptoms
of worsening asthma
• What type of environmental control measures to
take
• Which medications to take—and when
• When to seek medical care
46
Control Is the Goal
Monitoring and Achieving
Asthma Control
48
Defining Disease Control in Asthma Is Difficult
Asthma
Oncology
• Disease-free survival
• Tumor recurrence or
growth
Diabetes mellitus
• Serum glucose
• Hemoglobin A1C
Rheumatoid arthritis
• Composite disease
scores
• X-ray progression
•
•
•
•
•
•
•
•
•
Symptoms?
SABA use?
FEV1/PEF?
Quality of life?
Healthcare
utilization?
Exacerbations?
Exercise tolerance?
Exhaled nitric oxide?
Sputum eosinophils?
FEV1=forced expiratory volume at 1 second.
PEF=peak expiratory flow.
49
Asthma Is Not a Static Disease
Poor
control
Wheezing
Dyspnea
Cough
Use of rescue
medication
FEV1
PEF
variability
Good
control
EPR-3: Goals of Asthma Care
• Reduce Risk
– Prevent recurrent exacerbations and minimize the need
for ED visits/hospitalizations
– Prevent progressive loss of lung function; for children,
prevent reduced lung growth
– Provide optimal pharmacotherapy with minimal or no
adverse effects
• Reduce Impairment
– Prevent chronic and troublesome daytime and nighttime
symptoms
– Maintain normal activity, including work, school, leisure
activity, and exercise
– Provide pharmacotherapy with minimal or no adverse
effects
– Achieve patient and family satisfaction with asthma care
National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3) 2007.
Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August 2007. NIH
publication no. 08-4051.
50
51
New in EPR-3: Asthma Monitoring and Control
• Emphasis is placed on routine visits rather than
as-needed visits for out-of-control asthma
• Periodic assessments every 1-6 mos recommended
to monitor asthma control
• Modifications in therapy are based on assessments
of control
• Both the importance of environmental control and
management of comorbidities are given greater
prominence
National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3) 2007.
Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August 2007. NIH
publication no. 08-4051.
52
Assessing Asthma Control: EPR-3
53
Assessing Asthma Control: EPR-3
Asthma Control Test™ (ACT)
54
1. In the past 4 weeks, how much of the time did your asthma keep you from getting
as much done at work, school, or at home?
Score
2. During the past 4 weeks, how often have you had shortness of breath?
3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness
of breath, chest tightness or pain) wake you up at night, or earlier than usual in the morning?
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication
(such as albuterol)?
5. How would you rate your asthma control during the past 4 weeks?
A score of ≤19 means your patient’s asthma may not be under control.
ACT is for patients ≥12 years with asthma.
Asthma Control Test is a trademark of QualityMetric Incorporated. Copyright 2002, QualityMetric Incorporated.
Total
55
Actions Once Control Is Assessed
Well-Controlled
Not Well-Controlled
• Maintain current
step
• STEP UP 1 step
• Regular follow-up
every 1-6 mos
to maintain control
• Reevaluate in
2-6 wks
• Consider STEP
DOWN if wellcontrolled for at
least 3 mos
• For side effects,
consider alternative
treatment options
Very Poorly
Controlled
• Consider short
course of oral
systemic
corticosteroids
• STEP UP 1-2 steps
• Re-evaluate in
2 wks
• For side effects,
consider alternative
treatment options
Adapted from National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3) 2007. Bethesda,
MD: US Department of Health and Human Services, National Institutes of Health; August 2007. NIH publication no. 08-4051.
If Good Control Is Not Achieved
Consider possible contribution of:
• Adverse environmental/
allergen exposures
• Poor technique
• Poor adherence to therapy
• Comorbidities
56
Conclusions and Cases
58
Review: Treatment Differences
• ICS strongly recommended as most
important controller therapy for
persistent asthma
• Combination of ICS + LABA strongly
recommended for step 4 therapy and
above
• Omalizumab recommended in steps
5 & 6 for appropriate patients
Using the Guidelines
Initial Assessment
Follow-up Assessments
ASSESS SEVERITY using criteria
from the NIH guidelines
ASSESS CONTROL using criteria from the
NIH guidelines and a validated tool, such as
the Asthma Control Test™
SELECT ASTHMA THERAPY
2007 NIH steps of asthma therapy
59
Please go to www.rad-foundation.org
for additional information and resources
Thank You!
62
Patient Profile: Thomas F.
Patient: 46 y/o Hispanic man, diagnosed at age 27
• Landscaper; on temporary disability
History of
• Seen in office 5x over past yr (3 unscheduled visits)
Disease:
• One hospitalization in past 6 mos; was not intubated
• Waking 1-2x/night due to wheezing (frequently over past
6 mos)
Symptoms: • Concomitant rhinitis symptoms
• Asthma triggered by seasonal changes, mold, grasses, upper
respiratory infections, and strong odors
•
•
Current •
Medications: •
•
•
Inhaled fluticasone/salmeterol 500/50 mg BID
Montelukast 10 mg QD
Frequent corticosteroid bursts: prednisone 10 mg to 60 mg QD
Short-acting -agonists 2-3x/d
Theophylline 450 mg QD
Fexofenadine 180 mg QD
63
Patient Profile, Cont’d: Thomas F.
Current Visit
• FVC: 74%
Lung • FEV : 62%
1
Function: • FEV/FVC ratio: Reduced
Verified with skin testing:
• Dust mites
Known • Pollen
Allergens: • Cockroach
• Grass
• Mold
•
•
Lifestyle/ •
Satisfaction: •
On temporary disability from work
My asthma symptoms seem continual
My worst days feel worse now
Neither asthma nor rhinitis symptoms well managed
with current therapy
64
Case Questions
• What additional information might you like to
have?
• How would you assess this patient’s control?
• At what step is patient’s current therapy?
• Based on the guidelines, what
actions/recommendations might you suggest?
65
Patient Profile: Mary K
Patient:
• 24 y/o Caucasian woman
• Previously diagnosed with and treated for mild persistent
asthma and allergic rhinitis
Symptoms/
Rescue
Medications:
• Asthma exacerbations approx 1-2x/wk, often after exposure to
cat but sometimes unexpectedly at work (office job)
• Uses cromolyn sodium during allergy season and before likely
exposure to triggers
• Uses rescue medication 5-7x/mos
Lung
Function:
Previous Visit
• FVC: 89%
• FEV1: 91%
Current
Medications:
• Montelukast
• Nasal steroid for allergic rhinitis
• Albuterol, PRN
Lifestyle/
Satisfaction:
• Not happy with treatment, recently stopped jogging due to
asthma symptoms
• Rhinitis seems controlled
Current Visit
• FVC: 86%
• FEV1: 92%
66
Case Questions
• What additional information might you like to
have?
• How would you assess this patient’s control?
• At what step is patient’s current therapy?
• Based on the guidelines, what
actions/recommendations might you suggest?