Asthma in general practice dec 2010 (1)
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Transcript of Asthma in general practice dec 2010 (1)
Why asthmais goodfor your practice
Dr. Sujeet RajanRespiratory PhysicianBombay Hospital Institute of Medical Sciences
Greatopportunity
Easyopportunity
Asthma is so common….1 in 10 of your patients !
Most patients prefer treatment from their family doctor rather than a Chest Physician
Physicians / GPs can treat asthma just as well as Chest Physicians ( even better )
The 4 keys tosuccessful asthma practice
“Is it asthma?”
Just a few questions in a few minutes
1
The 4 keys tosuccessful asthma practice
Treating the disease2
Not much time
……..and easily.
The 4 keys tosuccessful asthma practice
Making things simple for your patient3
Child’s play
Low cost
The 4 keys tosuccessful asthma practice
Saying the right things
Answering patients’ questions
“Jo bolega, karega”
4
Which secret do you want to unlock?
1. “Is it asthma?”
2. Treating the disease
3. Making things simple
4. Saying the right things
Diagnosis: Why make it ?
The patient has alternatives
(if you don’t, someone else will !)
Excellent prognosis, esp. in children
Treatment is so simple
Do I need a lot of tests?
Nothing usually, besides a sharp history
What questions or statements can suggest asthma?
Do you have a persistent cough ?
Do you wheeze or often feel breathless while
coughing ?
Do your symptoms worsen with climate
change, or dust /other allergens ?
What questions or statements … Do the symptoms get worse at
night ? Do you get chest tightness with
the cough ? Does it all start with a cold ? Do your colds often “go down” into
the chest ?
What questions or statements … Do your symptoms get worse after
extremes of happiness or sadness ?
(emotional swings)
Do heavy meals or late nights worsen
your symptoms ? (GE reflux)
Are your symptoms worse at work than
at home ? (occupational asthma)
What questions or statements …
Does anyone else in your family suffer from any allergies ?
Ask about:skin allergies
eczemafrequent colds
‘bronchitis’
What questions or statements …
“I get relief with this medicine.”
Ask: which medicine?
(always check for bronchodilator)
Diagnosis in children
Commonest cause of a persistent cough is asthma
Cough after exercise, activity, play Vomiting Failure to thrive
( poor sleep, poor growth )
When do you need lung function tests ?
Spirometry ( 250 to 350 rupees )
To re-confirm the diagnosis
When in doubt
Normal Spirometry ( Challenge tests )
Things the patient may not tell you …
Stigma and discrimination from a “word”
Work/school absenteeism
Marital discord
Travel & holidays ‘controlled’
Other ‘advice’ the patient gets
Grandparents/neighbours/ ‘friends’ –
Inhalers ???
Steroids ???
Make the diagnosis but emphasize the prognosis
Instead of asthma controlling your
patient,
the patient can control asthma
Asthma therapy in India today
Completely control symptoms and
fast
Normal life
As good as abroad ( even better )
General practice and physician level
Doesn’t need Chest Physicians !
Asthma Disease:Spasm and swelling
Spasm needs a reliever
Bronchodilator
Swelling needs a contoller
Anti-inflammatory
Two types of drugs:
Reliever & Controller
Reliever
Bronchodilator (beta2 agonist)
Quickly relieves symptoms (within 2-3 minutes)
Not for regular use
Reliever …
Inhaled
Nebulised
Oral
Most of the time
For severe attacks; administer at your clinic/hospital
Rarely needed
Anti-inflammatory
Takes time to act (1-3 hours)
Long-term effect (12-24 hours)
Only for regular use
(whether well or not well)
Controller
If your patient uses reliever
medication every day, or even
more than three or four times a
week, preventive medication
must be added to the treatment
plan.
GINA Workshop Report, December 1995
WHAT HAPPENS WHEN YOU DON’T TREAT ASTHMA WELL
N orm al
Inflam ed(A sthm a)
P artly Treated
Fixed O bstruction(Lead P ipe)
R em odelledA irw ay
What is changing the lives of our asthma patients today?
Inhaled steroid
THE STORY OF ASTHMA TREATMENT
N orm al Inflam ed (untreated)
R egularInha ledS tero id
P artlyTreated
Corticosteroids are the most potent and effective anti-inflammatory medication currently available
for asthma*
*GINA (NHLBI & WHO Workshop Report), December 1995
*Guidelines for the diagnosis and management of Asthma NIH, NHLBI, May 1997
Controller ..
Inhaled corticosteroids Budesonide/ beclomethasone/
fluticasone/ciclesonide – use any Start (400-1000 mcg/day approx. in
2 divided doses) Maintain for 3 months Taper slowly Safe for long-term use (years)
Controllers …
Inhaled corticosteroids: how safe? Even in small children for several
years 30% of Olympic athletes Not anabolic (performance-enhancing)
steroid Even highest ICS dose is safer than
low dose oral steroid Best “Addiction” for asthmatics
Inhaled steroids : safe even for children? 400 mcg/day (budesonide) Over 13 years of continuous use No growth retardation Uncontrolled asthma causes growth
retardation
Pedersen & Agertoft NEJM 2000
Pregnancy and asthma
Don’t x-ray (if possible) All asthma medication is safe Even oral corticosteroids are safe for
exacerbations Uncontrolled asthma during pregnancy
is a serious risk factor for foetal distress and anoxia
Thorax
Inhaled Steroids Not Working ?
Add SRtheophylline
Check Inhaler Technique /
Check Regular UseAdd LABA
Formoterol / Salmeterol
Increase dose of inhaled steroid
Add Leukotriene modifier
Leukotriene Modifiers Oral anti-inflammatory
Not as effective as inhaled steroid
First-line for 2 to 5 yr. olds.
All your ‘regular’ bronchodilator users.
Theophylline
Sustained release for regular use
Inexpensive , but toxic
Not more than 600 mg per day usually
Weak bronchodilator, but A-I effects
Add-on drugs : ICS + ?
1. Long acting Beta²-agonist ( LABA )
2. Montelukast
3. SR Theophylline
ICS + LABA
Which ICS ?
Budesonide: Once daily
Even children < 4 years
Safe for long term use
ICS + LABA
Which LABA ?
Formoterol: Immediate relief (as fast as salbutamol)
12 hours effect
Can be combined with budesonide
Ideal combination
Formoterol ( fast relief and sustained relief ) +
Budesonide ( twice or even once daily use )
Dose: 1- 4 puffs ( OD/BD )
Can be used for relief as well as control
FORACORT
Guidelines for using SMART with FOACORT• SMART means patients take a daily maintenance dose of
FORACORT and in combination take FORACORT as needed in response to symptoms.
The recommended maintenance dosage is 2 inhalations per day
Patients should take 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. Not more than 6 inhalations should be taken on any single occasion.
A total daily dose of up of 12 inhalations could be used for a limited period.
Patients using more than 8 inhalations daily should be strongly recommended to seek medical advice.
Oral Steroid
Prednisolone Acute severe episodes
(20-60 mg/day “burst”along with bronchodilators)
Dispense preferably Steroid-dependent asthma
Steroid-Dependent Asthma
A patient who requires regular
oral corticosteroids for control of
his/her asthma
Why doctors don’t use inhalation therapy
Status quo :“my practice is good or ‘great’”
Oral therapy is easy
Too busy
Cost
Headache to explain
Which inhaler?
Inhalers
MDI DPIs Nebuliser
(acute severeepisodes only)
Scope for Inhalation Therapy highest in a child
< 5 yrs - High incidence of
wheezing
Parents want the best for
their child
The Rotahaler
Has transformed inhalation therapy Child’s play (Insert -Twist - Inhale) Economical (Rs. 74) Acceptable (v/s difficulties with MDI)
Every drug you need
Child below 3, or adult over 85
MDI + Spacer
MDI + Spacer + Baby Mask
When can you not use a Rotahaler ?
Why use a Spacer ?
Ensures correct use of an MDI by correcting co-ordination problems.
Reduces incidence of throat infections with inhaled steroid
As good as nebuliser for acute exacerbations ( with MDI )
Then do we need nebulisers ?
– YES
Acute severe asthma with impending respiratory failure
Intensive care / Hospital / Clinic / Ambulances
Managing asthma in clinic(patient who walks in wheezing quite badly)
Oral prednisolone 20 mg/day x 1 week
Foracort Rotacaps (100/200/400) (Form +
Bud) twice daily x 1 week and also as
rescue
Call patient after 1 week
If much better
Taper or omit Prednisolone
Continue Foracort Rotacaps for 2 months in same dose
Foracort Rotacaps SOS
Call patient after 1 week …
If not much better /still needs salbutamol often
Check Rotahaler Technique
Check whether using Foracort regularly
If still not better at 2-3 months
Consider adding SR theophylline or montelukast
Look for aggravating factors– GE Reflux– Emotions/ stress– Sinusitis– Allergic Rhinitis– Persistent allergens
Always check
Inhaler technique
Regularity of steroid use
What do you tell patients ?
Oh no ! I have asthma ?
Allergic disorder (allergies don’t have cures)
You could call it “allergic bronchitis”
To lead a normal life, accept regular therapy (like DM/ HT/ Epilepsy)
What do you tell patients …
How long do I need this inhaler?
Wont I get addicted ?
Inhalers are a delivery system, not the drug
The drug is in a “homeopathic” dose
The earlier you start steroid, the better. ….. best “addiction”
Untreated asthma will cripple you
What should you keep in your asthma clinic ? Rotahaler/ Revolizer Placebo Rotacaps Placebo MDI/ Spacer/ Baby Mask Nebuliser ( for emergencies only ) Height measure Breathe-o-meter Education material ( available in 9
languages )
The Breathe-o-Meterlike a thermometer for asthma
Inexpensive clinic instrument
Monitoring Builds confidence in
treatment
One ‘hard, fast blow’
The Breathe-o-Meter…
First visit and follow-ups
Improving symptoms
= improving peak flows
= improving confidence
Rarely for home use
What do you tell patients …
Today’s asthmatics are suffering as
they never received regular inhaled
steroids as children.
What costs more is not better (e.g.
nebulisers for home use)
Examples
Myopics Spherical glasses regularly
Everyone Brushing teeth regularly
Obesity Diet & exercise regularly
Asthmatics Inhaled steroid regularly
Asthma management: nothing specialistabout it
Dr. Sujeet RajanRespiratory PhysicianBombay Hospital Institute of Medical Sciences