Dr Api TalemaitogaGeneral Practitioner

South Auckland

7:00 - 7:55 GlaxoSmithKline Breakfast Session - Asthma Management in

NZ Primary Care: How we do more with less

Asthma in NZ Primary Care: How we do more with less

Dr Api Talemaitoga

Declaration of interests/conflicts

• General Practitioner – Normans Road Surgery (CHCH)

and Cavendish Clinic (Manukau)

• Ex Board Member (Elected), RNZCGP

• Chair, Pacific Chapter, RNZCGP

• Member Pegasus Health and Alliance Health Plus, PHOs

• I am not an employee of GSK

• I have received an honorarium for this talk

Respiratory diseases affect large numbers of Kiwis

Asthma + Respiratory Foundation of New Zealand: Respiratory Disease in New Zealand Infographic.

https://s3-ap-southeast-2.amazonaws.com/assets.asthmafoundation.org.nz/documents/Respiratory-Disease-in-NZ.pdf (Accessed 12/06/2019)

Māori/Pacific are disproportionately represented in asthma

hospitalisations vs non-Māori/Pacific/Asian (non-MPA)

Asthma + Respiratory Foundation of New Zealand: The impact of respiratory disease in New Zealand 2016 update.

https://www.asthmafoundation.org.nz/research/the-impact-of-respiratory-disease-in-new-zealand-2016-update (Accessed 13/06/2019)

Asthma

hospitalisations

per 100,000

people by ethnic

group, 2015

Māori/Pacific are disproportionately represented in asthma

mortalities vs non-Māori/Pacific/Asian (non-MPA)

Asthma mortality

per 100,000

people per year

by ethnic group,

2008-2013

Asthma + Respiratory Foundation of New Zealand: The impact of respiratory disease in New Zealand 2016 update.

https://www.asthmafoundation.org.nz/research/the-impact-of-respiratory-disease-in-new-zealand-2016-update (Accessed 13/06/2019)

Health literacy in Māori and New Zealanders in general is poor

7Ministry of Health. 2010. Korero Marama: Health Literacy and Maori. Results from the 2006 Adult Literacy and Life Skills Survey. Wellington: Ministry of Health

Distribution of health

literacy levels for Māori

and non-Māori, by rural

and urban

location, 2006

Health literacy in Pacific population is significantly poorer

compared to non-Pacific populations

Pacific adults were shown to be significantly less likely to have good health literacy skills compared to non-Pacific adults1

One of the barriers that hinder Pacific people’s access to, and utilisation of, PC is health literacy2

Health literacy was cited as a factor accounting for the high hospitalisation rates among Pacific children2

81. Ministry of Health, 2012

2. Jackson, G. Minster, J. et al. Health Partners Consulting Group 2012. Metro-Auckland Pacific Population Health Profile. Auckland: HPCG.

Many patients do not know what is meant by asthma

control

Adapted from: Haughney J, et al. Prim Care Respir J. 2004;13:28–35.9

Adherence remains a major barrier to achieving disease

control

*Slide is based on known patient patterns, not quantitative data.

1. Braido F. Scientifica (Cairo). 2013;2013:549252.10

Choose the most effective and

safe treatment

• Consider effectiveness data

• Correct inhaler technique

Get the basics right

1. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2018. Available from: www.ginasthma.org (Accessed November 2018). 2. BTS/SIGN British Guideline on the

Management of Asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016 (Accessed February 2019).

How can we address the gaps in asthma care?

Engage patients

• Share decision-making for

treatment decisions

• Provide disease education

and patient education

• Establish asthma plans

Assess asthma control

• Use validated tools

Asthma Control Test is a trademark of QualityMetric Inc. https://www.asthmacontroltest.com/New%20Zealand

1. Nathan RA, et al. J Allergy Clin Immunol. 2004;113:59–65 2. Schatz M, et al. J Allergy Clin Immunol. 2009;124:719–23.e1.

Use validated screening tools to assess asthma control

The Asthma Control Test has the following domains:1

Activity

limitation

Shortness

of breath

Reliever

medication

Awaking due to

asthma

symptomsPersonal assessment

of asthma control

All items refer to the last 4 weeks and are scaled from 1 to 5.1

The total score indicates current asthma control and future

healthcare status with values of:

≥ 20Well-controlled

16–19Not well-controlled

5–15Very poor control

Choose the most effective and

safe treatment

• Consider effectiveness data

• Correct inhaler technique

Get the basics right - engage patients

1. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2018. Available from: www.ginasthma.org (Accessed November 2018). 2. BTS/SIGN British Guideline on the

Management of Asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016 (Accessed February 2019).

Engage patients

• Share decision-making for

treatment decisions

• Provide disease education

and patient education

• Establish asthma plans

Assess asthma control

• Use validated tools

How can we address the gaps in asthma care?

Shared decision-making improves controller medication

adherence and clinical outcomes

Wilson SR et al. Am J Respir Crit Care Med. 2010;181:566–577.

61

2 p

oo

rly c

on

tro

lled

as

thm

a

pa

tie

nts

ra

nd

om

ise

d

Clinician

decision-

making

Set the

stage

Set the

stage

Gather patient

infoProvide info

PrescribeGather patient

infoNegotiate

Prescribe

Describe shared

decision-making

approach

Identify patient’s

goals and

preferences

Discuss treatment options,

their relative merits

in terms of patient goals

and preferences

Negotiate

a decision on

treatment

regimen

Shared decision-making (at follow-up in year 1) significantly improved controller medication adherence and clinical

outcomes (e.g. asthma-related quality of life and rescue use)

Shared

decision-

making

Choose the most effective and

safe treatment

• Consider effectiveness data

• Correct inhaler technique

Get the basics right – select the right treatment

1. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2018. Available from: www.ginasthma.org (Accessed February 2019). 2. BTS/SIGN British Guideline on the

Management of Asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016 (Accessed February 2019).

Engage patients

• Share decision-making for

treatment decisions

• Provide disease education

and patient education

• Establish asthma plans

Assess asthma control

• Use validated tools

How can we address the gaps in asthma care?

*Critical error: Defined as an error that was likely to result in no, or minimal (i.e. significantly reduced) medication being inhaled.4

1. Sharma R et al. Am J Respir Crit Car Med. 2014;189:A5693; 2. van der Palen J et al. NPJ Prim Care Respir Med. 2016;26:16079; 3. Breo Ellipta NZ Data sheet, Medsafe. 4. Svedsater H et al. NPJ Prim Care Resp

Med. 2014;24:14019.

Once-daily administration3

True 24-hour efficacy with

long lasting molecules3Easy-to-use inhaler2,4

High patient preference1,2

Fewer critical errors compared

with other inhalers*1,2

Breo Ellipta - a potential solution that meets the needs of

both doctors and patients?

The Salford Lung Study was carried out to assess Breo vs other

usual care in asthma patients in primary care

Randomisation

Pre-randomisation

prescription:

ICS 36%

ICS/LABA 64%

Continuous near real-time data collection of all interventions/

safety monitoring during the 12-month period

3 phone calls to assess ACT at

weeks 12, 24 and 40

GP prescribed usual care

(ICS or ICS/LABA)

Breo 100/25 mcg or

200/25 mcg OD

*Other endpoints include AQLQ, WPAI and rescue use

ACT, Asthma Control Test; AQLQ, Asthma Quality of Life Questionnaire; WPAI, Work Activity and Impairment Questionnaire

Woodcock A et al. Lancet 2017; 390:2247–2255.

4,233 patients

Broad patient profile

• Aged ≥18 years

• With GP diagnosis of

asthma

• Symptomatic

Primary endpoint:

• % patients who achieve ACT

≥20 or

• increase of 3 points or more at

6 months*

A significantly higher percentage of patients on Breo Ellipta had improved asthma symptom control vs other ICS/LABAs

25% more

patients with

improved asthma

control

Pro

po

rtio

n o

f A

CT

re

sp

on

ders

at

6 m

on

ths (

%) 56%

70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

ACT, Asthma Control Test; ICS, inhaled corticosteroid; LABA, long-acting β2-agonist; PEA, primary effectiveness analysis

Responder is defined as a patient with an increase in ACT from baseline of ≥3 or total ACT total score ≥20; analysed in the PEA population

1. Woodcock A et al. Lancet 2017; 390:2247–2255. 2. GSK.Clinical Study Report. 2017; HZA115150. Last accessed October 2018 (Table 27, page 114).

At baseline the most commonly prescribed

ICS/LABAs were:2

Seretide(fluticasone propionate/salmeterol)

Symbicort(budesonide/formoterol)

Other ICS/LABA

(n=511/916)Breo Ellipta

(n=637/908)

OR 1.95

(95% CI:1.60−2.38)

76

68

77

47

7569

56

69

32

64

0

20

40

60

80

100

Not getting as muchdone at work, school or

home

Shortness of breath Woken up at night orearlier than usual

Used rescue inhaler ornebuliser medication

Level of asthma control

ACT, Asthma Control Test; ICS, inhaled corticosteroid; LABA, long-acting β2-agonist; Patients whose asthma maintenance therapy at baseline per randomisation stratification was ICS/LABA and pre-randomisation

prescription was ICS/LABA. Analysis was not performed on the individual questions of the ACT. Svedsater H et al. Respir Med 2018; 141:198−206 (supplementary material).

Breo delivered greater improvements across all 5 ACT

components vs other ICS/LABAs

Patients

sele

cting 4 o

r 5 o

n the

AC

T a

t 6 m

onth

s (

%)

BREO patients

reported they’re able

to get more

done at work, school

and home

BREO

patients

reported less

shortness of

breath

BREO

patients

reported less

night

awakenings

More BREO

patients

reported they

felt well or

completely

controlled

BREO

patients

reported less

rescue

medication

Choose the most effective and

safe treatment

• Consider effectiveness data

• Correct inhaler technique

Get the basics right – select the right treatment

1. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2018. Available from: www.ginasthma.org (Accessed February 2019). 2. BTS/SIGN British Guideline on the

Management of Asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016 (Accessed February 2019).

Engage patients

• Share decision-making for

treatment decisions

• Provide disease education

and patient education

• Establish asthma plans

Assess asthma control

• Use validated tools

How can we address the gaps in asthma care?

0

5

10

15

20

25

30

35

40

45

50

MDI(n=10)

MDI +spacer(n=3)

Turbohaler(n=10)

Diskus(n=9)

Aerolizer(n=4)

HandiHaler(n=3)

45.6%

(95% CI: 26.0–66.6)

8.9%

(95% CI: 0.9–50.5)

40.1%

(95% CI: 28.6–52.9)

20.8%

(95% CI: 13.7–30.2)14.2%

(95% CI: 11.0–18.1)

42.4%

(95% CI: 28.8–57.1)

CI, confidence interval

Chrystyn H et al. Prim Care Respir Med 2017; 27:22.

Inhaler errors are commonplace

Device (number of studies)

Po

ole

d e

sti

ma

te o

f c

riti

ca

l

err

ors

(%

)

Frequency of critical errors in numerous studies

The ELLIPTA is intuitive and easy to use

Clear indication of doses remaining

Doses remaining Low dose warning Last dose Empty

Click

1. OPEN 2. INHALE 3. CLOSE

1. Svedsater H et al. Prim Care Respir Med. 2014;24:14019; 2. Sharma N et al. Am J Respir Crit Care Med. 2014;189:A5693.

0

20

40

60

80

100

Sub-study 1(N=70)

Sub-study 2(N=32)

Sub-study 3(N=60)

Patients

makin

g c

ritical err

ors

(%

)Fewer patients make critical errors with Ellipta vs.

commonly used inhalers

MDI, metered-dose inhaler

Van der Palen J et al. NPJ Prim Care Respir Med 2016; 26:16079.

p=0.074p=0.221 p<0.001

Critical error defined as an action that results in little or no medication being delivered

The difference reached statistical significance compared to Turbuhaler (5% vs. 33%; p<0.001), but not compared to Diskus (4% vs. 13%; p=0.221) and

MDI (6% vs. 25%; p=0.074)

*Single visit, placebo inhaler, crossover comparison in patients naive to Ellipta and the comparator inhaler.

van der Palen J et al. NPJ Prim Care Respir Med. 2016; 26:16079.

Ellipta is preferred by asthma patients compared to the

Turbuhaler across multiple attributes

n=60, *p≤0.001 for all other comparisons

8085

58

73

27

88

52

80

17

7 7 7

40

2

1812

38

35

20

33

10

30

8

0

10

20

30

40

50

60

70

80

90

100

Overallinhaler

preference

Prefer due tonumber of

steps

Prefer due totime taken to

use

Prefer due toease of use

Prefer due tosize of inhaler

Prefer due todose counternumber size

Prefer due tocomfort of

mouthpiece

Prefer due toease ofopening

Pa

tie

nts

(%

)

Ellipta Turbohaler No Preference

**

*

*

**

p=0.232

p=0.002

0

1

2

3

4

5

6

Ellipta vs. Diskus Ellipta vs. MDI Ellipta vs.Turbohaler

The Ellipta requires little time to be taught correct inhaler

technique

MDI, metered-dose inhaler. Median training time to demonstrate correct inhaler use after reading the Patient Information Leaflet and up to three healthcare provider instructions

Thomas M et al. Am J Respir Crit Care Med 2016; 193:A1739.

Me

dia

n t

rain

ing

tim

e (

min

s)

Teaching correct

technique was

numerically faster with

Ellipta

However, there were no

significant differences

between training timesAccuhaler

We can improve asthma outcomes through assessing control, shared decision-making

and appropriate prescribing

The Asthma Control Test (ACT) is a validated tool that can be used to objectively

assess patients’ level of asthma control

Breo Ellipta has been shown to be more effective helping patients improve asthma

control in an everyday setting compared with other ICS/LABAs1

Once-daily treatment in an easy-to-use device reduces errors

Treatment choices should be informed by effectiveness data, in addition to efficacy,

and how to overcome the challenges we face in general practice

1. Woodcock A et al. Lancet 2017; 390:2247–2255. 2. Bardsley G et al. Resp Res 2018; doi 10.1186/s12931-018-0836-6.

Take home messages

Insert your date / confidentiality text here16x9 core template 27

Thanks for your attention

Happy to take any

questions/comments

a.Talemaitoga@xtra.com or happy to

take other questions at GSK stand

Seretide® (fluticasone propionate/salmeterol xinafoate inhaler 50/25 or 125/25mcg per actuation and Accuhaler®

100/50, 250/50mcg per actuation) is a Prescription Medicine. Seretide is indicated for the treatment of children (4

years and older) and adults with reversible obstructive airway disease (ROAD) including asthma, and for the treatment

of adults with chronic obstructive pulmonary disease (COPD). Seretide is a fully funded medicine. Seretide

250/25mcg inhaler is a private purchase medicine; a prescription charge will apply. Maximum Daily Dose:

MDI 2 puffs twice daily, Accuhaler 1 inhalation twice daily. Maintenance Dose: Titrate to lowest effective dose 1-2

times daily. This medicine has risks and benefits. Warnings and Precautions: Not for relief of acute symptoms. Do

not discontinue abruptly. Use care when co-administering strong CYP3A4 inhibitors (e.g. ketoconazole) or in patients

with pulmonary tuberculosis or thyrotoxicosis. Common Side Effects: Hoarseness/dysphonia, throat irritation,

headache, oral candidiasis and palpitations. Paradoxical bronchospasm may occur. Avoid beta-blockers if possible.

Before prescribing Seretide, please review the Data Sheet at www.medsafe.govt.nz.

Seretide and Accuhaler are registered trade marks of the GlaxoSmithKline group of companies. Marketed by

GlaxoSmithKline NZ Limited, Auckland. Adverse events involving GlaxoSmithKline products should be reported

to GSK Medical Information on 0800 808 500.

Breo® Ellipta® (fluticasone furoate/vilanterol trifenatate inhaler 100/25mcg per inhalation) is a Prescription Medicine.

Breo Ellipta is indicated for the regular treatment of asthma in adults and adolescents aged 12 years and older where

use of a combination product (long-acting beta2 agonist and inhaled corticosteroid) is appropriate. Breo Ellipta is also

indicated for symptomatic treatment of patients with COPD with a FEV1<70% predicted normal (post-bronchodilator)

and with an exacerbation history. Breo Ellipta 100/25mcg is a fully funded medicine. Breo Ellipta 200/25mcg is a

private purchase medicine (dose indicated in asthma only); a prescription charge will apply. Maximum Daily

Dose: One inhalation once daily. Contraindications: Patients with severe milk-protein allergy or those who have

hypersensitivity to fluticasone furoate, vilanterol or any excipients. Side Effects: Candidiasis of mouth and throat,

headache, nasopharyngitis, oropharyngeal pain, sinusitis, pharyngitis, rhinitis, cough, dysphonia, upper respiratory

tract infection, bronchitis, influenza, abdominal pain, arthralgia, back pain, pyrexia, fractures. Warnings and

Precautions: Not to be used for the treatment of acute asthma symptoms or an acute COPD exacerbation, for which

a short-acting bronchodilator is required. Paradoxical bronchospasm may occur. Use care when co-administering with

strong CYP3A4 inhibitors (e.g. ketoconazole), beta-blockers and in patients with severe cardiovascular disease.

Physicians should remain vigilant for the possible development of pneumonia in patients with COPD as the clinical

features of such infections overlap with the symptoms of COPD exacerbations. The incidence of pneumonia and

fractures in patients with asthma was uncommon. Before prescribing Breo Ellipta, please review the Data Sheet at

www.medsafe.govt.nz.

Breo and Ellipta are registered trade marks of the GlaxoSmithKline group of companies. Breo Ellipta was developed in

collaboration with Innoviva Inc. Marketed by GlaxoSmithKline NZ Limited, Auckland. Adverse events involving

GlaxoSmithKline products should be reported to GSK Medical Information on 0800 808 500.

TAPS DA1924JB-PM-NZ-FFV-PPTX-19JN0001