Update Asthma management in adult VS pediatric
description
Transcript of Update Asthma management in adult VS pediatric
Orapan poachanukoon, MDA/P of Allergy and Immunology
Thammasat Universsity
ASTHMA TREATMENT IN CHILDREN AND
ADULTS
Outline of my talk:
²Children and adults: what’s difference?²How to measure of asthma control?²What’s new in asthma guideline? ²Variability response to medications
(asthma phenotype)
93.66 98.69 104.23 109.41 105.76 104.61
201.34
247.89 239.31 239.14
226.64
260.65
0
50
100
150
200
250
300
ป ี 2548 ป ี 2549 ป ี 2550 ป ี 2551 ป ี 2552 ป ี 2553
อ ัตรา
ต อ
1000
00 ปชก
UC
หอบห ืดในผ ู ใหญ
หอบห ืดในเด ็ก
อัตราการรับไวรักษาในรพ.ตอ 100,000 ปชก.UC : ป 2548 – 2553 ของผูปวยโรคหืดในผูใหญและเด็ก
ที่มา : แหลงขอมูล ฐานขอมูลผูปวยในรายบุคคล (IP individual records) ป 2548-2553
adults
children
อัตราตอ
100,
000
อัตราปวยตายของผูปวยที่รับไวรักษาในโรงพยาบาลดวยโรคหืดในผูใหญและเด็กป 2548 – 2553
ที่มา : แหลงขอมูล ฐานขอมูลผูปวยในรายบุคคล (IP individual records) ป 2548-2552 ขอมูลป 2553
ผลการประเมินคุณภาพการดูแลผูปวยโรคหืด ป 2549 - 2550
• การรักษาตามมาตรฐานการดูแลผูปวย
• การประเมินความรุนแรงของโรคโดยการวัด PEF นอย
• มีการรักษาดวยยา inhale corticosteroid นอย
• ขาดการใหความรูเรื่องโรค
• ขาดการประเมินการใชยาพนอยางถูกวิธี
• หนวยบริการรับภาระคาใชจายการใหบริการผูปวยนอกเพ่ิมข้ึน
ป 2549 ป 2550
มีการประเมินสมรรถภาพปอด 2.43% 1.08%
มีการรักษาดวยยาพนสเตียรอยด 27.21% 10.92%
การใหคําแนะนําเรื่องการใชยาพนอยางถูกวิธ ี 14.70% 10.08%
การสนับสนุน ของ สปสช.
1. การอบรม ฟนฟู ความรูการดูแลผูปวยโรคหืด
2. การจัดต้ังคลินิกโรคหืด Easy asthma clinic
3. การชดเชยคายาสูดสเตียรอยด
4. การสนับสนุนงบประมาณตามคุณภาพผลงานบริการ
• 2549-2550 ประเมินคุณภาพการดูแลผูปวยโ รคหืด (audit)
• 2551 สนับสนุนการจัดทําและเผยแพร guideline
• 2551-2552 นํารองการจัดต้ัง EAC เขตพ้ืนท่ีขอนแกน• 2551-2554 สนับสนุนงบประมาณ• 2553 -2554 ขยาย EAC คลอบคลุมหนวยบริการประจําทุกแหง และ จายชดเชยคายา ICS
การพัฒนาระบบการดูแลผูปวยโรคหืด โดย สปสช.
โ รคหืดเปนโ รคท่ีพบบอยในเด็กมากกวาผูใหญ
Haahtela et al. Thorax 2006
0
1
2
3
4
5
6
7
Inci
denc
e (/1
000)
0–45–9
10–1415–19
20–2425–29
30–3435–39
40–4445–49
50–5455–59
60–6465–69
70–7475–79
80–8485+
Age group
ขอแตกตางระหวางโ รคหืดในเด็กและผูใหญ
²Diagnosis: WARI , COPD
²Natural history
²Management: asthma control, medications
Challenges in Diagnosing and Managing Pediatric Asthma
1. GINA 2010. 2. Wardlaw AJ et al. Clin Exp Allergy. 2005 3. Henderson J et al. Thorax. 2008. 4. Bacharier LB et al. Allergy. 2008. 5. Guilbert TW et al. N Engl J Med. 2006. 6. Castro-Rodríguez JA et al. Am J Respir Crit Care Med. 2000. 7. Henderson J et al. Arch Dis Child. 2009. 8. Bloomberg GR et al. Pediatrics. 2009. 9. LemanskeRF Jr et al. N Engl J Med. 2010. 10. Langmack EL et al. Curr Opin Pulm Med. 2010. 11. Lima JJ et al. Curr OpinPulm Med. 2009.
diagnosis difficult.1,2
Measuring lung function can
pose problems.1,7
Difficult to predict which wheeze will
continue to be symptomatic when
they are older.5,6
Difficult to predict respond to
medication.9–11
Compliance with prescribed
therapy8
Symptoms may
change with age.3,4
Presentation of Asthma May Overlap With Other Airway Disorders
1. Wardlaw AJ et al. Clin Exp Allergy. 2005;35:1254–1262.
Asthma COPD
Viral wheeze
(children) Emphysema
Hyperventilationsyndrome Infective
(bacterial)asthma ABPA
Bronchiectasis
Nonsmokingfixed obstruction
Obliterativebronchiolitis
EosinophilicbronchitisChronic
cough
Taussig et al J Allergy Clin Immunol 2003; 111: 661-75
Phenotypes wheezing in childhood..
Asthma Predictive Index (API) Developed and Modified to Help Predict Asthma1–4
1. History of ≥4 wheezing episodes with ≥1 physician diagnosis2. Must meet ≥1 major criteria or ≥2 minor criteria:1. Major Criteria 1. Minor Criteria1. Parental history of asthma2. Physician-diagnosed atopic dermatitis3. Allergic sensitization to ≥1
aeroallergen
1. Allergic sensitization to milk, egg, or peanuts
2. Wheezing unrelated to colds3. Eosinophilia >4%
1. Castro-Rodríguez JA et al. Am J Respir Crit Care Med. 2000;162:1403–1406. 2. Guilbert TW et al. J Allergy Clin Immunol. 2004;114:1282–1287. 3. Guilbert TW et al. N Engl J Med. 2006;354(19):1985–1997. 4. Thai guideline 2008
Modified API for Use in Young Children With Wheeze
Outcomes with original API (Tucson Study)1
• Negative predictive value: 91.6% at Year 6; 84.2% at Year 13• Positive predictive value: 47.5% at Year 6; 51.5% at Year 13
Atopic dermatitis
Allergy TestingSkin prick test / positive result
25372540
2547 2548
• GINA guideline definition of control – a gold standard
GINA 2009
Characteristic Controlled (all of the following)
Daytime symptoms Twice or less per week
Limitations on activities None
Nocturnal symptoms or awakenings None
Need for reliever/‘rescue’ treatment Twice or less per week
Lung function Normal
Ideal Tool for Assessing Asthma Control
Frequency of different asthma outcomes
50-80
30045050
????
1
Soren Pedersen. Primary Care Respiratory Journal 2009.
Assessing Asthma Control: PEF
• Use for objective evaluation in• acute asthma• chronic home monitoring
• Normal values• 5 x Ht (cm) – 400
• Blow in sitting/standing position• Techniques• Best of 3 blows
Assessing Asthma Control: HRQL
• Generic: SF-36, EQ-5D, CHQ (lack of responsiveness)
• Specific: AQLQ, MiniAQLQ, PAQLQ, MiniPAQLQ, C-PAQLQ, CAQ• Need cultural adaptation and modification
Poachanukoon et al. Pediatr Allergy Immunol 2006; 17: 207-212.
Lertsinudom S et al. J Med Assoc Thai 2010; 93(3): 373-7.
Development and Validation of MiniPAQLQ in Thai Asthmatic Children
Poachanukoon O 2010.
• 15 items: activities (4 items), emotions (3 items), symptoms (5 items), environment (3 items)
Domains Validity Reliability
Controlled Asthma
Uncontrolled Cronbach’salpha
SymptomsActivitiesEmotionsEnvironmentsOverall
6.6 + 0.546.7 + 0.576.4 + 0.915.3 + 1.106.3 + 0.51
4.7 + 1.14*5.0 + 1.36*4.6 + 1.67*4.1 + 1.24*4.6 + 0.96*
0.8550.8860.7650.6160.910
Lertsinudom S et al. J Med Assoc Thai 2010; 93(3): 373-7.
Correlation between QoL score and asthma parameters
Juniper EF1 Poachanukoon O2, 3
PPEFR morningPEFR eveningFEV1Asthma controlAsthma severitySalbutamol use
0.50.40.38
--
0.4
0.30.3
0.370.4
P < 0.05-
1. Am J Respir Crit Care Med 199.52. Pediatr Allergy Immunolgy 2006 3. Thai Journal of Pediatrics 2005
QoL questionnaire Summary
²There are only weak to moderate correlations between asthma quality of life and conventional clinical measures of asthma control²To evaluate the effect of interventions, QoL assessments should included in clinical studies in conjunction with conventional clinical measures.²Limitation: not available for all age groups, need validation and cultural adaptation
Assessing asthma control: Inflammation
•Which indicator of inflammation should we measure?- sputum eosinophils- exhaled NO- BHR
§How practical is the measurement?
Inflammation can also be present during symptom-free periods
Adapted from Woolcock A. Clin Exp Allergy Rev 2001; 1: 62–64.
AHR is a marker of inflammation
AHR
Rescue medication useImpaired am PEFImpaired FEV1
Start of treatment (months)
% R
educ
tion
2 4 6 18
Rate of response of different measures of asthma control over 18 months of ICS treatment
Nightsymptoms
Green RH et al. Lancet 2002; 360: 1715-21.
§If eosinophil < 1% -step down§If eosinophil 1-3% -no change§If eosinophil > 3% -step up§Results:
-sputum eosinophil and FeNO in sputum management group lower than BTS (P < 0.05)
-PC20 better (P < 0.05)
6 asthma admission
1 asthma admission
Exhaled NO: Non-invasive marker of inflammation
The Cochrane Library 2009
§ Randomized controlled comparisons of adjustment of asthma therapybased on FeNO compared to traditional methods§ 6 studies (4 children/adults, 2 adults), 1053 participants § No significant difference between groups
(asthma exacerbation, symptoms, spirometry)
“The role of utility FeNO to tailor the dose of ICS can’t routinely recommended for clinical practice”
Conclusions of 2 parts
§Asthma in adult and children are difference in diagnosis and measuring of asthma control.§Asthma control is a key goal in asthma management and
should be monitored on a regular basis§Clinical Asthma Score and QoL questionnaire may easy
to asssess§Monitoring airway inflammation may better reflect asthma
control but is not readily available at this time-helpful in research, not clinically applicable
§There is no instrument. Each one has been developed for a different purpose and has different measurement properties.
Asthma guideline and response to medications
Step 1 Step 2 Step 3 Step 4 Step 5
Low-dose ICS plus sustained-release
theophyline
Sustained release theophyline
Low-dose ICS plus leukotriene modifier
Anti-IgE treatmentLeukotriene modifierMedium- or
high-dose ICSLeukotriene modifier
Oral glucocorticosteroid
(lowest dose)
Medium- or high-dose ICS
plus long-acting ß2-agonist
Low-dose ICS plus long-acting ß2-agonist
Low-dose inhaled ICS
Add one or moreAdd one or moreSelect oneSelect one
Controlleroptions
As needed rapid-acting ß2-agonistAs needed rapid-acting ß2-agonist
Asthma educationEnvironmental control
Management approach based on control (Adults and children> 5 years)
GINA and Thai Guideline 2011.
1-5%
Thai Guideline for children < 5 years
Thai Guideline
ICS 200 μg or LTRA
ICS 400 or ICS+LTRA
ICS 800 or ICS+LTRA or ICS+LABA
Theophylline or oral steroids
เด็กหญิงอาย ุ20 ปมีประวัติหอบบอยตอนกลางคืน ไ อเวลาออกกําลังกาย เคยนอนรพ. ดวยเรื่องหอบกําเริบทุกป เขา ICU 1 ครั้งเม่ือ 2 เดือนท่ีผานมาจงใหการรักษา
ก. Medium dose ICSข. ICS +LABAข. LTRAค. ICS+theophyllineง. RABA prn
• เด็กชายอายุ 2 ป มีอาการหอบงายชวงเปนหวัด พนยาขยายหลอดลมแลวอาการดีขึ้น บางครั้งเลนแลวเหน่ือย ชวงน้ีอากาศเย็นมีอาการจาม นํ้ามูก คัดจมูกเปนๆหายๆ
• ไ ดรับยา ICS 200 g
จงใหการรักษาก. ICS+LABAข . Add LTRAค. Add theophyllineง. Double dose ICS
Regularly assess:-Control-Triggers-Compliance-Inhaler technique-Comorbidity
Environmental controlEducation, Written action plan and Follow-up
Fast-acting bronchodilator on demand
Inhaled corticosteroids
Low Moderate High
Add-on therapy
Pred
Anti IgE
Modify maintenance therapy
Verymild
Mild Moderate Moderatelysevere
Severe
The dose response curve of ICS
Kankaanranta H et al. Respiratory Research 2004.
Dose-response study with ICS
Kankaanranta H et al. Respiratory Research 2004.
Doses of ICS for children
Drug Low dose (μg) Medium dose(μg)
High dose(μg)
BDPBudesonide*Budesonide neb.Ciclesonide*FluticasoneMometasone*Triamcinolone
100-200100-200250-50080-160
100-200100-200400-800
> 200-400> 200-400> 500-1000> 160-320> 200-500> 200-400> 800-1200
>400>400>1000>320>500>400>1200
*Approved for once-daily dosing in mild patients
GINA 2009
Drug Low dose (μg)
Medium dose(μg)
High dose(μg)
BDPBudesonideCiclesonideFluticasoneMometasone
200-500200-40080-160
100-250200-400
> 500-1000> 400-800> 160-320> 250-500> 400-800
>1000-1200>800-1600>320-1280>500-1000>500-1200
Doses of ICS for adult
GINA 2009
Pharmacologic factors that promote efficacy and safety of ICS
Efficacy
Lung depositionDeviceParticle size
TechniqueProdrug
Pum. RetentionLipophilicitySlow distribution
safety
- low oral bioa.- fast systemic
clearance-Increased PPB-lung deposition-activation prodrug
PK/PD properties of ICSs
CS RRA Oral bioavailability
(%)
Clearance(L/hr)
VD(L)
Mometasone FFluticasone PBDPCiclesonideBudesonideTriamcinolone
23001800
5312
935233
< 1< 1
15-20121123
5466-901501528437
-318-859
20207
183-301103
Clinical Asthma 2008.
HOW TO CHOOSE ADD-ON MEDICATION?
Seretide evohaler (Non-CFC MDI)25/50, 25/125, 25/250Acculaher (DPI)50/100, 50/250, 50/500
Choice of ICS+LABA in Thailand
Symbicort Turbuhaler (DPI)4.5/80, 4.5/160, 4.5/320
β2-Agonist Basics: Are They All the Same?
Fast
Fast onset, short duration
Inhaled terbutalineInhaled albuterol
Fast onset, long duration
Inhaled formoterol
Slow
Slow onset, short duration
Oral terbutalineOral albuterol
Oral formoterol
Slow onset, long duration
Inhaled salmeterolOral bambuterol
Short Long
Speed of Onset
Duration of Action
The addition of LABA to ICS in asthma
•Safety concerns regarding LABA (FDA)•Should LABA+ICS be used as initial therapy?•Should ICS+LABA be used in children?•Can LABA be withdrawn once asthma is controlled?
Sears MR. Current Opinion in Pulmonary Medicine 2011, 17: 23-28.
Additional of LABA to ICS vs. same dose of ICS for asthma in adults and children
Cochrane Review 2010
• Inclusion criteria: RCTs in children aged > 2 years, and adults• Results:
- 77 studies, 21,248 pts. (4625 children, 16623 adults) - LABA reduced risk of exacerbation (RR 0.77, 28 studies), improve FEV1, symptoms free days, reduced use of RABA
- In children, superior to ICS alone but NS (RR 0.89)- No serious S/E with LABA (RR 1.09)
• Conclusions: - In Adults: effects and no serious S/E- In Children: effects are much more uncertain
The addition of LABA to ICS in asthma
• Should LABA+ICS be used as initial therapy?-cochrane reviewin 27 trials: ICS+LABA did not reduce exacerbation, admissions compared with ICS alone-In steroid-naïve patients, dose of ICS should sufficient to control is critical requirement before adding LABA
- Conclusion: combination should not be considered as first-line therapy without prior trial of ICS
Sears MR. Current Opinion in Pulmonary Medicine 2011, 17: 23-28.
Variability in Treatment Response: Distribution of Individual Responses for FEV1
Patie
nts,
%
<–30 –30 to<–20
–20 to<–10
–10 to<0
0 to<10
10 to<20
20 to<30
30 to<40
40 to<50
≥50
Change in FEV1 From Baseline, %
Montelukast sodium 10 mg qdb (n=387)Beclomethasone 200 mcg (4 puffs) bidc (n=251)
Malmstrom K et al. Ann Intern Med .1999;130:487–495.
0
30
20
10
a
Variability in Response to ICS Treatment:Distribution of Responses Recorded in 3 Studies
ICS=inhaled corticosteroid; CAMP=Childhood Asthma Management Program; ACRN=Asthma Clinical Research Network.
Tantisira KG et al. Hum Mol Genet. 2004;13:1353–1359.
0
5
10
15
20
25
30
35
40
Patie
nts,
%
Change in FEV1 From Baseline, %
Adult StudyCAMPACRN
>4030 to 0
20 to30
10 to20
0 to10
–10 to 0
–20 to –10
<–20
CLIC Primary Outcome: FEV1 Response1
FEV1 Change With Fluticasone Propionate30
Bothmedicationsn=22(17%)
Montelukast sodium alone
n=6 (5%)
Line o
f iden
tity
Neither medicationn=69 (55%)
Fluticasonepropionate alone
n=29 (23%)
Concordance Correlation 0.55 (0.43, 0.65)
–50 –40 –30 –20 –10 0 10 20 40–50
–40
–30
–20
–10
0
10
20
30
40
FEV 1
Cha
nge
With
Mon
telu
kast
Sod
ium
CLIC=Characterizing Response to a Leukotriene Receptor Antagonist and an Inhaled Corticosteroid. Szefler SJ et al. J Allergy Clin Immunol. 2005;115:233–242,
≥7.5% FP response
CLIC: Difference in Asthma Control(Days-per-Week Response)1,a
Better responseto montelukast sodium (n=15)
Better response to fluticasone
propionate(n=36)
Part
icip
ants
–7 –6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6 7
Zeiger RS et al. J Allergy Clin Immunol. 2006;117:45–52,
Good response:Younger age < 10 yFemaleMild asthma
BADGER – study design
• 182 children (6–17 years of age) with uncontrolled asthma while on ICS 100 μg bd randomised to each of three blinded step-up therapies in random order for 16 weeks (triple cross-over design):
• ICS 250 μg bd (ICS step-up),
• ICS 100 μg plus LABA 50 μg bd (LABA step-up)
• ICS 100 μg bd plus 5 or 10 mg daily (LTRA step-up)
• Primary endpoint: composite of exacerbations, asthma-control days and FEV1 to assess whether differential response to step-up regimens >25%
Lemanske RF et al. N Engl J Med 2010
LABA step-up significantly more likely to provide best response compared with ICS or LTRA step-up
Lemanske et al. N Engl J Med 2010
p=0.004
p=0.02
p=NS
0 10 20 30 40 50 60
% Patients
LABA vs ICS
LABA betterNeutralICS better
LABA vs LTRA
ICS vs LTRA
LABA betterNeutralLTRA better
ICS betterNeutralLTRA better
Possible Predictors of Responsiveness to Asthma Therapy in Clinical Trials
1. Szefler SJ et al. J Allergy Clin Immunol. 2005;115:223–242. 2. Zeiger RS et al. J Allergy Clin Immunol. 2006;117:45–52. 3. Bacharier LB et al. Allergy. 2008;63(1):5–34. 4. Knuffman JE et al. J Allergy Clin Immunol. 2009;123(2):411–416.
Therapy Some Possible Predictors of ResponseICS1-5 ↓ Lung function
↑ Bronchodilator use↑ Inflammation, spumtum eosinophiliaPositive skin test responseParental history of asthma
Montelukast1-3, 6 Young age (<10 years)Shorter asthma durationLess severe asthma↑ Levels of urinary leukotrienesETS, aspirin induced asthma
6. Scadding et al. Cur Opinion in Allergy and Clinical Immunology 2010 5. Current Opinion in Pulmonary Medicine 2011, 17: 16-22.
Asthma Phenotype: Clinical applications
•Variable response to controller therapies•One treatment plan cannot be expected to be efficacious for all different asthma
•Asthma phenotype is still important!!!
Role of Phenotypes in Management of Asthma
Asthma: A Result of Complex Interactions1,2
Slide 65
Genes Environmentalfactors
1. Drake KA et al. Pharmacogenomics. 2008;9(4):453–462. 2. Papadopoulos NG et al. Pediatr Allergy Immunol. 2008:19(suppl 19):51–59.
Demographicfactors
Social factors
Gene–environment interactions
Gene–gene interactions
Geneticancestry
Multiple clinical manifestations(phenotypes)
Asthma syndrome
Our Understanding of Asthma Continues to Increase Over Time1–6
1. Kiley J et al. Curr Opin Pulm Med. 2007;13:19–23. 2. Tang EA et al. In: Adkinson NF Jr. Middleton’s Allergy. Principles & Practice. 7th ed. Mosby Elsevier; 2009:715–767. 3. Vignola AM et al. J Allergy Clin Immunol. 2000;105:1041–1053. 4. Bousquet J et al. Allergy. 1992:47:3–11. 5. Henderson J et al. Arch Dis Child. 2009;94(5):333–336. 6. Postma DS et al. Proc Am Thorac Soc. 2009;6:283–287.
Airway Hyperresponsiveness
Inflammation and Remodeling
Phenotypes and Genetics
Bronchoconstriction IMPO
RTA
NT
CO
NC
EPTS
IN A
STH
MA
Measure response:-clinical outcomes-pulmonary function-inflammation marker
Associate response:-patient charac.-biomarkers-genetics
Monitor response:-asthma control day-need rescue Rx-FEV1-eNO-sputum
Characteristics associated with drug responses
Szefler SJ. J Allergy Clin Immunol 2011; 127: 102-15.
Identification of Asthma Phenotypes Is Critical
Modified from Bacharier LB et al. Allergy. 2008;63(1):5–34.
Trigger-Based Pediatric Phenotypes: Virus-Induced Asthma
1. Papadopoulos NG et al. Allergy. 2007;62:457–470.
Pathophysiology of Virus-Induced Asthma Exacerbations1
Viral infection
Cellular damageIrritant and allergen
penetration
Mediators
Chemotaxis Immune response Neural effects
Virus-Induced Asthma: Management Approaches
• Nonpharmacologic measures• Avoidance of infections as much as possible1 (eg, by frequent hand
washing, avoiding contact with sick people)2
• Pharmacologic therapy• Use of controller medication may be especially important before
virus season when exacerbation rate would be high.3
• ICSs have shown a limited role in treating asthma triggered by the common cold.4
• LTRAs may reduce exacerbations.3
1. Bacharier LB et al. Allergy. 2008;63:5–34. 2. Mayo Clinic. mayoclinic.com/health/asthma/as00024/method=print. Accessed 23 April 2010.3. Bisgaard H et al. Am J Respir Crit Care Med. 2005;171:315–322. 4. McKean MC et al. Cochrane Database Syst Rev. 2000;(1):CD001107.
Prevention of Viral Induced Asthma (PREVIA)
2.34
1.60
0
1
2
3
Montelukast 4 mg (n=265)
Placebo (n=257)
Exacerbationepisoderate / year 32%
p≤0.001
Bisgaard H et al. Am J Respir Crit Care Med 2005.
Trigger-Based Pediatric Phenotypes: Exercise-Induced Asthma
Slide 72
Model of the Pathophysiology of Exercise-Induced Bronchoconstriction1
1. Hallstrand TS et al. Curr Allergy Asthma Rep. 2009;9:18–25.
Exercise-induced water lossCooling dehydrationMucin release
Epithelialcells
Basementmembrane
Sensory nerve
Airwaysmoothmuscle
Neurokinin A
EosinophilsMast cell
PGD2
cysLTs15-LO-1
5-LOCOX
15S-HETECOX
PGE2
cPLA2
sPLA2-X
MUC5AC
Gobletcell
PL AA
Trigger-Based Pediatric Phenotypes: Exercise-Induced Asthma
•Exercise: a common trigger of symptoms1
•Affects up to 90% of children with asthma2
•May occur with other triggers2
• Loss of water and heat from airway appears to initiate pathologic/proinflammatory response to exercise.3,4
1. Parsons JP et al. Curr Opin Pulm Med. 2009;15:25–28. 2. Stempel DA. In: Leung DYM. Pediatric Asthma: Principles and Practice. Mosby; 2003:435–443. 3. Hallstrand TS et al. Curr Allergy Asthma Rep. 2009;9:18–25. 4. Schwartz LB et al. Allergy. 2008:63:953–961.
Exercise-Induced Asthma: Management Approaches• Nonpharmacologic measures1–4
• Participation in sports encouraged• Warmup and cooldown periods• Nose breathing• Avoidance of known allergens
• Pharmacologic• Long-term control medications: Antiinflammatory therapy (eg, ICS and
LTRAs), associated with reduced frequency and severity of EIB5
• Pretreatment before exercise: SABAs preferred therapy;LABAs, although frequent/chronic use not recommended;LTRAs; cromolyn5,6
ICS=inhaled corticosteroids; LTRA=leukotriene receptor antagonist; LABA=long-acting β-agonist; SABA=short-acting β-agonist.1. Bacharier LB et al. Allergy. 2008;63:5–34. 2. Global Initiative for Asthma. ginasthma.org/guidelineitem.asp??i1=2&i2=1&intid=1689. Accessed 9 April 2010. 3. Schwartz LB et al. Alergy. 2008:63:953–961. 4. Billen A et al. Postgrad Med J. 2008;84:512–517. 5. Expert Panel Report 3. Summary Report 2007. J Allergy Clin Immunol. 2007;120:S94–S138. 6. National Asthma Education and Prevention Program, National Heart, Lung, and Blood Institute, National Institutes of Health. The Expert Panel Report 3 (EPR-3) Full Report 2007. National Institutes of Health; 2007.
Trigger-Based Pediatric Phenotypes: Allergen-Induced Asthma
1. Gern JE et al. Nat Rev Immunol. 2002;2:132–138.
Pathophysiology of Allergen-Induced Asthma1
A. Acute phase B. Chronic phase
Allergen
Mast cell
IL-4
IL-5
HistamineLeukotrienes
IgE
IL-4 IL-5 IL-13Eosinophil
Leukocyterecruitment
Degranulation
MucusMacrophage
TNF-α
Goblet cell
Epithelial cell
Airway damage/
inflammation
Th2
Predictors of response to ICSs
• Corticosteroids better response in atopic or severe AS• Biomarkers such as -BHR-eosinophilic inflammation-eNO-severe asthma-older age at onset of asthma
Clinical Asthma 2008.
สิ่งสําคัญในการเลือกใช ยา controller
²ความรุนแรงของโ รค²ลักษณะผูปวย (asthma phenotype)²ความรวมมือในการรักษา²การมียาในโ รงพยาบาล การเบิกจาย²ประสิท ธิภาพและราคายา
Adherence
Disease Control
↓ Morbidity
↓ Economic Burden
↓ Mortality
Achieve Goals
Environmental Modification
Irritant Occupational Trigger
Allergen
Monitoring Asthma Control
Disease Variability
Appropriate Pharmacotherapy
Manage Comorbidities
AR
GERD
CRSCost-effectivenessEvidence-based Decision-making
Pharmacogenetics
Asthma Management Paradigm
Components of Asthma Education
• Understand what is asthma
• Recognize and avoid triggers
• Understand when and why to use each medication
• Understand how to monitor asthma
• Use inhalers and peak flow meters properly
• Develop an asthma “Action Plan”
• Recognize acute severe asthma
Level of knowledge about disease and treatment in asthmatic patients
Poachanukoon O et al. Thai J Ped 2011.
Asthma control and compliance from different sites and age of patients
Children Elderly patients
Compliance < 50% Compliance > 80%
Asthma Action Plan
• รูสึกวาสบายดี• อาการกําเริบ• มีอาการมาก/อาการแยมาก
-หายใจแรงและเร็ว-หอบจนอกบุม กระสับกระสาย-ปลายนิ้วหรือริมฝปากเขียว-ไมมีแรง ใชยาขยายหลอดลมแลวไมดีข้ึน
บัตรประจําตัวและแผนปฏิบัติตัวเมื่อมีอาการ
Important factors if uncontrolled with ICS
1. Poor compliance in patients with ICS is very common for treatment failure (compliance with ICS < 50%)
2. Problems with inhalation techniques are very common, especially in children and elderly
3. Environmental factors
Conclusions
•Asthma is a chronic inflammatory disorder of the airways
•The phenotype of asthma and its progression varies
•It is important to consistently monitor patients in order to achieve maximum control
•The new asthma guidelines will provide an excellent framework for clinical practice