Asthma Control - Spire Healthcare

Report
Asthma Update
Dr Ed Cetti
Consultant Respiratory Physician
Spire Gatwick Park Hospital
Surrey & Sussex Healthcare NHS Trust
Asthma Locally
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5 – 6% of local population have asthma (Incidence is
one of highest in world)
Approximately 2 adults per week attend ED with acute
asthma
Large proportion of these are repeat offenders
DOH - >80% of these are avoidable
Approximately 1 death every 2 months from asthma –
probably all avoidable
Age 13 - 85
Local Asthma Project
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6 month project across 18 practices
‘At risk’ asthma patients reviewed
Treatment optimised according to guidelines
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30% drop in admissions – acute asthma
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Cost Effective Treatment
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Patients use the right drugs at the right times
through the right devices in the right way
So that:
Symptoms are minimised
 Impact on daily life is minimised
 Exacerbations, Admissions and Deaths are
prevented
 Side-effects are minimised
 Costs are minimised
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Variability
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Degree of Asthma symptoms, airflow
obstruction, inflammation varies over time
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Need to increase treatment when bad
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To avoid side-effects and cost, reduce treatment
when good
The BTS/SIGN Guidelines
recommend a
stepwise approach4
4. British Guideline on the Management of Asthma. British
Thoracic Society/Scottish Intercollegiate Guidelines Network 2009.
www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/
Asthma /Guidelines/sign101%20revised%20June%2009.pdf
How do we apply the
stepwise approach?
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Start treatment at the step most
appropriate to initial severity4
Achieve early control4
Maintain control by
stepping up
treatment as
necessary.4
4. British Guideline on the Management of Asthma. British
Thoracic Society/Scottish Intercollegiate Guidelines Network 2009.
www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/
Asthma /Guidelines/sign101%20revised%20June%2009.pdf
Stepping down
• Ensure regular review of patients
as treatment is stepped down4
• Decide which drug to step down
first and at what rate4
When control
is good,
step down.4
4. British Guideline on the Management of Asthma. British
Thoracic Society/Scottish Intercollegiate Guidelines Network 2009.
www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/
Asthma /Guidelines/sign101%20revised%20June%2009.pdf
Adults
Step 2 – Starting Point
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Most symptomatic new diagnoses – start at step
2
ICS – 200mcg Beclometasone equivalent bd
Use Clenil mdi 100mcg 2 puffs bd via spacer
Alternative – Qvar Easibreathe 50mcg 2 puffs
bd
Assess response – asthma control
What is Asthma
Control?
Current asthma guidelines
BTS/SIGN:1
GINA:2
 No daytime symptoms
 No daytime symptoms
 No night time awakenings due
• No nocturnal symptoms or
to asthma
awakenings
• No need for reliever
• No need for reliever medication
medication
• No exacerbations
• No exacerbations
• No limitations on activities
• No limitation of physical
activity
• Normal lung function (PEF, FEV1)
• Normal lung function (in
practical terms FEV1) and/or
PEF 80% predicted or best 1. BTS/SIGN. 2008 British Guideline on the Management of Asthma – updated June 2009.
2. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2008.
Asthma Control Test™ (ACT)
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?
2.
3.
During the past 4 weeks, how often have you had shortness
of breath?
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 salbutamol)?
5.
How would you rate your asthma control during the past
4 weeks?
Copyright 2002, QualityMetric Incorporated.
Asthma Control Test Is a Trademark of QualityMetric Incorporated.
Patient Total Score
Score
ACT Scores
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25 – Well done. Asthma has been under control
for last month.
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20-24 – On Target. Asthma has been reasonably
well controlled for last month.
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<20 – Off Target. Asthma may not have been
controlled over last month.
An ED attendance = Suboptimal Control
If control is sub-optimal
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Assess compliance
Re-assess inhaler technique
Reassess diagnosis
Look for exacerbating factors and treat
GORD
 Rhinitis / Allergies
 Smoking
 Occupational exposures
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Step up
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Make 1 step at a time, change 1 thing
Step 3 practically means stopping ICS and
starting a combination inhaler – ensures dual
therapy, improves compliance
Symbicort 200/6 1 puff bd
Seretide accuhaler 100 1 puff bd
Seretide evohaler 50 2 puffs bd
Flutiform mdi 50/5 2 puffs bd
Increasing dose at Step 3
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Reassess as before
Increase Symbicort / Seretide strength to 800mcg BDP
equivalent
Symbicort 200/6 2 puffs bd
Seretide 125 evohaler 2 puffs bd
Seretide 250 accuhaler 1 puff bd
Flutiform 125/5 mdi 2 puffs bd
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Consider Montelukast 10mg od
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Step 4
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Consider chest physician
Reassess
Increase ICS to 2000mcg:
Symbicort 400/12 2 puffs bd
(Seretide evohaler 250 2 puffs bd)
Seretide accuhaler 500 1 puff bd
Flutiform 250/10 mdi 2 puffs bd
Montelukast + Uniphyllin 200mg bd
Step 5
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Reassess
Under Chest Physician
Good Control – Should we change
anything?
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Safe to step-down
RCT Scotland: 259 adult asthmatics, ≥800mcg
Well controlled step down vs. sham step down
No difference in exacerbation rates
Hawkins et al. BMJ 2003;326:1115
Risks of Overtreatment
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Dose-response curve means benefits of
increased ICS dose may be minimal
Side-effects – dysphonia, candida
Purpura, skin thinning – dose response
≥400mcg/day
Adrenal suppression – occurs ≥800mcg/day
Osteoporosis occurs ≥800mcg/day – every
500mcg increase – 9% increase in fractures
Geddes. Thorax 1992;47:404-407
Loke. Thorax 2011;66:699-708
Costs of Overtreatment
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Symbicort 400/12 ii bd:
Seretide 250 ii bd:
Flutiform 250 ii bd:
£76
£59
£46
Symbicort 200/6 ii bd:
Seretide 125 ii bd:
Flutiform 125 ii bd:
£38
£35
£29
Symbicort 200/6 i bd:
Seretide 50 ii bd:
Flutiform 50 ii bd:
£19
£18
£18
? Tiotropium - Step 3
Allergic asthma
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Currently 80% of asthma expenditure goes on
20% of patients – severe asthma
50% of severe asthmatics have ‘allergic’ asthma
IgE antibody has a central role in allergic
inflammatory cascade
Prevalence of asthma is closely linked to total
serum IgE level
Specific IgE antibodies correlate with ‘allergies’
Xolair – Omalizumab
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First Recombinant
humanised monoclonal
antibody vs. IgE
Binds to all forms of IgE
INNOVATE Trial 2005
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419 pts – 12-75 yrs
Severe persistent allergic asthma FEV1 <80%
Recent exacerbation
Total IgE >30 <700
Skin prick +ve
Optimised inhaled Step 3 + Xolair vs. placebo
Xolair significantly reduces exacerbation rates by 43% in
patients not receiving maintenance OCS.
Severe exacerbation rate in patients not receiving
maintenance OCS.3
Adapted from Bleeker et al (2005)3; a subgroup analysis of
INNOVATE4 comparing patients requiring OCS at baseline
with those that did not.
In the overall INNOVATE population, when
added in to standard care of high-dose
inhaled corticosteroids (ICS) plus a long
acting B2-agonist, XOLAIR significantly
reduced severe exacerbation rate by 50%
versus placebo (p=0.002).4
Xolair significantly reduces the mean number of
asthma exacerbations in patients with SPAA in
normal clinical practice.5
Results from Niven & Radwan (2011); the APEX study, a
retrospective review of 136 patients with severe persistent
allergic asthma prescribed omalizumab as part of usual
clinical practice.
In the APEX study, exacerbation rates decreased
significantly in both cohorts in the 12 months after
omalizumab initiation, by a mean of –2.02 (±3.02) in
the continuous OCS cohort (p<0.001);and by –1.78
(±2.55) in the non-continuous OCS cohort (p<0.001)
−− the between-group difference was not statistically
significant (0.24 [95% CI –0.79, 1.27]; p=0.6458).5
XOLAIR is well tolerated
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Cumulative exposure of more than 279,000 patientyears XOLAIR worldwide since first launch.8
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Adverse events in clinical trials with XOLAIR were
mostly mild to moderate in severity.9
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In adult and adolescent patient age 12 years and above,
the most commonly reported adverse events were
injection site reactions including injection site pain
swelling, erythema, pruritis and headache.8
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In children 6 to <12 years of age, the most commonly
reported adverse reaction were headache, pyrexia and
upper abdominal pain.8
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XOLAIR has a favourable safety profile for use in
patients taking multiple medications.
Refer to Summary of Product Characteristics for a full list of adverse events.
Prescribe Xolair before
maintenance OCS for…
43% reduction in severe
exacerbations3
74% reduction in A+E visits5
62 % reduction in
Hospitalisations5
46% improvement in Qol7
Why wait?
Xolair
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Sub-cut administration every 2-4 weeks
£3000 - £15000 per year
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Dependent on body-weight and IgE level
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16 week trial for each patient - ?responder – symptoms,
exacerbations, PFT, QoL
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If non-responder – stop and Novartis replaces all drug
used free-of-charge
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Xolair – anti-IgE
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NICE approved as add-on therapy for severe persistent
allergic asthma, >12 yrs old
FEV1 <80%, frequent day or night symptoms
IgE mediated allergy to perennial allergen, skin-prick /
RAST confirmed (HDM, cat, dog, grass)
2 or more admissions with exacerbations in 12/12 or…
3 or more severe exacerbations in 12/12 requiring ED
attendance, 1 of which led to admission
Summary
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To optimise asthma treatment need to identify
those patients who need treatment changing
All those who attend ED need asthma reviewing
Remember: Compliance, technique, exacerbating
factors
Allergic asthma – consider referring

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