Presentation on theme: "The Saudi Initiative for Asthma Guidelines for the Diagnosis and Management of Asthma in Adults and Children Out-patient Management of Asthma in Adults."— Presentation transcript:
1The Saudi Initiative for Asthma Guidelines for the Diagnosis and Management of Asthma in Adults and ChildrenOut-patient Management of Asthma in AdultsOn behalf of the SINA panelMohamed S. Al-Moamary, FRCP (Edin) FCCPDep. of Medicine, King Abdulaziz Medical City-RiyadhKing Saud bin Abdulaziz University for Health Sciences
2Enter presenter name Enter the presenter’s institute Out-patient Management of Asthma in AdultsEnter presenter nameEnter the presenter’s institute
3What is SINA?SINA is developed by a task force originated from the Saudi Initiative for Asthma Group under the umbrella of the Saudi Thoracic SocietySINA is a practical approach for a comprehensive management of asthma in adults and children and when to refer to a specialist.International recommendations were customized to the local setting for asthma diagnosis and managementDirected to HCW dealing with asthma who are not specialists in the field.
4Purpose of SINATo provide a document that is easy to follow, simple to understand yet totally updated and carefully prepared for use by non-asthma specialist including primary care doctors and general practice physicians
5The SINA guidelines booklet is available at: www.sinagroup.org Where do you find SINA?The SINA guideline was published in the Annals of Thoracic Medicine (www.thoracicmedicine.org):Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, Al-Ghobain MO, Idrees MM, Zeitouni MO, Al-Harbi AS, Al Dabbagh MM, Al-Matar H, Alorainy HS. The Saudi initiative for asthma update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2012;7:The SINA guidelines booklet is available at:
6Saudi Thoracic Society commitment The STS is committed to improve the care of asthma by a long term plan:Periodic scientific meetingsAnnual asthma meeting (since 2001)Frequent asthma coursesEducational brochuresPublishing new and updated asthma guidelines
7What is new in SINA-2012Comprehensive revision with the addition of new 125 referencesAddition of charts and algorithms for asthma diagnosis and managementUpdating asthma managementRewritten “asthma in children” sectionNew section on “difficult to treat asthma”
8SINA PanelMohamed S. Al-Moamary (Chairman), King Saud bin Abdulaziz University for Health Sciences, RiyadhSami Alhaider, King Faisal Specialist Hospital and Research Center, RiyadhMohamed S. Al-Hajjaj, King Saud University, RiyadhMohammed O. AlGhobain, King Saud bin Abdulaziz University for Health Sciences, RiyadhMajdy M. Idrees, Military Hospital, RiyadhMohamed O. Zeitouni, King Faisal Specialist Hospital and Research Center, RiyadhAdel S. Alharbi, Military Hospital, Riyadh Hussain Al-Matar, Imam Abdulrahman Al Faisal, DammamMaha M. Al Dabbagh, King Fahd Armed Forces Hospital, Jeddah Hassan S Alorainy, King Faisal Specialist Hospital and Research Center, Riyadh
9AcknowledgmentThe SINA panel would like to thank the following reviewers :Prof. J. Mark FitzGerald from the University of British Columbia, Vancouver, BC, CanadaProf. Qutayba Hamid from the Meakins-Christie Laboratories, and the Montreal Chest Research InstituteProf. Sheldon Spier, the University of British Columbia, Vancouver, CanadaProf. Eric Bateman from the University of Cape Town Lung Institute, Cape Town, South Africa (SINA 2009)Prof. Ronald Olivenstein from the Meakins-Christie Laboratories and the Montreal Chest Research Institute, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada. (SINA 2009)
11Sections of SINAEpidemiologyPathophysiologyDiagnosisMedicationsApproach to ManagementTreatment StepsSpecial SituationsAcute Asthma
12Prevalence of asthma has increased between 1986 – 1995 Alfrayyah et al. Ann Allergy Asthma Immunol 2001;86:292–296
13Burden of AsthmaAsthma is among the most common chronic illnesses in Saudi Arabia53% had missed school or work (AIRKSA-2007)35% attempted Unconventional therapy (Al Moamary, ATM 2008)46% were controlled in Riyadh (AIRKSA-2007)36% were controlled in 5 tertiary care centers in Riyadh (Aljahdali SMJ-2008)48% were controlled in one center (Al Moamary, ATM 2008)
14AIRKSA report (Ministry of Health) 78 % of adults & 84% of kids reported acute asthma over 12 months (AIRKSA)54 % of adults & 80% of kids reported ER over 12 months (AIRKSA)45-68% of adults & 37-56% of kids reported limitation of activity over 12 months (AIRKSA)76 % of adults & 78% of kids never had spirometry(AIRKSA)
15The prevalence of wheeze and associated symptoms in the study group Al-Ghobain et al, NBC Pulm Med 2012;12:39
16Pattern of asthma treatment Al-Shimemeri, Ann Thorac Med 2006;1:20-5
17Airway Hyper-responsiveness Pathology of AsthmaInflammationAirway Hyper-responsivenessAirway ObstructionSymptoms of Asthma
20Diagnosis - History Episodic attacks: CoughBreathlessnessWheezingNocturnal symptomsPatient could be asymptomatic between attacksco-existent conditions: GERD, rhinosinusitis.
21Relevant QuestionsDoes the patient or his/her family have a history of asthma or other atopic conditions, such as eczema or allergic rhinitis?Does the patient have recurrent attacks of wheezing?Does the patient have a troublesome cough at night?Does the patient wheeze or cough after exercise?Does the patient experience wheezing, chest tightness, or cough after exposure to pollens, dust, feathered or furry animals, exercise, viral infection, or environmental smoke?
22Relevant QuestionsDoes the patient experience worsening of symptoms after taking aspirin/nonsteroidal inflammatory medication or use of B-blockers?Does the patient's cold “go to the chest” or take more than 10 days to clear up?Are symptoms improved by appropriate asthma treatment?Are there any features suggestive of occupational asthma
23Physical Examination Normal between attacks Bilateral expiratory wheezingExamination of the upper airwaysOther allergic manifestations: e.g., atopic dermatitis/eczemaConsider alternative Dx when there is localized wheeze, crackles, stridor, clubbing
24Measurements of lung function: InvestigationsMeasurements of lung function:SpirometryPeak expiratory flow (PEF)Normal Spirometry does not role out asthmaSpirometry is superior to PEF
25Bronchodilator response Proper instructions on how to perform the forced expiratory maneuver must be given to patients, and the highest value of three readings taken.The degree of significant reversibility is defined as an improvement in FEV1 ≥12% and ≥200 ml from the pre-bronchodilator value.
26Clinical AssessmentMeasurements of allergic status to identify risk factors (if indicated)Chest X-ray is not routinely recommendedRoutine blood tests are not routinely recommendedIgE measurement is indicated in severe cases
28Asthma Control Test Level of Control: Total: 25 Control: 20-24 Partial control:Uncontrolled: < 16
29Differential Diagnosis Upper airway diseasesAllergic rhinitis and sinusitisObstructions involving large airwaysForeign body in trachea or bronchusVocal cord dysfunctionVascular rings or laryngeal websLaryngotracheomalacia, tracheal stenosis, or bronchostenosisEnlarged lymph nodes or tumorObstructions involving small airwaysViral bronchiolitis or obliterative bronchiolitisCystic fibrosisBronchopulmonary dysplasiaHeart diseaseOther causesRecurrent cough not due to asthmaAspiration from swallowing mechanism dysfunction or GERD
30Differential Diagnosis COPD (e.g., chronic bronchitis or emphysema)Congestive heart failurePulmonary embolismMechanical obstruction of the airways (benign and malignant tumors)Pulmonary infiltration with eosinophiliaCough secondary to drugs (e.g., angiotensin-converting enzyme (ACE) inhibitors)Vocal cord dysfunction
32Patient/Dr Partnership Enhance the chance of disease controlAgreed goals of managementGuided self-management plan
33Asthma EducationCreation of partnership between patient and healthcare workerUnderstanding clinical presentation of asthma and diagnosisAbility to differentiate between “relievers” and “controllers” medications and their appropriate indicationsRecognition of potential side effects of medications and the appropriate action to minimize themPerformance of the proper technique of devicesIdentification of symptoms and signs that suggest worsening of asthma control and the appropriate action to be takenUnderstanding the approach for monitoring asthma controlRecognition of the situations that need urgent medical attentionAbility to use a written self-management plan
34Non-Adherence Drugs: Non-drugs Poor technique of inhaler devices. Regimen with multiple drugs.Occurrence of Side effects from the drugs.Cost of medications.Non-drugsLack of knowledge about asthma.Lack of partnership in the management.Inappropriate expectations.Underestimation of severity.Cultural issues.
35Precipitating Factors Indoor Allergens and Air PollutantsOutdoor AllergensOccupational ExposureFood and Drugs
37Self-management plan www.tnfos.com لكل مريض خطة علاجية ذاتية خاصة به توضع تحت إشراف الطبيب المختص حسب حالتهالإجراء الواجب إتباعه : الإستمرار على الأدوية المعطاة :إستخدام البخاخ الموسع للشعب الهوائية_____ بخة كل ____ ساعات عند الضرورة وقبل التمارين ارياضية ب 15 – 30 دقيقة .إستخدام البخاخ الواقي _____ بخة ______ مرة يومياً و بشكل منتظم لمدة ( ) . أدوية أخرى :1- الحالة المستقرة :ممارسة الحياة بشكل طبيعي (لعب ، نوم ، دراسة)إختفاء أعراض الربو في الليل .ندرة إستخدام البخاخ في الموسع للشعب الهوائية (أقل من 3 مرات أسبوعياً)سرعة تدفق الهواء أكثر من 80% من الحد الطبيعيالإجراء الواجب إتخاذه :زيادة جرعة البخاخ الواقي ______إلى ______بخة _____مرة يومياً لمدة 10أيام ثم الرجوع إلى الجرعة السابقةإستخدام البخاخ الموسع للشعب الهوائية ( ) ( ) بخة كل ____ ساعات بإنتظام لمدة _____أيام أو حتى تتحسن الحالةإستشارة الطبيب في أقرب وقت ممكن .2 - الحالة المتوسطة الإستقرار (أزمة ربو على وشك الحدوث) :إستخدام البخاخ الموسع للشعب الهوائية أكثر من مرات يومياً .الإستيقاظ في الليل بسبب (كحة ، كتمة ، صفير في الصدر)وجود أعراض نزلة برد فيروسية .القدرة على نفخ الهواء بين 60 – 80 % من الحد الطبيعي .الإجراء الواجب إتخاذه :إستخدام البخاخ الموسع للشعب الهوائية ___بخة كل ____ ساعاتطلب الإستشارة الطبية بصفة عاجلة .زيادة جرعة البخاخ الواقي ____)إلى ______بخة ____)مرة يومياً لمدة 10أيام ثم الرجوع إلى الجرعة السابقة عمل ما يلي :3 - الحالة المتأزمة الحادة (سارع بطلب المساعدة الطبية) إذا لم تحدث استجابة لما سبق أو حدث :زيادة أعراض أزمة الربو .عدم القدرة على إتمام كلمتين في نفس واحد .عودة أعراض الربو بعد أقل من نصف ساعة من إستخدام البخاخ الموسع للشعب الهوائية .القدرة على نفخ الهواء أقل 50% من الحد الطبيعي .لابد من التوجه لقسم الطوارئ فوراً .(توجه للطوارئ أو أطلب الإسعاف) : إذا تدهورت أزمة الربو على الرغم من الإجراءات السابقة ، أو حدث إزرقاق فيالأطراف أو تدهور في مستوى الوعى ، أو تدني في سرعة تدفق الهواء لأقل من 50 % من المعدل الطبيعي
38Asthma MedicationsControllers are medications taken daily on a long-term basis to keep asthma under clinical control chiefly through their anti-inflammatory effects.Relievers are medications used on an as-needed basis that act quickly to reverse bronchoconstriction and relieve symptoms.
40Inhaled Corticosteroids The most effective antiinflammatory medications for asthma treatmentBenefits of ICS:reduce symptomsimprove quality of lifeimprove lung functiondecrease airway hyperresponsivenesscontrol airway inflammationreduce frequency and severity of exacerbations, and reduce mortality.
41Inhaled Corticosteroids When ICS discontinued, deterioration of clinical control may follow within weeksMost of the benefits from ICS are achieved in adults at relatively low dosesIncreasing to higher doses may provide further benefits in terms of asthma control but increases the risk of side effectsTobacco smoking reduces the responsiveness to ICS
42Inhaled Corticosteroids To reach control, add-on therapy with another class of controller is preferred to increasing the dose of ICSICS are generally safe and well-toleratedThough low-medium dose of ICS may affect growth velocity, this effect is clinically insignificant and may be reversible.
43Inhaled Corticosteroids Local adverse effects:oropharyngeal candidiasisdysphonia – may be e reduced by using MDI with spacer devices and mouth washingSystemic side effects are occasionally reported with high doses and long-term treatment
45Leukotriene modifiers (LTRA) LTRA reduces airway inflammation, improve asthma symptoms and lung functionIt has less consistent effect on exacerbations when compared to ICS.Alternative treatment to ICS for patients with mild asthma, especially in those who have clinical rhinitisSome patients with aspirin-sensitive asthma respond well to the LTRA
46Leukotriene modifiers (LTRA) Available as montelokast in Saudi ArabiaTheir effects are generally less than that of low dose ICSWhen added to ICS, LTRA may reduce the dose of ICS required by patients with uncontrolled asthma, and may improve asthma controlLTRA are generally well-tolerated. There is no clinical data to support their use under the age of six months.
47LABA LABA: (formoterol and salmeterol) Should not be used as monotherapyCombination with ICS lead to:improves symptomsdecreases nocturnal asthmaimproves lung functiondecreases the use of rapid-onset inhaled B2-agonistsreduces the number of exacerbationsachieves clinical control of asthma in more patients, more rapidly, and at a lower dose of ICS
48Dual Pathways of Inflammation Steroid-sensitive mediators play a key role in asthmatic inflammationCysLTs play a key role in asthmatic inflammationMontelukastInhaled steroidsblocks the effects of CysLTsblock steroid- sensitive mediatorsDUAL PATHWAYThe slide represents an artistic rendition.Adapted from Peters-Golden M, Sampson AP J Allergy Clin Immunol 2003;111(1 suppl):S37-S42; Bisgaard H Allergy 2001;56(suppl 66):7-11.
49Long acting anti-chlenergics It was superior to a doubling of the dose of an inhaled glucocorticoid for patients at step 3It was non-inferior to LABAIt improves lung function in patients with severe uncontrolled asthmaIt is effective as add-on therapy to combination devices at step 4Daily home peak expiratory flow measurements were higher with tiotropium dosesPeters et al. N Engl J Med 2010; 363:
50Sympicort turbohaler: Seretide: Combination devicesSympicort turbohaler:Combination of budesonide/formeterol: 160/4.5Seretide:Combination of fluticasone/salmeterolEvohaler: 50/ /25 250/25Diskus: 100/50 250/50 500/50
51TheophyllineWeak bronchodilator with modest anti-inflammatory propertiesIt may provide benefit as add-on therapy in patients who do not achieve control on ICS aloneLess effective than LABA and LTR.Side effects:gastrointestinal symptomscardiac arrhythmiasseizures, and even deathdrug interaction
52Omalizumab (Xolair) indication: Anti-IgEOmalizumab (Xolair) indication:Uncontrolled severe allergic asthma on high dose ICS and other controllers.Needs specialist consultation.Side effects:Pain and bruising at injection site and very rarely anaphylaxis (0.1%).
53Oral glucocorticosteroids Long-term oral glucocorticosteroid therapy may be required for uncontrolled asthma despite maximum standard therapy.It is limited by the risk of significant adverse effects.Side effects:Osteoporosis, hypertension, diabetes, adrenal insufficiency, obesity, cataracts, glaucoma, skin thinning, and muscle weakness.Withdrawal can elicit adrenal failure.In patients prescribed long-term systemic glucocorticosteroids, prophylactic treatment for osteoporosis should be considered.
55Short-acting B2-agonists The medications of choice for symptoms reliefPretreatment for exercise-induced bronchoconstriction.Formoterol is used for symptom relief because of its rapid onset of action.Increased use, especially daily use, is a warning of deterioration of asthma controlSide effects: B2-agonists are associated with adverse systemic effects such as tremor and tachycardia.
56Short-Acting Anticholinergics Less effective than SABA.Used in combination with SABA in acute asthma.An alternative bronchodilator for patients with adverse effects from rapid acting B2agonists.Side effects: can cause a dryness of the mouth and a bitter taste.
57Asthma control Control asthma symptoms Minimal use (≤2 days a week) of reliever therapyMaintain (near) normal pulmonary functionMaintain normal exercise and physical activity levelsPrevent recurrent exacerbations of asthmaMinimize the need for ER visits or hospitalizationsOptimize control with the minimal dose of medicationsReduce mortalityOptimize quality of life
58Principles of management The principles of asthma management in adults will follow 3 stages:InitiationAdjustmentMaintenance
59Initiation based on SINA approach The consensus among SINA panel is to simplify the approach to initiate asthma therapy by using ACT scoreACT Score ≥ 20 Step 1ACT Score 16–19 Step 2ACT Score 16 Step 3Al-Moamary et al, BMC Pulm Med 2012;12
60Initiation based on GINA approach Step 1 SABA on as needed basesStep 2 For patients who are not currently taking long-term controller medications.Step 3 If the initial symptoms are more frequent.
61SINA v.s. GINA approaches Al-Moamary et al, BMC Pulm Med 2012;12
63Adjustment of treatment Clinical AssessmentObtain ACT score and perform PFMBased on ACT, Adjust treatment:ACT = 20-25: Controlled Maintain treatmentACT = 16-19: Partial control Step upACT < 16: Uncontrolled Step up Introduce self-management plan
64Approach to Asthma Treatment in Adults and children > 5 years
65Principles of Asthma Treatment Daily long-term controller medication is the corner stone of treatmentICS are considered as the most effective controllerRelievers or rescue medications must be available to all patients at any stepSABA should be taken as needed to relieve symptomsIncreasing use of reliever treatment is an early sign of worsening asthma control
66Principles of Asthma Treatment Treat patients who may have seasonal asthma as having uncontrolled asthma during the season, then at step 1 for the rest of the yearPatients who had two or more exacerbations requiring oral corticosteroids or hospital admissions in the past year, should be treated as patients with uncontrolled asthma
67Step 1 - Recommendations Mild and infrequent symptomsInitial ACT 20 – 25Consider rapid onset B2-agonist to be taken “as needed” to treat symptomsPatient experiencing sudden, severe, or life-threatening exacerbations treat flare-up accordingly
68Step 2 - Recommendations Daily ICS at a low dose (< 500 μg of beclomethasone equivalent/day or equivalent)Alternative treatment isLTRA (montelukast)
69Step 3 – Recommendations Add a LABA to a low-medium dose ICS for patients whose asthma is not controlled on a low dose ICS alone, such as:Fluticasone/Salmeterol (Seretide)Budesonide/Formoterol (Symbicort)Use a maintenance dose of the combination drugs twice dailyUse the rapid onset B2-agonist as a reliever treatment.
70Step 3 - GOAL studyGOAL study has shown that an escalating dose of combination of Fluticasone/ Salmeterol (Seretide) achievesWell controlled asthma in 85% of patientsTotally controlled asthma in 30% of patients
71Step 3 - S.M.A.R.T® approachS.M.A.R.T® approach: Use of Formoterol/Budesonide for both rescue and maintenanceMaintenance dose single inhaler (1–2 puff 160/4.5 BID) plus extra puffs from the same inhaler up to a total of 12 puffs per day.Those patients who require such high dose should seek medical advice to step up therapy that may include use of short course of oral prednisone.
72Step 3 – Alternative therapy Adding LTRA to ICS, especially those with concomitant rhinitis orIncreasing ICS dose to the medium to high dose range as a monotherapy orAdding sustained release theophylline orAdding long acting anti-cholinergicConsultation with a specialist is recommended for patients whenever there is a difficulty in achieving control
73Step 4 – Recommendations Maximizing treatment is recommended by combining high-dose ICS with LABA orAdding LTRA, tiotropium, or theophylline to high-dose ICS and LABA orOmalizumab may be considered:Allergic asthma (as determined by skin test or RAST study) and still uncontrolled.Special knowledge about the drugConsultation is recommended
74Step 5 - Recommendations Omalizumab to be considered for patients who have allergic asthma and persistent symptoms despite the maximum therapy mentioned abovelowest possible dose of long-term oral corticosteroids for patient who:Does not have allergic asthmaOmalizumab is not available or not adequately controlling the disease
75Step 5 – long term steroids Long-term systemic corticosteroids:lowest possible dose to maintain controlMonitor for the development of side effectsContinue attempts to reduce the doseMaintaining high-dose of ICS therapyStrongly consider concurrent treatments with calcium supplements and vitamin DConsultation is mandatory
76Obtain ACT score and perform PFM Based on ACT score, adjust treatment: Maintaining ControlClinical AssessmentObtain ACT score and perform PFMBased on ACT score, adjust treatment:ACT= 20-25: well controlled Maintain treatment with lowest ICS dose (may step down)ACT= 16-19: Partial control Step upACT < 16: uncontrolled Step upFollow-up at 1 to 3 month intervals
77Allergen-specific immunotherapy (AIT) Gradual administration of increasing quantities of an allergen product to an individual with IgE-mediated allergic diseaseadministered either subcutaneously or sublinguallyinduces clinical and immunologic tolerance, has long term efficacy, and may prevent the progression of allergic disease, may improves the quality of life
78Allergen-specific immunotherapy (AIT) more effective in seasonal asthma than in perennial asthma, particularly when used against a single allergen.may be considered if strict environmental avoidance and comprehensive pharmacologic It has been a controversial treatment for asthma; however, beneficial clinical effects have been demonstratedconcerns regarding safety and cost, there was no demonstrated consistent effect on lung function
80Asthma and pregnancy - 1Unpredictable course: one third will have worsening of their of asthma controlMaintaining adequate control of asthma during pregnancy is essential for the health and well-being of the mother and her baby.Identifying and avoiding triggering factors should be the first step of therapy for asthma during pregnancy
81Asthma and pregnancy - 2Same stepwise approach as in non-pregnant patient.Salbutamol is the preferred SABAICSs are the preferred controllersUse of ICS, theophylline, antihistamines, B2-agonists, and LTRA is generally safeAcute exacerbations of asthma during pregnancy should be treated on the same outlines as in non-pregnant patients
82Asthma and pregnancy - 3Continuous fetal monitoring in severe asthma exacerbationIf anesthesia is required during labor, regional anesthesia is recommended whenever possibleThe use of prostaglandin F2α may be associated with severe bronchospasm
83Cough is the main symptom Cough-variant asthmaCough is the main symptomIt is common in children, and is often more problematic at nightOther diagnoses to be considered are:Drug-induced cough caused by angiotensin-converting-enzyme inhibitorsGERDPostnasal drip and chronic sinusitisTreatment is similar to long-term management of asthma
84Exercise-induced Asthma Bronchoconstriction peaks within 10 to 15 minutes after completing the exercise and resolves within 60 minutes.Prevention:SABA before exerciseWarm-up period before exerciseSome patients may need maintenance therapyRegular use of LTRA may help in this condition especially in children
85Aspirin/NSAID induced Asthma Occurs in 10–20% of adults with asthmaThe majority experience first symptoms during the third to fourth decade.Once aspirin or NSAID hypersensitivity develops, it is present for life.Within 1-2 hours following ingestion of aspirin, an acute, severe attack may develop, and is usually accompanied by rhinorrhea, nasal obstruction, conjunctival irritation, and scarlet flush of the head and neck
86Aspirin/NSAID induced Asthma Prevention by avoidance of aspirin/NSAIDPatients for whom aspirin is considered essential, they should be referred to an allergy specialist for aspirin desensitizationAspirin and NSAID can be used in asthmatic patients who do not have aspirin induced asthma
87GERD is more prevalent in asthmatics GERD triggered asthmaGERD is more prevalent in asthmaticsMechanisms of GERD triggered asthma:vagal mediated reflexreflux of micro-aspiration of gastric contents into the upper airwaysIf GERD symptoms presents, a trial of GERD therapy for 6–8 weeks wit lifestyle modificationsAsymptomatic patients with uncontrolled asthma may not benefit from GERD therapy
88Difficult to treat asthma (DTA) - 1 It is also called chronic severe asthma, steroid-dependent asthma, difficult-to-control asthma, and refractory asthmaDefined as asthma in patients who require very high doses of inhaled steroids with other controller agents, or near continuous oral steroid treatment to maintain asthma control.Accounts for 5-10 % of adult asthma, but the health cost is disproportionally highMorbidity and mortality are also higher than in regular asthma
89Difficult to treat asthma (DTA) - 2 Prior to labeling a patient to have DTA:Ensure patient is adherent to medications with good techniqueMisdiagnosis e.g. bronchiectasis, endo-bronchial tumors, and vocal cord dysfunctionControl other diseases preciptatnts, e.g. chronic sinusitis, gastro-esophageal disease, sleep apnea syndrome, obesity, and congestive heart failure (CHF)Confounding factors, e.g. non-adherence with treatment, the presence of allergens at home
90Difficult to treat asthma (DTA) - 3 Some patients may have the "pseudo-steroid" resistance in patients with persistent symptoms despite high doses of ICS and other "non-steroidal" asthma therapyThe aim is to reach the best possible outcome as it may be difficult to achieve full controlPatients should be at maximum therapy is given (Step 5 therapy)Anti-IgE treatment (Omalizumab) is given if the patients fulfill the criteria for this treatment
91Difficult to treat asthma (DTA) - 4 There are New modalities that may help to control DTA e.g.,:Mepolizumab has been shown to reduce exacerbations and improves asthma control in patients with refractory eosinophilic asthmaBronchial thermoplasty that utilizes radiofrequency energy to alter the smooth muscles of the airways. In severe persistent asthma, it leads to improvements in various measures of asthma, including FEV1, quality of life, asthma control, and use of rescue medications