A 2017 Update on Asthma Management Akshay Sood, MD, MPH UNM Division of Pulmonary Medicine

Case Discussion Question 1:What pointers exist in this case to suggest the diagnosis of asthma?

Initial Assessment & Diagnosis Determine that: History of episodic symptoms of airflow obstruction Airflow obstruction is at least partially reversible Alternative diagnoses are excluded

Detailed history Does patient have history of episodic symptoms of airflow obstruction? Wheeze, shortness of breath, chest tightness, or cough Symptoms vary through the day/night and season Absence of symptoms/signs at the time of exam does not exclude asthma

Spirometry Is airflow obstruction at least partially reversible? Use spirometry to establish airflow obstruction: FEV1/FVC below the lower limit of normal Use spirometry to establish reversibility: FEV1 increases >12% and at least 200 mL after using a short-acting inhaled beta2-agonist Not always seen

Initial Assessment & Diagnosis Are alternative diagnoses excluded? Vocal cord dysfunction Vascular rings & pulmonary embolism Airway obstruction from foreign bodies/tumors Tracheomalacia/tracheal stenosis COPD Other pulmonary diseases

Pathophysiology of Asthma

Case Discussion Question 2: What additional tests would you perform on this patient?

Additional Tests Reasons for Additional Tests The Tests Patient has symptoms but spirometry is normal or – Bronchoprovocation test near normal. , Suspect infection, large airway lesions, heart – Chest x-ray disease, or obstruction by foreign object Suspect coexisting chronic obstructive pulmonary – Additional pulmonary function studies disease, restrictive defect, or central airway – Diffusing capacity test obstruction Suspect other factors contribute to asthma – Allergy tests—skin or in vitro (These are not diagnostic tests for asthma.) – Nasal examination – Gastroesophageal reflux assessment

Case Discussion Question 3: How would you classify his asthma severity?

Asthma Control Test™ (ACT) 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? SCORE 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? During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? How would you rate your asthma control during the past 4 weeks? A score of ≤19 means asthma may not be under control. TOTAL ACT is for patients with asthma 12 years and older. Asthma Control Test is a trademark of QualityMetric Incorporated. Copyright 2002, by QualityMetric Incorporated.

Case Discussion Question 4: What are the goals of his asthma therapy?

Goals of Asthma Therapy Prevent chronic and troublesome symptoms Maintain (near-) “normal” pulmonary function Maintain normal activity levels (including exercise and other physical activity)

Goals of Asthma Therapy (continued) Prevent recurrent exacerbations and minimize the need for emergency department visits or hospitalizations Provide optimal pharmacotherapy with minimal or no adverse effects Meet patients’ and families’ expectations of, and satisfaction with, asthma care

Risk Factors for Asthma Mortality prior intubation or prior ICU admission history of sudden severe exacerbations >2 hospital admits or >3 ED visits for asthma in the last year; admit or ED visit within last month current oral steroid usage or recent taper use of >2 canisters/month of -agonist MDI comorbid illness, illicit drug use, urban area lack of a written asthma action plan, sensitivity to Alternaria Factors identified by NAEPP

Case Discussion Question 5: What environmental and occupational factors are possibly contributing to his asthma severity and what measures would you suggest to control them?

Factors Contributing to Asthma Severity Assess exposure and sensitivity to: Inhalant allergens Occupational exposures Irritants: Indoor air (including tobacco smoke) Air pollution

Teach Patients To Reduce Exposure to Their Inhalant Allergens Animal Dander Remove pet from house (ideal) Keep animal out of patient’s bedroom (at a minimum) Seal or put a filter on air ducts that lead to bedroom

Teach Patients To Reduce Exposure to Their Inhalant Allergens (continued) House-Dust Mites Essential: Encase mattress in an allergen-impermeable cover Encase pillow in an allergen-impermeable cover or wash weekly Wash sheets and blankets in hot water weekly (>130 F is necessary for killing mites)

Teach Patients To Reduce Exposure to Their Inhalant Allergens (continued) Indoor mold Fix all leaks and eliminate water sources associated with mold growth Clean moldy surfaces Consider reducing indoor humidity to less than 50%

Work-Aggravated Asthma: Evaluation Recognize the potential for workplace-relatedness Sensitizers (e.g., isocyanates, plant or animal products) Irritants or physical stimuli (e.g., cold/heat, dust, humidity)

Case Discussion Question 6: What other factors are possibly contributing to his asthma severity and what measures would you suggest to control them?

Control of Factors Contributing to Asthma Severity Assess contribution of other factors: Rhinitis/sinusitis Gastroesophageal reflux Obstructive sleep apnea Drugs (NSAIDs, beta-blockers) Viral respiratory infections Sulfite sensitivity

Control Other Factors That Can Influence Asthma Severity Rhinitis Intranasal corticosteroids are most effective Sinusitis Promote drainage; antibiotics for complicating acute bacterial infection Gastroesophageal reflux Medications; no food before bedtime; elevate head of bed Obstructive sleep apnea Diagnosis and treatment helpful

Control Other Factors That Can Influence Asthma Severity (continued) Viral infections Annual influenza vaccination Aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs) Ask adult patients about sensitivity Counsel avoidance for those with sensitivity, severe asthma, or nasal polyps

Case discussion Question 7: What is the correct pharmacological regimen for his asthma management?

Inhaled Medication Delivery Devices Metered-dose inhaler (MDI) Dry powder inhaler (DPI) Spacer/holding chamber Spacer/holding chamber and face mask Nebulizer

Overview of Asthma Medications (continued) As-needed: Quick Relief Short-acting beta2-agonists Anticholinergics Systemic corticosteroids

Overview of Asthma Medications Daily: Long-Term Control Corticosteroids (inhaled and systemic) Cromolyn/nedocromil Long-acting beta2-agonists Methylxanthines Leukotriene modifiers Omalizumab Long-acting muscarinic antagonists

The Rule of Twos* (Who Needs Controller Therapy, >) Two beta-agonist canisters/year Two doses of beta-agonist/week Two nocturnal awakenings/month Two unscheduled visits/year Two prednisone bursts/year *Trademark of Baylor Health Care System

Inhaled Corticosteroids Most effective long-term-control therapy for persistent asthma Small risk for adverse events at recommended dosage Reduce potential for adverse events by: Using spacer and rinsing mouth Using lowest dose possible Using in combination with long-acting beta2-agonists Monitoring growth in children

Long-Acting Beta2-Agonists Not a substitute for anti-inflammatory therapy Not appropriate for monotherapy Beneficial when added to inhaled corticosteroids Not for acute symptoms or exacerbations

Short-Acting Beta2-Agonists Most effective medication for relief of acute bronchospasm More than one canister per month suggests inadequate asthma control Regularly scheduled use is not generally recommended May lower effectiveness May increase airway hyperresponsiveness

Stepwise Approach to Therapy: Gaining Control 1. Start high and step down. 2. Start at initial level of severity; gradually step up. STEP 4 Severe Persistent STEP 3 2 1 Moderate Persistent STEP 2 Mild Persistent STEP 1 Mild Intermittent

Step 6 Step 5 Step 4 Step 3 Step 2 Step 1 Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3. Step 6 Preferred: High-dose ICS + LABA + oral corticosteroid AND Consider Omalizumab for patients who have allergies Step up if needed (first, check adherence, environmental control, and comorbid conditions) Step down if possible (and asthma is well controlled at least 3 months) Step 5 Preferred: High-dose ICS + LABA AND Consider Omalizumab for patients who have allergies ≥ 12 years old Step 4 Preferred: Medium-dose ICS + LABA AlternativeMedium-dose ICS + either LTRA, Theophylline, or Zileuton Step 3 Preferred: Medium-dose ICS OR Low-dose ICS + LABA Alternative Low-dose ICS + either LTRA, Theophylline, or Zileuton Step 2 Preferred: Low-dose ICS AlternativeCromolyn, Nedocromil, LTRA, or Theophylline Step 1 Preferred: SABA PRN Assess control Patient Education and Environmental Control at Each Step Steps 2-4: Consider SQ allergen immunotherapy for allergic patients Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed. Use of beta2-agonist >2 days a week for symptom control (not prevention of EIB) indicates inadequate control and the need to step up treatment.

Indicators of Poor Asthma Control Step up therapy if patient: Awakens at night with symptoms Has an urgent care visit Has increased need for short-acting inhaled beta2-agonists Uses more than one canister of short-acting beta2-agonist in 1 month

Indicators of Poor Asthma Control (continued) Before increasing medications, check: Inhaler technique Adherence to prescribed regimen Environmental changes Also consider alternative diagnoses

Other Targeted Therapies Likely only specific asthma phenotypes may benefit from these therapies Dupilumab Blocks effects of IL-4 and IL-13 by blocking common subunit in their receptor Wenzel NEJM 2013 368:2455 Brodalumab Anti-IL-17 receptor antibody Busse Am J Respir Crit Care Med 2013 188:1294 Lebrikizumab Anti-IL-13 antibody

Bronchial Thermoplasty Thermal energy to the airways during 3 bronchosopies to reduce smooth muscle mass. No reduction in hyperresponsiveness or change in FEV1 Improved QOL, reduction in ED visits and rates of severe exacerbations Wahidi AJRCCM 2012 185:700

           

Questions

Websites for further info www.cdc.gov www.nhlbi.nih.gov/guidelines/asthma