M.E.D.C Sezione di Pneumologia ed Allergologia, U.O. Pediatria 1 Azienda Ospedaliero-Universitaria Pisana, Pisa

M.E.D.C Get the right diagnosis Give an appropriate level of treatment Eliminate trigger factors from the environment Make sure the child and family know what it is all about and how to use the medication delivery device Bush A, Fleming L. Prim Care Respir J. 2012; 21: 242-4

M.E.D.C Get the right diagnosis Give an appropriate level of treatment Eliminate trigger factors from the environment Make sure the child and family know what it is all about and how to use the medication delivery device Bush A, Fleming L. Prim Care Respir J. 2012; 21: Give an appropriate level of treatment

M.E.D.C. 2015

2012 What is new in GINA 2014? 2014 Major Revision

Asthma is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation A ‘new’ definition of asthma for clinical practice Global Initiative for Asthma (GINA) Guidelines

Reddel HK et al. Int J Tuberc Lung Dis. 2014; 18: The 2014 GINA report covers all age groups, and includes a new chapter describing a syndromic approach to diagnosis of the asthma-COPD overlap syndrome (ACOS) M.E.D.C Comprehensive and practical approach to asthma management (foundational role of ICS therapy, importance of non-pharmacological options) What is new in GINA 2014? Focus on common problems such as poor inhaler technique and adherence New sections on diagnosis and management for special populations, such as obesity and pregnancy

M.E.D.C GINA 2012 GINA 2014

M.E.D.C To achieve good control of symptoms and maintain normal activity levels To minimize future risk of exacerbations, fixed airflow limitation and side-effects Global Initiative for Asthma (GINA) Guidelines Long-term goals of asthma management in GINA 2014

Global Initiative for Asthma (GINA) Guidelines The control-based asthma management cycle M.E.D.C. 2015

Treatment options at a POPULATION level: e.g. national formularies, health maintenance organisations, national guidelines The ‘preferred treatment’ at each step is based on:  Efficacy  Effectiveness  Safety  Availability and cost at the population level based on group mean data for symptoms, exacerbations and lung function (from RCTs, pragmatic studies and observational data) M.E.D.C Population level vs Patient level decisions about asthma treatment

Decisions for individual PATIENTS Use shared decision-making wth the patient/parent/carer to discuss the following: 1.Preferred treatment for symptom control and for risk reduction 2.Patient characteristics (phenotype) Does the patient have any known predictors of risk or response? (e.g. smoker, history of exacerbations, blood eosinophilia) 3. Patient preference What are the patient’s goals and concerns for their asthma? 4. Practical issues Inhaler technique - can the patient use the device correctly after training? Adherence: how often is the patient likely to take the medication? Cost: can the patient afford the medication? M.E.D.C Population level vs Patient level decisions about asthma treatment

CONTROLLED (All of the following) PARTLY CONTROLLED (Any measure in any week) UNCONTROLLED Daytime symptoms None (2 or less a week) > 2 a week Three or more features of partly controlled asthma present in any week Limitations of activities NoneAny Nocturnal symptoms NoneAny Need for reliever/rescue treatment None (2 or less a week) > 2 a week Lung function (PEF or FEV 1 ) Normal <80% predicted or personal best Levels of asthma control - GINA 2012 M.E.D.C Global Initiative for Asthma (GINA) Guidelines

Levels of asthma control - GINA 2014 M.E.D.C. 2015

Levels of asthma control - GINA 2014 M.E.D.C. 2015

Risk factors for exacerbations include: Ever intubated for asthma Uncontrolled asthma symptoms Having ≥1 exacerbation in last 12 months Low FEV 1 (measure lung function at start of treatment, at 3-6 months to assess personal best, and periodically thereafter) Incorrect inhaler technique and/or poor adherence Smoking Obesity, pregnancy, blood eosinophilia Risk factors for fixed airflow limitation include: No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia Risk factors for medication side-effects include: Frequent oral steroids, high dose/potent ICS, P450 inhibitors Risk factors for poor asthma outcomes M.E.D.C Global Initiative for Asthma (GINA) Guidelines

M.E.D.C. 2015

Management of Asthma - GINA 2012 M.E.D.C Global Initiative for Asthma (GINA) Guidelines

Asthma stepwise management - GINA 2014 M.E.D.C. 2015

MILD ASTHMA MODERATE ASTHMA SEVERE ASTHMA Categories of asthma severity - GINA 2014

Asthma stepwise management - GINA 2014 Treatment with regular daily low dose ICS is highly effective in reducing asthma symptoms and reducing the risk of asthma-related exacerbations, hospitalization and death M.E.D.C Global Initiative for Asthma (GINA) Guidelines

Asthma stepwise management - GINA 2014 Treatment with regular daily low dose ICS is highly effective in reducing asthma symptoms and reducing the risk of asthma-related exacerbations, hospitalization and death M.E.D.C Global Initiative for Asthma (GINA) Guidelines

Asthma stepwise management - GINA 2014 Consider step up but first check for common problems such as inhaler technique, adherence, persistent allergen exposure and comorbidities M.E.D.C Global Initiative for Asthma (GINA) Guidelines

Categories of asthma severity - GINA 2014 M.E.D.C MILD ASTHMA

M.E.D.C MILD ASTHMA MODERATE ASTHMA Categories of asthma severity - GINA 2014

How to start astma controller treatment Start controller treatment early For best outcomes, initiate controller treatment as early as possible after making the diagnosis of asthma Indications for regular low-dose ICS - any of: Asthma symptoms > 2 a month Waking due to asthma > 1 a month Any asthma symptoms plus any risk factors for exacerbations Consider starting at a higher step if: Troublesome asthma symptoms on most days Waking from asthma ≥ 1 a week, especially if any risk factors for exacerbations If initial asthma presentation is with an exacerbation: Give a short course of oral steroids and start regular controller treatment (e.g. high dose ICS or medium dose ICS/LABA, then step down) M.E.D.C Global Initiative for Asthma (GINA) Guidelines

Remember to… IMM AMBU Consider step down once good asthma control has been achieved and maintained for about 3 months, to find the patient’s lowest treatment that controls both symptoms and exacerbations M.E.D.C Global Initiative for Asthma (GINA) Guidelines

Approach each step as a therapeutic trial. Engage the patient in the process; provide clear instructions, written asthma action plan, monitor symptoms and/or PEF; schedule a follow-up visit… M.E.D.C Choose an appropriate time (no respiratory infection, patient not travelling, not pregnant); close supervision Stepping down ICS doses by 25-50% at 3 month intervals is feasible and safe for most patients Global Initiative for Asthma (GINA) Guidelines How to step down asthma treatment? Consider step down once good asthma control has been achieved and maintained for about 3 months, to find the patient’s lowest treatment that controls both symptoms and exacerbations

Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen (may be initiated by patient with written asthma action plan) How to step up asthma treatment? M.E.D.C Sustained step-up, for at least 2-3 months if asthma poorly controlled (Important: first check for common causes like symptoms not due to asthma, incorrect inhaler technique, poor adherence) Day-to-day adjustment (For patients prescribed low-dose ICS/formoterol maintenance and reliever regimen) Global Initiative for Asthma (GINA) Guidelines

How to distinguish between Uncontrolled and Severe asthma M.E.D.C. 2015

Low, medium and high dose ICS Children 6-11 years Inhaled corticosteroidTotal daily dose (mcg) LowMediumHigh Beclometasone dipropionate (HFA)50-100> >200 Budesonide (DPI) > >400 Budesonide (nebules) > >1000 Ciclesonide80>80-160>160 Fluticasone propionate (DPI ) > >400 Fluticasone propionate (HFA) > >500 Mometasone furoate110≥220 <440≥440 Triamcinolone acetonide > >1200 M.E.D.C Global Initiative for Asthma (GINA) Guidelines

Inhaled corticosteroidTotal daily dose (mcg) LowMediumHigh Beclometasone dipropionate (HFA) > >400 Budesonide (DPI) > >800 Ciclesonide (HFA)80-160> >320 Fluticasone propionate (DPI or HFA) > >500 Mometasone furoate > >440 Triamcinolone acetonide > >2000 M.E.D.C Low, medium and high dose ICS Adults and adolescents (≥12 years) Adults and adolescents (≥12 years) Global Initiative for Asthma (GINA) Guidelines

M.E.D.C. 2015

What is new in BTS/SIGN GL 2014?

M.E.D.C. 2015

What is new in BTS/SIGN GL 2014?

M.E.D.C What is new in BTS/SIGN GL 2014? Bronchial termoplasty may be considered for the treatment of adult patients who have poorly controlled asthma depite optimal therapy BTS / SIGN Asthma Guidelines

M.E.D.C What is new in BTS/SIGN GL 2014? BTS / SIGN Asthma Guidelines Normal Airway Asthmatic Airway Asthmatic Airway during attack

In lung diseases exacerbations are not a temporary inconvenience, and can be associated with permanent damage and a worse prognosis which should call forth immediate action Full review of all aspects of the problem, including co-morbidities, management, adherence, environmental factors… Bush A. Thorax. 2011; 66: 367 M.E.D.C The term ‘lung attack’ may resonate more with patients and the broader community

Effects of repeated bronchoconstriction Grainge CL, Lau LC, Ward JA et al. N Engl J Med. 2011; 364: This study shows that repeated bronchoconstriction in asthma promotes airway remodeling The changes were evident 4 days after repeated airway challenges and were independent of the stimulus causing the bronchoconstriction M.E.D.C. 2015

Steroid Phobia M.E.D.C. 2015

Zhang L, Prietsch SOM, Ducharme FM. Cochrane Database Sys Rev. 2014; 7: CD Pruteanu AI, Chauhan BF, Zhang L. et al. Cochrane Database Sys Rev. 2014; 7: CD Small but statistically significant group difference in growth velocity (0,2 cm/yr) between low doses of ICS and low to medium doses of HFA-beclomethasone equivalent, favouring the use of low-dose ICS Regular use of ICS at low or medium daily doses is associated with a mean reduction of 0.48 cm/y in linear growth velocity and a 0.61 cm change from baseline in height during a one- year treatment period

What about steroid-phobia? ”Asthma inhalers make children half a centimeter shorter” - The Telegraph 2014, July the 17th “Half a centimeter in growth is a a small price to pay for medicine which may save your child’s life!” M.E.D.C. 2015

XIX Congresso SIMRI - Torino 22-24/10/15

© Global Initiative for Asthma Avoidance of tobacco smoke exposure  Provide advice and resources at every visit; advise against exposure of children to environmental tobacco smoke (house, car) Physical activity  Encouraged because of its general health benefits. Provide advice about exercise-induced bronchoconstriction Occupational asthma  Ask patients with adult-onset asthma about work history. Remove sensitizers as soon as possible. Refer for expert advice, if available Avoid medications that may worsen asthma  Always ask about asthma before prescribing NSAIDs or beta-blockers Breathing techniques (no specific technique)  May be a useful supplement to asthma medications (Allergen avoidance)  (Not recommended as a general strategy for asthma) See GINA Box 3-9 and online Appendix for details Non-pharmacological interventions GINA 2014, Box 3-9 This slide shows examples of interventions with high quality evidence

Presenting symptoms Preferred initial controller Asthma symptoms or need for SABA < 2 a month; no waking due to asthma in last month; and no risk factors for exacerbations including no exacerbations in the last year No controller Infrequent asthma symptoms, but the patient has one or more risk factors for exacerbations; e.g. low lung function, or exacerbation requiring OCS in the last year, or has ever been in intensive care for asthma Low dose ICS Asthma symptoms or need for SABA between 2 a month and 2 a week, or patient wakes due to asthma once or more a month Low dose ICS Asthma symptoms or need for SABA > 2 a week Low dose ICS Other less effective options: LTRA or Theophylline Recommended options for initial controller treatment in adults and adolescents M.E.D.C. 2015

Presenting symptoms Preferred initial controller Troublesome asthma symptoms most days; or waking due to asthma once a week or more, especially if any risk factors exist Medium/high dose ICS or Low dose ICS/LABA Initial asthma presentation is with severely uncontrolled asthma, or with an acute exacerbation Short course of oral corticosteroids AND Start regular controller treatment; options are High-dose ICS or Moderate-dose ICS/LABA Recommended options for initial controller treatment in adults and adolescents M.E.D.C. 2015

© Global Initiative for Asthma Treating modifiable risk factors Provide skills and support for guided asthma self-management This comprises self-monitoring of symptoms and/or PEF, a written asthma action plan and regular medical review Prescribe medications or regimen that minimize exacerbations ICS-containing controller medications reduce risk of exacerbations For patients with ≥1 exacerbations in previous year, consider low-dose ICS/formoterol maintenance and reliever regimen* Encourage avoidance of tobacco smoke (active or ETS) Provide smoking cessation advice and resources at every visit For patients with severe asthma Refer to a specialist center, if available, for consideration of add-on medications and/or sputum-guided treatment For patients with confirmed food allergy: Appropriate food avoidance Ensure availability of injectable epinephrine for anaphylaxis M.E.D.C. 2015