Case approach in Asthma and COPD. Assoc.Prof.Sunee Lertsinudom BSc.Grad.Diplo.BCP. Department of Clinical pharmacy Khonkaen University

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1 Case approach in Asthma and COPD Assoc.Prof.Sunee Lertsinudom BSc.Grad.Diplo.BCP. Department of Clinical pharmacy Khonkaen University

2 Asthma Diagnosis History and patterns of symptoms Physical examination Measurements of lung function

3 Is it Asthma? Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants Colds go to the chest or take more than 10 days to clear Symptoms respond to anti-asthma therapy

4 Peak Flow meter 4

5 Measure lung function by spirometry or peak flow meter before and after bronchodilator 15 minutes FEV1 increase >/= 12 %(>/=200 ml) or PEFR increase >/= 20 % (60 L/ml) Salbutamol inhaler 2 puff wait 15 min PEFR increase ( )x PEFR =300 L/min PEFR =390 L/min = 30% 5

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8 Asthma predictive index Wheezing 3 คร งในช วง 1 ป ท แต ละคร งม อาการมากกว า 1 ว น ร วมก บเกณฑ หล ก 1 ข อ เกณฑ รอง 2 ข อ เกณฑ หล ก บ ดา มารดา เป นโรคห ด Atopic dermatitis เกณฑ รอง AR Eo 5 % ม wheezing ในช วงท ไม เป นหว ด

9 GINA Pediatric Guidelines 2009 Asthma Management Approach Based on Control for Children 5 Years and Younger Asthma education Environmental control As needed rapid-acting β 2 -agonist Controlled on as needed rapidacting ß 2 -agonists Partly controlled on as needed rapidacting ß 2 -agonists Uncontrolled or only partly controlled on low-dose inhaled glucocorticosteroid* Continue as needed rapid-acting ß 2 -agonists Controller options Low-dose inhaled glucocorticosteroid Leukotriene modifier Double low-dose inhaled glucocorticosteroid Low-dose inhaled glucocorticosteroid plus leukotriene modifier *Oral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma. Shaded boxes represent the preferred treatment options.

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11 Differentiating allergic rhinitis from other causes Symptom suggestive of allergic rhinitis Symptom usually NOT associated with allergic rhinitis 2 or more following symptoms for >1 hr on most day -watery anterior rhinorhea -sneezing,especially paroxysmal -nasal obstruction -nasal pruritus +/- conjunctivitis Classify and assess severity ARIA = Allergic Rhinitis and its Impact on Asthma. Bousquet et al. J Allergy Clin Immunol. 2001;108 (5 suppl):s147. Bousquet et al. Allergy. 2002;57:841. -unilateral symptoms -nasal obstruction without other symptoms -mucopurulent rhinorhea -posterior rhinorrhea (post nasal drip) with thick mucous and /or no anterior rhinorrhea -pain -recurrent epistaxis -anosmia Refer the patient rapidly to a physician

12 Intermittent symptoms 4 days per week Or 4 weeks Mild Normal sleep Normal daily activities, sport, leisure Normal work and school No troublesome symptoms Persistent symptoms >4 days per week And >4 weeks Moderate/Severe One or more items Abnormal sleep Impairment of daily activities, sport, leisure Problems caused at work or school Troublesome symptoms Bousquet J. Reid J. Weel C.V. et al. Allergic rhinitis management pocket reference Allergy 2008: 63:

13 Non-sedating AH decongestant or LTRA Mild intermittent symptoms INS added to non-sedating AH decongestant or LTRA Moderate persistent symptoms, bothersome Immunotherapy if symptoms: Show inadequate response to therapy Prolonged Impact upon HRQoL Lead to co-morbid conditions Short course of corticosteroids added to INS, non-sedating AH decongestant or LTRA Inadequate response to therapy, symptoms impact upon HRQoL, co-morbidities Step-down as symptoms improve: Reduce number of drugs Reduce dose Change therapy AH, antihistamine; HRQoL, health-related quality of life; Bousquet J et al. Allergy 2008;63(Suppl 86):8 160.

14 SYMPTOMS ± cough sputum shortness of breath EXPOSURE TO RISK FACTORS Tobacco Occupation Indoor/outdoor pollution SPIROMETRY FEV1/FVC < 70% Global Initiative for Chronic Obstructive Lung Disease,

15 Future risks GOLD 2011 revision GOLD 4 >2 GOLD 3 C D 2 GOLD 2 A B 1 Exacerbations / y GOLD 1 0 MRC 0-1 CAT<10 MRC 2+ CAT 10+ Current symptoms

16 Future risks GOLD 2011 revision GOLD 4 GOLD 3 ICS/LABA or LAMA ICS/LABA and LAMA >2 2 GOLD 2 GOLD 1 SABA or SAMA LABA or LAMA 1 0 Exacerbations / y MRC 0-1 CAT<10 MRC 2+ CAT 10+ Current symptoms

17 Patient Group First choice Second choice Alternative choice A SABA or SAMA LABA or LAMA or SABA/SAMA Theophylline B LABA or LAMA LABA/LAMA SAMA and/or SABA Theophylline C ICS/LABA or LAMA LABA/LAMA PDE-4 Inhibitor SAMA and/or SABA Theophylline D ICS/LABA or LAMA ICS/LAMA or ICS/LABA/LAMA or ICS/LABA/PDE-4 inh. or LABA/LAMA or LAMA/PDE4 inh. Carbocysteine SAMA and/or SABA Theophylline 17

18 Any questions?