4/23/2014. Learning Objectives. Disclosures. Making the BEST Recommendations for Your Patients

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1 Making the BEST Recommendations for Your Patients Learning Objectives Answer commonly asked questions regarding asthma Recommend optimal management strategies for asthma patients at different stages of life Review the role of the pharmacist in asthma education Disclosures Speaker or consultant fees: Apotex Teva Novo Nordisk Astra Zeneca Janssen Purdue Eli Lilly Takeda 1

2 We All Know Asthma Pharmacists educate patients on asthma every day We are comfortable with so many aspects of asthma management BUT. Scope of practice is changing Pharmaceutical opinion Therapeutic substitution Adaptation Care Plans We are now going to require the knowledge to help patients make the best management decisions Presentation will focus on helping you answer your patient s questions about asthma management Interactive Session Test your knowledge on frequently asked questions Check your current asthma knowledge Keep your score Be honest Who will be the asthma master? 13 questions and score sheet Meant to be tough so let s see how much you know about asthma! Asthma is Different at these Stages Young Children 5 Children 6-11 Adolescents Adults 2

3 Meet Alyssa Alyssa - 2 years old She has been having some wheezing at night Her Mom is in for a recommendation for coughing She is worried that it might be asthma She has a few questions for you Question 1 Asthma Risk Factors Alyssa s mom is really worried that she has asthma. Which of the following is a PROVEN risk factor for development of asthma? a) Obesity b) Female sex c) Pet in the household d) Air pollution e) Cigarette smoke exposure f) All of the above 3

4 Asthma Risk Factors Host & Environment Host Factors Environmental Factors Genetics Obesity Sex Allergen Sensitization Infections Hygiene Hypothesis Occupational Sensitizers Tobacco Smoke Pollution Diet Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Hygiene Hypothesis Factors favouring the TH1 phenotype Rural environment Tuberculosis, measles or hepatitis A infection Older siblings Early exposure to daycare Factors favouring the TH2 phenotype Widespread use of antibiotics Western lifestyle and diet Sensitization to dust mites and cockroaches Urban environment Protective immunity Allergic diseases including asthma 1. U.S. Department of Health and Human Services. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Washington, D.C.: National Heart, Lung and Blood In; Available at: Question 2 Wheezing = Asthma? Alyssa s mom is concerned that Alyssa s wheezing is asthma. Which of the following is the MOST appropriate answer? a) Preschool wheeze is NOT very common and it is likely that Alyssa will develop asthma b) Most preschool wheezers will get worse over time c) Most preschool wheezers will improve by their 4 th birthday d) It is virtually impossible to predict if a child with symptoms of wheezing will go on to develop asthma 4

5 Preschool Wheezing Most cases of asthma start in the first 5 years of life Recurrent wheeze is common in early childhood Only 30% will go on to develop asthma Wheezing is usually transient, related to airway caliber and viral infections Transient early wheezing before 3 years of age - 60% of all infant wheezers Remission of symptoms by 5-7 years of age in the majority of patients Persistent wheezers Mother with asthma, IgE levels, normal lung function first year, by 6 th year Modified Asthma Predictive Index (MAPI) and predictors Guerra S, Martinez FD. Chapter 3 - Natural History. In: Asthma and COPD (Second Edition). Oxford: Academic Press; 2009: Panettieri Jr. RA, et al. Journal of Allergy and Clinical Immunology. 2008;121(3): Warner JO. Asthma in Infancy and Childhood. In: Allergy and Allergic Diseases. 2nd ed. West Sussex: Blackwell Publishing; : Question 3 Delivery System You referred Alyssa to the local walk-in clinic. MD thought viral wheezing and prescribed salbutamol MDI. Which of the following statements is TRUE? a) The preferred delivery system for a 2 year old is a nebulizer b) She would also be a good candidate for a dry-powder inhaler c) The best VHCs for all children up to 10 years of age are the ones with a mask as they increase the amount of medication reaching the lungs d) For most patients there are several equally effective inhalation options Many Ways of Administering 5

6 Choosing the Device for Children Choosing an Inhaler Device for Children with Asthma Choosing a VHC for a Patient Age Group Preferred Devices < 4 years MDI plus dedicated chamber with face mask 4-6 years MDI plus dedicated chamber with mouthpiece > 6 years MDI, MDI plus dedicated chamber with mouthpiece, DPI Age Group Infants (up to 18 months) Children (18 months - 5 years) Older children (5+ years) and adults Preferred Devices Small mask Medium mask Large mask Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, VHCs Make a Difference Address many issues: Coordination of breathing Higher lung, lower oropharyngeal deposition Tidal breathing in children Whistle to train on inhalation speed Feedback on current use Most outpatient children VHC over nebulizer As soon as possible mouthpiece Laube BL, Janssens HM, de Jongh FHC, et al. Eur. Respir. J. 2011;37(6): Children 6 to 11 years 6

7 Meet Connor 8 years old, just diagnosed with asthma Mom presents a prescription for a preventer and reliever Mom is nervous about using inhalers as she has heard they have many side effects Question 4 When Is Controller Indicated? Connor s mom asks if he really needs a controller medication. Which of the following would be an indicator of the need for controller therapy? a) Connor has wheezing twice weekly during the day b) Connor wakes up once weekly due to asthma symptoms c) Connor needs his salbutamol 3 doses per week d) All of the above are indications for controller therapy Question 5 Salbutamol Inhaler Connor s mom really does not want to start controller therapy. She says Connor s inhaler lasts ~ 60 days. How long should a salbutamol inhaler last if Connor s asthma is under control (he takes 2 puffs per dose)? a) 30 days b) 60 days c) 120 days d) 230 days 7

8 Indication for Controller Therapy Initiation of regular controller therapy is indicated for children 6 years of age and adults who have one or more indicators of poor control Asthma Control Criteria Daytime symptoms Nighttime symptoms Physical activity Exacerbations Absence from work or school due to asthma Need for a fast acting beta2-agonist FEV 1 or PEF < 4 days per week < 1 night per week Normal Mild, infrequent None < 4 doses/week 90% of personal best PEF diurnal variation < 10% to 15 % Lougheed, MD, et al. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society 17, no. 1 (2010): Question 6 Starting ICS You look at Connor s prescription. Which of the following would be the MOST appropriate controller to start with? a) Beclomethasone 100 mcg 2 puffs BID b) Fluticasone 125 mcg 2 puffs BID c) Budesonide 200 mcg 2 puffs BID d) Ciclesonide 100 mcg 2 puffs once daily e) Montelukast 5 mg once daily f) All of the above are appropriate ICS Key Learning Points Individualized - during poor control, lowest level to keep control Most patients can achieve asthma control Low doses of ICS (Max. clinical benefit & minimal risk of AE) Low-dose ICS therapy: 6 11 years of age - less than 200 mcg/day HFA beclomethasone equivalent 12 years of age mcg/day or less HFA beclomethasone equivalent Preschool - low dose is FIRST-line therapy Exacerbation Short course of systemic corticosteroid, daily low/moderate ICS should be initiated (1 mg/kg X 3-5 days or mg for at least 5 days) Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Lougheed, M Diane, et al. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society 19, no. 2 (April 2012):

9 ICS Adverse Effects Local: Oral candidiasis, hoarseness seldom a problem Mostly seen with high dose or combination with antibiotics Rinsing and VHCs help Systemic Growth Bones HPA Suppression Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Lougheed, M Diane, et al. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society 19, no. 2 (April 2012): Dosing of ICS Low, Medium, High Paediatric Daily ICS Dose (mcg) (6-11 years) Adult Daily ICS Dose (mcg) ( 12 years) Product Low Medium High Low Medium High Beclomethasone DPA HFA (Qvar) > >500 Budesonide (PulmicortTurbuhaler) > >800 Ciclesonide (Alvesco) > >400 Fluticasone (Flovent) > >500 Mometasone (Asmanex) >800 Lougheed, M Diane, et al. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society 19, no. 2 (April 2012): Question 7 Adjunct Therapy Connor was started on Fluticasone 50 mcg 2 puffs BID. His asthma is still not under control. Which of the following is the BEST option based on guideline recommendations? a) Increase his dose to fluticasone 125 mcg 1 puff BID b) Add montelukast 5 mg daily c) Add salmeterol 50 mcg twice daily d) Any of the above are equivalent 9

10 Lougheed, M D, et al. Canadian Respiratory Journal : Journal of the Canadian Thoracic Society 17, no. 1 (2010): Leukotriene Receptor Antagonists Second-line in children, third-line in adults. Consider when: Adherence to ICS is unsatisfactory ICS dose to maintain control is very low ( 100 mcg/day) Mild allergic rhinitis They work in all asthma severities and in children 2 years Just not as well as low-dose ICS therapy Children 5 years Reduce viral-induced exacerbations in patients with history of intermittent asthma Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Lougheed, M Diane, et al. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society 19, no. 2 (April 2012): Question 8 Trigger Avoidance With the decrease in control, you decide to review asthma trigger avoidance. Which of the following interventions has evidence of clinical benefit to support its use? a) Wash bedding in the hot cycle b) Replace carpets with hardwood floors c) Remove, hot wash or freeze toys d) HEPA-filter air cleaners e) All of the above f) None of the above 10

11 Avoidance of Indoor Allergens Conflicting evidence about whether a low-allergen environment in homes or decreased exposure to indoor allergens are effective in reducing symptoms Measure Impermeable covers on bedding Allergen Levels Clinical Benefit Measure Allergen Levels Clinical Benefit Some Some Remove cat/dog from home Weak None Wash bedding in hot cycle Some None Keep pet from bedrooms Weak None Replace carpets hardwood Some None HEPA-filter air cleaners Some None Minimize clutter None None Wash pet Weak None Remove, hot wash or freeze soft toys None None Vacuum with HEPA-filter Weak None Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, What Do You Recommend? Every patient with asthma has different triggers Avoidance of triggers that induce response may help Don t kill yourself trying to do it Strategies to consider household humidity to < 50% Stay indoors on poor air quality or high allergen days Avoid exposure to secondhand smoke Avoid certain foods and drugs ONLY if they have caused asthma symptoms Influenza immunization Obesity management Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Adolescents 11

12 Meet Jason 17 years old, coming in for a refill of his salbutamol inhaler (45 days since refill) Claims it was not working 78 days since refill of budesonide inhaler Asthma is not controlled What are you going to do? What are you going to say to him? Group Work How would you approach Jason, what would you say? How do you customize your approach for each patient? How do you address Jason s adherence to controller medication? Don t tell me what you are going to do BUT exactly what you are going to say Motivational Interviewing Find out what is relevant to the patient Why is he non-adherent? Don t make assumptions Patient makes 90% of health-related decisions; you have to make the reason important to him Motivational Interviewing What ICS does: symptoms, QoL, lung function, airway hyper-responsiveness & airway inflammation, exacerbations, asthma mortality Does NOT cure the disease Relate back to school, activities, quality of life, progression of disease Low risk of adverse effects for most patients Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention,

13 Question 9 Exercise-Induced Symptoms If Jason said he is exercising all the time and uses his inhaler before and after exercising, would this indicate poor overall asthma control? a) Yes b) No Question 10 LABA Therapy Jason mentions that a friend uses an inhaler that opens up the chest and gets rid of inflammation. He wonders if he would be a candidate for this. Which of the following statements is TRUE regarding LABA therapy? a) Can be used first-line for patients over 12 years of age b) Can be used in children as young as 4 years of age c) Single inhaler (LABA/ICS) can be used for children as young as 6 years d) High-dose ICS is not recommended over LABA adjunct therapy for most patients due to adverse effects Long-Acting Beta-Agonists NEVER as monotherapy in any age group for treatment of asthma NOT indicated for preschoolers Third-line for children 6-11 years old Typically added to ICS monotherapy Combination products are preferred Combination budesonide/formoterol (> 12 years) SABA for first-line as reliever: As a reliever in individuals with moderate asthma and poor control despite fixed dose maintenance ICS/LABA combination As a reliever and a controller in a single inhaler for exacerbation-prone individuals with uncontrolled asthma despite high maintenance doses of ICS or ICS/LABA combination therapy Lougheed, M Diane, et al. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society 19, no. 2 (April 2012):

14 Adjunct in Patients > 12 Years of Age Add adjunct to low-dose ICS versus increasing dose Not responding on low-dose ICS: Wrong diagnosis of asthma Poor inhaler technique Poor adherence Exposure to trigger Comorbidities LABA are considered first-line adjunct then leukotriene receptor antagonists High-dose ICS associated with adverse effects, only prescribed by asthma specialists Lougheed, M Diane, et al. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society 19, no. 2 (April 2012): Adults Meet Allan 48 years old; diagnosed with asthma in his thirties Currently using salbutamol and ciclesonide His asthma control is good most days but flares up during the week New family doctor, has referred for spirometry Patient is nervous about the test 14

15 Question 11 Spirometry Allan wants more information about spirometry. Which of the following statements is TRUE? a) Spirometry measures speed and volume of air passage b) Spirometry is recommended for the diagnosis of asthma c) FEV 1 and FVC are crucial measurements with spirometry d) Peak flow meter can be used as an alternative to spirometry for monitoring e) All of the above Spirometry Quantitative assessment of lung function Measures volume and flow of air Recommended for the diagnosis of asthma and COPD Vastly underutilized FEV 1 Force expiratory volume in 1 second FVC Forced vital capacity Test is painless but effort-dependent Diagnosis criteria for asthma FEV 1 /FVC less than lower limit based on age, sex, height, ethnicity FEV 1 after bronchodilator - 12% Lougheed, MD, et al. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society 17, no. 1 (2010): Question 12 Occupational Asthma Allan s symptoms tend to be worse during the week. His physician thinks he could have occupational asthma. Which of the following statements is TRUE? a) Occupational asthma is mainly due to sensitization to something in the environment b) Occupational asthma usually appears in the first week of work c) Occupational asthma can occur in almost any industry d) All of the above 15

16 Occupational Asthma Large portion of adult onset asthma Could be due to sensitization or irritation Sensitization can develop over time and exposure (e.g., latex) Irritation from high exposure to irritant (e.g., chemicals such as bleach) Assessing for occupational asthma Were there changes in work processes in the period preceding the onset of symptoms? Was there an unusual work exposure within 24 hours before the onset of initial asthma symptoms? Do asthma symptoms differ during times away from work such as weekends or holidays or other extended times away from work? Are there symptoms of allergic rhinitis and/or conjunctivitis that are worse with work? Malo J-L. Future advances in work-related asthma and the impact on occupational health. Occupational Medicine. 2005;55(8): Tarlo SM, Balmes J, Balkissoon R, et al. Diagnosis and Management of Work-Related Asthma. Chest. 2008;134(3 suppl): 1S -41S. Question 13 COPD versus Asthma Allan is wondering if his asthma could be COPD related. Which of the following would be more likely with COPD versus asthma? a) Allergies are common b) Worsening of control over time c) Infrequent sputum production d) All of the above COPD versus Asthma Feature COPD Asthma Age of Onset Mid-life (usually > 40 years) Early in life (often childhood and usually < 40 years) Symptom Progression Slowly progressive. Symptoms generally Symptoms vary from day to day and during persistent throughout day if environment the day (diurnal variation with symptoms (e.g., physical activity status) remains often worse at night and early morning) constant. Dyspnea during exercise. Exacerbated by triggers Allergies Infrequent Often Smoking History Usually > 10 pack-years Possible but not causal Lung Function (spirometry) May improve, but never normalizes Often normalizes Sputum Production Often Infrequent Response to Therapy Less predictable response to bronchodilators and limited role for inhaled corticosteroids Good response to bronchodilators, and inhaled corticosteroids are cornerstone of therapy 16

17 COPD Treatment Increasing Disability and Lung Function Impairment Mild Moderate Severe Infrequent AECOPD (< 1/year) Frequent AECOPD (> 1/year) SABD prn persistent disability LAAC + SABD prn or LABA + SABD prn LAAC or LABA+ SABA prn persistent disability LAAC + LABA + SABA prn persistent disability LAAC + ICS/LABA* + SABA prn LAAC + ICS/LABA + SABA prn persistent disability LAAC + ICS/LABA + SABA prn +/- Theophylline *Inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) combination with lower ICS dose (i.e., fluticasone propionate 250 mcg bid or less) should be used for patients with infrequent acute exacerbations of COPD (AECOPD) Canadian Thoracic Society recommendations for COPD. Can Respir J 2008;15 Suppl A Asthma Education Guidelines 1. Written action plan 2. What is asthma? 3. Asthma control for all patients 4. Reliever versus controller 5. Identify triggers 6. Inhaler technique 7. Medication safety and side effects Lougheed, MD, et al. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society 17, no. 1 (2010):

18 Device Education 90% of patients poorly administer inhalers Show and have them repeat Consider integrating into yearly medication review Long-term use does not = proper administration Switch device based on patient needs and desires Ideally the SAME type for each medication (MDI, DPI) Combination products are preferred over separate inhalers Use Your Expanded Scope Depends on province of practice Assess your patient s control Assess causes for poor control Assess dose: Too often asthma medications are started and NEVER adjusted Minimal dose to control symptoms Step-back during periods of control Watch patient on high-dose ICS - can you reduce? Step-up during periods of exacerbation (Asthma Action Plan) Asthma screams for better collaboration with MDs and we see these patients often 30-Second Control Test Question Yes No Do you cough, wheeze or have a tight chest because of your asthma? (4 or more days a week) Does coughing, wheezing, or chest tightness wake you at night? (1 or more times a week) Do you stop exercising because of your asthma? (in the past 3 months) Do you ever miss work or school because of your asthma? (in the past 3 months) Do you use your rescue medication (blue puffer) 4 or more times a week? 18

19 Lung Health Risk Checkup Resources for Your Practice Guidelines: CTS - GINA - Spirometry (video) Occupational asthma Comprehensive Online Asthma, COPD and Patient Education Program (Qualifies successful participant to write exam to become Certified Respiratory Educator CRE) Resources for your Practice Asthma Society Asthma Action Plan onplan_eng.pdf Family Physician Airways Group of Canada Asthma/COPD action pans Asthma flow sheets (diagnostic visit and follow up) Proper inhaler use: 19

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