Inhaler Confusion. Today s Speaker Dr. Randall Brown. Director of Asthma Programs 6/7/2016. Dr. Randall Brown March 31, 2016

Transcription

1 + Inhaler Confusion Dr. Randall Brown March 31, Today s Speaker Dr. Randall Brown Director of Asthma Programs Center for Managing Chronic Disease University of Michigan 1

2 ASTHMA ESSENTIALS IN PRIMARY CARE: INHALER HYSTERIA: WHAT TO DO? MARCH 31, 2016 Overall Asthma Education Objectives: Advance understanding of asthma epidemiology in US Advance knowledge of disease pathophysiology and appropriate asthma diagnostic tools, including spirometry Augment knowledge and familiarity with the inhaled therapeutic options and delivery systems for the various medications used to treat airway inflammation and bronchospasm Increase ability to apply guideline recommended treatment strategies into patient care Improve ability to enhance communication and implement effective strategies to enhance the patient/family ability to comply with the recommended treatment regimens 2

3 FACULTY/DISCLOSURES Randall Brown, MD MPH AE C Director, Asthma Programs Center for Managing Chronic Disease University of Michigan Ann Arbor, MI Honorary Fellow, AAOA Board of Directors, AAN and NAECB Advisor: Spirometrix, Teva Speaker: AAN, NJH, AstraZeneca, Meda, Teva Research Grants: NIH, JPB Foundation Asthma: A Chronic Inflammatory Disease of Mostly Small Airways Large Airways: Trachea Bronchi Bronchioles Small Airways: Terminal bronchioles Respiratory Bronchioles 3

4 Asthma Pathophysiology INDIVIDUAL IMPACT AIRWAY INFLAMMATION Symptoms Airway Obstruction AHR/Bronchospasm Airway Remodeling Genetic predisposition Innate vulnerability Atopy/allergy Environmental triggers Inflammation underlies disease processes Phenotype varies by individual and over time Clinical symptoms also vary by individual and over time AHR=airway hyperresponsiveness National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Available: Asthma Insight and Management Survey: Asthma Control in the Last 4 Weeks Well Controlled 40% Patient Perspective 31% Completely Controlled 2007 NAEPP EPR-3 Control Classification 47% 29% Very Poorly Controlled 24% Somewhat Controlled Not Controlled (2%) Poorly Controlled (4%) NAEPP, National Asthma Education and Prevention Program; EPR-3, Expert Panel Report 3. 24% Not Well Controlled Well Controlled Asthma Insight and Management Survey. Executive Summary. SRBI; This survey was sponsored by Schering Plough. 4

5 Classifying Asthma Severity as a Basis to Initiate Asthma Therapy Classifying Asthma Severity and Initiating Treatment in Youths 12 years and Adults Components of Severity Impairment Normal FEV 1 /FVC 8 19 yr 85% yr 80% yr 75% yr 70% Risk INTERMITTENT CLASSIFICATION OF ASTHMA SEVERITY PERSISTENT Mild Moderate Severe Symptoms 2 days/week >2 days/week not daily Daily Continuous Nighttime awakenings SABA use for sx control (not for EIB) Interference with normal activity Lung Function Exacerbations requiring oral corticosteroids Recommended Step for Initiating Treatment 2x/month 3 4x/month >1x/week not nightly 2 days/week >2 days/week not daily Daily Often nightly Several times daily None Minor limitation Some limitation Extremely limited Normal FEV 1 between exacerbations FEV 1 > 80% FEV 1 /FVC normal FEV 1 >80% FEV 1 /FVC normal FEV 1 >60% but <80% FEV 1 /FVC reduced 5% FEV 1 <60% FEV 1 /FVC reduced >5% 0 2/year >2/year > Frequency and severity may vary over time for patients in any category Relative annual risk of exacerbation may be related to FEV STEP 1 STEP 2 STEP 3 STEP 4 or 5 Consider short course of oral steroids In 2 6 weeks, evaluate asthma control that is achieved and adjust therapy accordingly National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Available: 5

6 Let s Get to the Bottom Line: Determine if your patient has intermittent vs. persistent asthma INTERMITTENT Mild, infrequent (< twice weekly) symptoms or use of albuterol Infrequent (< twice monthly) night awakenings Normal exercise tolerance RX: prn Albuterol PERSISTENT Moderate and more frequent (> twice weekly symptoms or use of albuterol More frequent sleep disruption Altered exercise tolerance RX: Controller Therapy + prn Albuterol Stepwise Approach for Managing Asthma in Youths 12 Years and Adults Intermittent Asthma Step 1 SABA prn Step 2 Low dose ICS (A) Alternative: LTRA (A) Cromolyn (A) Theophylline (B) Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Step 3 Medium dose ICS (A) OR Low dose ICS + LABA (A), or LTRA (A), Theophylline (B) or Zileutin (D) Step 4 Medium dose ICS + LABA (B) Alternative: Medium dose ICS + either LTRA (B), Theophylline (B), or Zileutin (D) Step 5 High dose ICS + LABA (B) AND Consider Omalizumab for patients with allergies (B) Step 6 High dose ICS + LABA + oral Corticosteroid AND Consider Omalizumab for patients with allergies Step up if needed (check adherence, environmental control and comorbidities) Assess Control Step down if possible (asthma well controlled for 3 months) Patient Education and Environmental Control at Each Step National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Available: 6

7 Assessing Asthma Control Assessing Asthma Control and Adjusting Therapy in Youths 12 Years of Age and Adults Components of Control Impairment Risk CLASSIFICATION OF ASTHMA CONTROL WELL CONTROLLED NOT WELL CONTROLLED VERY POORLY CONTROLLED Symptoms 2 days/week > 2 days/week Throughout the day Nighttime awakenings 1/month 2x/month 2x/week Interference with normal activity None Some limitation Extremely limited SABA use 2 days/week 2 days/week Several times/day FEV 1 or peak flow Validated questionnaires ATAQ/ACT 80% predicted 60 80% predicted/personal best <60% predicted/personal best 0/ / / 15 Exacerbations 0 1 per year 2 3 per year > 3 per year Progressive loss of lung function Evaluation requires long term follow up care Rx related adverse effects Consider in overall assessment risk Recommended Action for Treatment Maintain current step Consider step down if well controlled at least 3 months Step up 1 step Reevaluate in 2 6 weeks Consider oral steroids Step up 1 2 weeks and reevaluate in 2 weeks National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Available: 7

8 Asthma Control Test (ACT) Score 1. 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? All of the time 2. During the past 4 weeks, how often have you had shortness of breath? More than once a day Most of the Some of the A little of the 1 None of the time time 2 time 3 time to 6 times Once or twice 1 Once a day 2 Not at all a week 3 a week 4 5 Score 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? 4 or more nights a week 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 3 or more times per day 5. How would you rate your asthma control during the past 4 weeks? Not controlled at all 2 or 3 nights Once 1 Once a week Not at all a week 2 3 or twice or 2 times 2 or 3 time Once a week 1 Not at all per day 2 per week 3 or less 4 5 Poorly controlled Somewhat controlled Scoring: 15=poorly controlled; 16 19=not well controlled, 20=well controlled Well controlled Score Completely controlled Once Again, Way Too Many Boxes! Let s Get to the Bottom Line: Determine if your patient is controlled or not CONTROLLED No or infrequent symptoms No or infrequent use of albuterol Normal lung function Normal exercise tolerance RX: Maintain or step down (1 step) therapy NOT CONTROLLED Persistently frequent (> twice weekly) symptoms or use of albuterol Persistent sleep disruption Altered exercise tolerance Persistently abnormal lung function RX: Increase (go up 1 step) therapy 8

9 Stepwise Approach for Managing Asthma in Youths 12 Years and Adults Intermittent Asthma Step 1 SABA prn Step 2 Low dose ICS (A) Alternative: LTRA (A) Cromolyn (A) Theophylline (B) Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Step 3 Medium dose ICS (A) OR Low dose ICS + LABA (A), or LTRA (A), Theophylline (B) or Zileutin (D) Step 4 Medium dose ICS + LABA (B) Alternative: Medium dose ICS + either LTRA (B), Theophylline (B), or Zileutin (D) Step 5 High dose ICS + LABA (B) AND Consider Omalizumab for patients with allergies (B) Step 6 High dose ICS + LABA + oral Corticosteroid AND Consider Omalizumab for patients with allergies Step up if needed (check adherence, environmental control and comorbidities) Assess Control Step down if possible (asthma well controlled for 3 months) Patient Education and Environmental Control at Each Step National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Available: A Good Example 9

10 Asthma 2016: Disease of Inflammation & Communication PACE: Physician Asthma Care Education Barriers To Effective Communication Studies show that patients often: Feel they are wasting the clinician s valuable time Omit details they deem unimportant Are embarrassed to mention things they think will make them look bad Don t understand medical terms May believe the clinician has not really listened and therefore doesn t have the information needed to make a good treatment decision Believe the clinician doesn t understand their social and cultural experience 10

11 Case Presentations Case Study 1 You meet a 43 year old woman of northern European heritage with a long history of recurrent bronchitis who was recently seen in urgent care due to a severe cough. She was given qid albuterol and oral steroids for 3 days and is improving, and is finishing a course of azithromycin as well. Today her chest is clear and she s not in any distress. Her history is remarkable for several emergency room visits all of which resolve with machine breathing treatments. She only needs her albuterol puffer twice daily when healthy and smokes occasionally when well. What is your diagnosis? What management plan do you choose and why? 11

12 Two months later Inhaler Hysteria 12

13 Nasal Nonsense Recent (past 8 years) Inhaler Design Warm Cool Slow Fast Small Large Breathe Twist Click Push/Pull Exhale/Inhale Relax??? 13

14 Inhaler Misuse is Common 1 Cross-sectional study of 3955 patients with asthma Patients had been treated for 3 months with inhaled corticosteroids and short-acting beta-agonists (SABAs) via MDI 29% Good users 33% Misusers with poor coordination 71% misusers* 38% Misusers without poor coordination *Misuse = Making at least 1 error or omission in technique. Poor coordination = Making at least 1 of 3 potential errors (inspiration by nose, actuation at the end of inspiration, no inspiration) and/or if the device was not actuated at the beginning of inspiration. Reference: 1. Giraud V, et al. Eur Respir J. 2002;19(2): and Can Impact Outcomes 1 In the study of 3955 patients with asthma, disease was: Less stable in MDI misusers vs good users Less stable among misusers/poor coordinators vs misusers/good coordinators Asthma Instability Score* MDI misusers 3.93 Good users 2.86 Misusers/poor coordinators 4.38 Misusers/good coordinators 3.56 P<0.001 for both comparisons Asthma Instability Score: A composite index of respiratory symptom frequency, EIB, beta 2- agonist usage, emergency visits, and global perception of asthma control within preceding month. Scale of 0 (best) to 9 (worst). The use of devices which alleviate coordination problems should be reinforced in pressurized metered-dose inhaler misusers. 1 Reference: 1. Giraud V, et al. Eur Respir J. 2002;19(2):

15 Control of Asthma and COPD Is Suboptimal Estimated Annual Toll Emergency department (ED) Hospitalizations Outpatient care 1.8 million asthma-related ED visits; 285,000 ED visits with chronic and unspecified bronchitis as primary diagnosis 439,000 hospitalizations for asthma; 614,000 for chronic bronchitis 14.2 million asthma visits to physicians offices; 10.8% of residents in assisted living/residential care facilities with COPD References: 1. Centers for Disease Control and Prevention. FastStats: Asthma. asthma.htm. Accessed April 27, Centers for Disease Control and Prevention. FastStats: Chronic Obstructive Pulmonary Disease (COPD) Includes: Chronic Bronchitis and Emphysema. Accessed April 28, Case Study 2 Mrs. Jones is an African American grandmother who brings her 17 year old grandchild, Charles, in to see you. Charles has a history of numerous asthma hospitalizations and emergency department visits over the past year. You find Charles uses his medications faithfully as prescribed by his prior physician, and even uses a spacer with his combination (inhaled steroid LABA) medication. His grandmother has switched to you as his doctor because Charles has been in such poor health over the past year. Also, she says she has recently learned one of the components of Charles' daily medication "can cause death especially in black folks 15

16 Inhaler Solutions Every Office Must Haves All inhaled medications have product website Free sites (like National Jewish Health): 5D440D0F155 Paid sites with free stuff (like use inhalers.com) Multi lingual, accessible Picture (or video) worth 10,000 exacerbations? Allergy and Asthma Network Poster(s) 16

17 Summary Asthma is indeed an inflammatory disease of the small and large airways However, asthma is also a disease of communication and culture that preys upon practice as usual Proper inhaler education or use is NOT a given Patients should regularly demonstrate their technique Achieving good asthma control (with correct medication use) is important to reducing the risk of exacerbation and improving quality of life Visit Allergy and Asthma Network for helpful tools! THANK YOU 17

18 + Questions? Check out our website at + Join us for our April Webinar April 27, :00 PM Eastern The Yellow Zone Dr. Chitra Dinakar 18