Disclosure Asthma: A GINA Update to the NAEPP 2007 Guidelines Robert (RC) Hellinga, Pharm.D. PGY 1 Pharmacy Resident Wolfson Children s Hospital/Baptist Health I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation Objectives Describe how to appropriately use both Metered Dose and Dry Powder Inhalers Compare major differences in GINA 2014 to NAEPP 2007 Justify when to use the SMART therapy Case 27 year old Caucasian male Presents with initial asthma exacerbation Currently no insurance Discharged with 3 medications: Albuterol HFA 2 puffs q4h PRN wheezing Symbicort 80/4.5 2 puffs twice daily Prednisone 60 mg qd for 3 days Case Continued Inhalers Patient asks: How much each medication would cost? Upon hearing the cost of the inhalers, he states he could only afford one inhaler What would you recommend? Metered Dose Inhalers: Works like a spray can Can be used with a spacer Contains hydrofluoroalkane (HFA) propellant Dry Powder Inhalers: Cannot be used with a spacer Does not spray medication Contains no propellant 1
Inhalers Metered Dose Inhaler Instructions MDIs: Albuterol Fluticasone Fluticasone/Salmeterol Mometasone/Formoterol Budesonide/Formoterol Ciclesonide Beclomethasone And more DPIs: Fluticasone Fluticasone/Salmeterol Salmeterol Mometasone Budesonide And more Shake well (3 or 4 shakes) Breathe out Put inhaler in mouth Place lips around mouthpiece Start to breathe in slowly. Actuate the inhaler Continue to breathe in until your full breath Remove the inhaler Hold your breath Breathe out Dry Powder Instructions Breathe out fully Hold the inhaler as directed Place the mouthpiece between your lips. Breathe in strongly Hold your breath for about 10 seconds. Breathe out slowly Repeat if more puffs are needed. Rinse your mouth with water Do not swallow the rinse water. HFA Inhaler Myths 2 finger method Was a method with CFC inhalers Place inhaler canisters in water Manufacturers do not recommend this at all The new inhalers do NOT work Same medication, different or no taste NAEPP 2007 NAEPP 2007: Classification (Children) Diagnosis: Medical history Physical exam Spirometry Figure 11 (Children) & Figure 14 (Adults) Treatment: 3 patient populations Children 0 4 Children 5 11 Children 12 and adults Figure 13: children 11 and under Figure 16: Children 12 and older and adults 2
NAEPP 2007: Classification (Adults) NAEPP 2007: Treatment (Children) NAEPP 2007: Treatment (Adults) NAEPP 2007 continued Assessment Daytime symptoms (weekly) Nighttime symptoms (monthly) Albuterol use (weekly) Rule of 2 Exacerbation Oxygen Albuterol (+/ ipratropium) Systemic corticosteroids Prednisone, prednisolone, or methylprednisolone GINA 2014 Diagnosis: Box 1 2 Diagnosis: 5 phenotypes Box 1 2 If initial presentation asthma exacerbation Start controller therapy Treatment: 2 patient populations: Adults, adolescents, children 6 11 years old Children < 5 years old Box 3 5 SMART therapy 3
Treatment: Box 3 5 (Adults) SMART Therapy Single inhaler for both: Controller Relief Only approved for low dose ICS/formoterol Max of 48 mcg of formoterol/day 3+ randomized controlled studies: Soes Petersen 2011 Patel 2013 Pilcher 2014 GINA 2014: Assessment GINA 2014 Exacerbation: Oxygen Albuterol (+/ ipratropium) Corticosteroids: dexamethasone added Nebulized budesonide an option SMART Study: Soes Petersen 2011 Objective: Compare the efficacy of budesonide/formoterol maintenance and reliever therapy (SMART) with conventional best standard treatment in patients with persistent asthma in an attempted real life setting Methods: 1835 patients from Denmark, Finland, and Norway Aged >= 12 years of age Documented asthma for 3 months and prescription for ICS >= 320 mcg/day with or without a LABA 26 week treatment Budesonide/formoterol 160/4.5 mcg SMART study continued Results: 21% reduction in time to first severe asthma exacerbation (HR=0.794,p=0.189) Reduction in the rate of severe exacerbations 16/100 patient years vs 22/100 patient years (p=0.058) % of patients with well controlled asthma increased significantly (45% vs 40%; OR 1.39; p < 0.01) Significant 31% reduction in total mean daily ICS dose (p < 0.0001) 4
Case Wrap Up Questions? Recommendations: Inhaler Technique Teaching Pick up Symbicort 80 mcg/4.5 mcg Controller: 2 puffs twice a day Relief: 1 puff as needed, may repeat if no relief Max: 10 puffs per day 5