asthma banda aceh 2011
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Optimum Therapy and QOLin Asthma Patient
Tamsil Syafiuddin
Department Pulmonology and Respiratory Medicine
Faculty of Medicine
Universitas Islam Sumatera Utara/Universitas Sumatera Utara
Medan-Indonesia
2011
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Levels of competence
Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006
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Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006
Level of competence 4:
Mampu membuat diagnos is kl in ikberdasarkan
pemeriksaan f is ik dan pemeriksaan tambahan
yang diminta oleh dokter (misalnya: pemeriksaan
laboratorum sederhana atau X-ray).
Dokter dapatmemutuskandan mampu menangani
problem itu secara mandir ihingga tuntas.
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Treatment targets in common
chronic diseases Clear therapeutic targets exist for many chronic
diseases
Philosophy of treat to target
Hypertension : BP 140/90 mmHg or less
Diabetes : HbA1c 7% or less
Dyslipidaemia : LDL-cholesterol
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Definition of asthma Chronic inflammatory disease of airways (AW)
Hyper responsiveness of tracheo bronchial tree
Physiologic manifestation:AW narrowing relieved spontaneously or with BD
Cster
Clinical manifestations:
a triad of paroxysms of cough, dyspnea andwheezing.
(GINA 2009)
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Disease Pattern Episodic --- acute exacerbations
interspersed
with symptom-free periods Chronic --- daily AW obstruction which
may be mild, moderate or severe
superimposed acute exacerbations
Life-threatening--- slow-onset or fast-onset
(fatal within 2 hours)(GINA 2009)
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Why inhalation therapy?
Oral
Slow onset of action
Large dosage used
Greater side effects
Not useful in acute
symptoms
Inhaled route
Rapid onset of action
Less amount of drugused
Better tolerated
Treatment of choice
in acute symptoms
(GINA 2009)
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assessed to establish:
current treatment regimen,
adherence to the current regimen,
and level of asthma control.
Optimum/Adequate
management
Appropriatemanagement
(GINA 2009)
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assessed to establish:
current treatment regimen,
adherence to the current regimen,and level of asthma control.
Adequate
management (GINA 2009)
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Guidelines on Asthma Management:
Past and Current Trends
Combination TherapyCSCombination Therapy
GINA 1998(adapted)GINA 2009
SeverepersistentModeratepersistentMildpersistentIntermittent
Inhalation of SABA
Exacerbation
Stable condition
Total control Partially control Uncontrol
Old classification
New classificationGINA 2009
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Asthma Pathology and Therapy Evolution
1975
1980
1985
1990 19952000
Large use of
short-acting
2-agonistsFear of
short-acting
2-agonists
Combinationtherapy
Adding
LAA to ICS therapyKips et al, AJRCCM 2000
Pauwels et al, NEJM 1997
Greening et al, Lancet 1992
Bronchospasm Inflammation Remodelling (GINA 2009)
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Anti-inflammatory effect Bronchodilatation
Barnes PJ. Eur Respir J 2002;19:182191.
Interactions between corticosteroids
and 2-agonists
Effect of corticosteroids on 2-adrenoceptors Effect of2-agonists on glucocorticoid receptors
Glucocorticoid
receptor
Corticosteroid
2-adrenoceptor
2-agonist
Combine Agents give a positive and Strengthen Impact
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Gaining OptimalAsthma controL(GOAL) study
A 1-year, multicentre, randomised, double-blind,stratified, parallel-group, trial in adults and adolescents,comparing:
ICS + LABA ( seretide, salmeterol+fluticasone propionate)
ICS alone (flixotide ,fluticasone propionate) Dose stepped-up to achieve TOTAL CONTROL (or until
maximum dose reached)
Conducted between December 2000 and December
2002 Involving 326 sites in 44 countries across 6 continents
1. Bateman ED et al.Am J Respir Crit Care Med2004; 170: 836844.
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Week 7Week 2
0
0.2
0.4
0.6
0.8
1.0
P
robabilityofweek
withguideline-
definedco
ntrol
0 1 2 3 4 5 6 7 8 9 10 11 12 13
ICS alone/FP
ICS+LABA /SFC
Week in which guideline-defined control status first
achieved
Weeks 112 (stratum 2)
p=0.001
Control of asthma symptoms achieved faster with
ICS+LABA compared with ICS alone
SFC = Salmeterol/Fluticasone
Bateman ED et al.Am J Respir Crit Care Med2004; 170: 836844.
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Total Control
0 4
0.2
0.8
1.0
0
0.6
0.4
8 36 40 44 48 5212 16 20 24 28 32
Probability of control
Time to first Total Control week
Patients previously on low-dose ICS (S2)
Week 45Week 21
Time to ach ieve control
ICS+ LABA (SFC)
ICS alone (FP)
1. Bateman ED et al.Am J Respir Crit Care Med2004; 170: 836844.
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assessed to establish:
current treatment regimen,
adherence to the current regimen,and level of asthma control.
Adequate
management (GINA 2009)
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AHR continues to improve even after lung
function has plateaued
95
100
105
110
-2
-1
0
1
Baseline 3 6 12 1 month
after
treatmentTime (months)
FEV
1(%
b
ase
line
)
Log10
PD
20
(mg
)
AHR FEV1
Ward et al. Thorax 2002
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Inflammation can also be present
during symptom-free periods
Adapted from Woolcock A. Clin Exp Allergy Rev2001; 1: 6264.
AHR is a marker of inflammation
AHR
Rescue medication useImpaired am PEF
Impaired FEV1
Start of
treatment
%R
eduction
2 4 6 18
Rate of response of different measures of asthma control over 18
months of ICS treatment
Night
symptoms
Months
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Treating ongoing inflammation Rate of response of different measures of asthma control over 18
months of ICS treatment
AHR, airway hyperresponsiveness; FEV1, forced expiratory volume in
1 second; ICS, inhaled corticosteroid; PEF, peak expiratory flow
AHR is a marker of inflammation
AHR
Rescue medication use
Impaired am PEFImpaired FEV1
Start of treatment(months)
%Re
duc
tion
2 4 6 18
Night
symptoms
Short term
ACHIEVE CONTROL
Long term
Maintain CONTROL
An ongoing requirement for rescue medication is a sign that the underlying inflammation is
uncontrolled
Woolcock Clin Exp Allergy Rev 2001; GINA 2009
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assessed to establish:
current treatment regimen,
adherence to the current regimen,and level of asthma control.
Adequate
management (GINA 2009)
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The goal of asthma treatment
(GINA 2009)
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Treatment targets in common chronic diseases
Clear therapeutic targets exist for many
chronic diseases
Philosophy of treat to target
Diabetes HbA1c 7% or less
Hypertension BP 140/90 mmHg or less
Dyslipidaemia LDL-cholesterol
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Control Level Based on GINA 2009
None (2 or less
/ week)
None
None
None (2 or less /
week)
Normal
None
Daytime symptoms
Limitations of
activities
Nocturnal
symptoms /
awakening
Need for rescue /
reliever treatment
Lung function
(PEF or FEV1)
Exacerbation
CONTROLLEDCharacteristics
More than
twice / week
Any
Any
More than
twice / week
< 80% predicted or
personal best (if known)
on any day
Once/more per
year
PARTLYCONTROLLED
3 or more
features of
partly controlled
asthma present
in any week
One in any
week
UNCONTROLLEDAsthmaClassification
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The goal of asthma treatment
To achieve and maintainclinical control
Q o L
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Control Level Based on GINA 2009
None (2 or less
/ week)
None
None
None (2 or less /
week)
Normal
None
Daytime symptoms
Limitations of
activities
Nocturnal
symptoms /
awakening
Need for rescue /
reliever treatment
Lung function
(PEF or FEV1)
Exacerbation
CONTROLLEDCharacteristics
More than
twice / week
Any
Any
More than
twice / week
< 80% predicted or
personal best (if known)
on any day
Once/more per
year
PARTLYCONTROLLED
3 or morefeatures of
partly controlled
asthma present
in any week
One in any
week
UNCONTROLLEDAsthmaClassification
QoL
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Definition of Quality of life
Quality of life: An important
consideration in medical care, quality of
life refers to the patient's ability to enjoy
normal life activities.
E l f C l
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Medical Outcomes Clinical
* Symptoms (frequency/severity)* Exercise tolerance* Medication usage* Adverse eventsBiological
* Inflammation markers* Skin PT* Total/specific IgEFunctional
* Lung function* PEF variability* BHR
Clinical* Symptoms (frequency/severity)
* Exercise tolerance* Medication usage* Adverse eventsBiological* Inflammation markers* Skin PT* Total/specific IgEFunctional
* Lung function* PEF variability* BHR
Humanistic Outcomes
Quality of Life* Life satisfaction* Social & role functioning* Sense of community* Spiritual fulfillement* Self-esteem* Enjoyment* Pleasure
* AppreciationPatient satisfaction* With asthma control* With Quality of Life
Quality of Life* Life satisfaction
* Social & role functioning* Sense of community* Spiritual fulfillement* Self-esteem* Enjoyment* Pleasure* Appreciation
Patient satisfaction* With asthma control* With Quality of LifeEconomic Outcomes * Cost-utility* Cost-benefit* Cost-identification* Cost-effectiveness
* Cost-utility* Cost-benefit* Cost-identification* Cost-effectiveness
Evaluation of Control
Modified from BLAISS MS, JAMA 1997
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Why aim for control?
Patients perspectives Clinicians perspectives
Payers perspectives
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PATIENTS PERSPECTIVES
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More than 50% of the asthmatic patients want to have a normal life
& free from exacerbation
Patients perspective
What is your expectation if you areasthmatic?
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CLINICIANS PERSPECTIVES
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Eosinophil
T-lymphocyte
Mast cell
Macrophage
Dendritic cell
Numbers(apoptosis)
Cytokines
Numbers
Cytokines
Numbers
CORTICOSTEROIDS
Inf lammatory cel ls Structural c ellsEpithelial cell
Endothelial cell
Airway smooth muscle
Mucus gland
Cytokines Mediators
Leak
2-receptors
Mucussecretion
Cellular effects of corticosteroids
Barnes PJ & Adcock IM. Ann Intern Med 2003;139:359370.
CORTICOSTEROIDS
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PAYERS PERSPECTIVES
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Deaths and hospital days fall despite increase in
patients eligible for asthma treatment
Haahtela et al. Thorax 2006
450
400
350
300
250
200
150
100
50
0
Va
lueo
fthe
inde
x
Finnish Asthma Programme 2005
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Several compositecontrol measures
(GINA 2009)
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Asthma Control Test
Asthma Control Questionnaire
Asthma Therapy Assessment Questionnaire
Asthma Control Scoring System
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Objective use of ACT1. ACT is a scored tool which allows numerical targets
to be set. Simple to complete 5 questions with a 5point rating scale(max: 25)
19 or less = Uncontrolled asthma
20-24 = Well controlled
25 = Total Control
2. Improves patient / physician communication.Clear and concise questions that engage patientsin a more open, candid discussion
3. Validated using spirometry and specialist
assessment
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Terima Kasih
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