asthma banda aceh 2011

7/28/2019 Asthma Banda Aceh 2011

1/39

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


2/39

Levels of competence

Standar Kompetensi Dokter , Konsil Kedokteran Indonesia, 2006


3/39

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.


4/39

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


5/39

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)


6/39

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)


7/39

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)


8/39

assessed to establish:

current treatment regimen,

adherence to the current regimen,

and level of asthma control.

Optimum/Adequate

management

Appropriatemanagement

(GINA 2009)


9/39



adherence to the current regimen,and level of asthma control.

Adequate

management (GINA 2009)


10/39

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


11/39

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)


12/39

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


13/39

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.


14/39

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.


15/39

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.


16/39




Adequate



17/39

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


18/39

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


19/39

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


20/39




Adequate



21/39

The goal of asthma treatment

(GINA 2009)


22/39

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


23/39

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


24/39

The goal of asthma treatment

To achieve and maintainclinical control

Q o L


25/39

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


26/39

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


27/39

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


28/39

Why aim for control?

Patients perspectives Clinicians perspectives

Payers perspectives


29/39

PATIENTS PERSPECTIVES


30/39

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?


31/39

CLINICIANS PERSPECTIVES


32/39

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


33/39

PAYERS PERSPECTIVES


34/39

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


35/39

Several compositecontrol measures

(GINA 2009)


36/39

Asthma Control Test

Asthma Control Questionnaire

Asthma Therapy Assessment Questionnaire

Asthma Control Scoring System


37/39


38/39

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


39/39

Terima Kasih

asthma banda aceh 2011

Documents