ASTHMA MANAGEMENTLONG-TERM THERAPY

Pathogenesis of asthma

Pathogenesis of asthma (NHLBI/WHO 1995)InflammationEnvironmental risk factorAirway hyperresponsivenessTriggersAirflow limitationSymptoms

Asthma is an inflammatory disease

NormalAsthmaInflammation(+)() Bronchial hyperreactivityBronchial hyperreactivity (-)Symptoms (+)Symptoms (-)Triggers

Ig EAgYYMethyl transferasePhospholipidPhosphatidylethanolaminePhosphatidyl cholinePhospholipase A2Ca++HistaminCa++HistaminECF, NCFArachidonic acidlypoxygenasecyclooxygenase5-HETELeucotrienesLTB4LTC4LTD4LTE4ThromboxanesTXA2ProstaglandinsPGDPGF2Mediator release in asthma reactions

ASTHMA PROFILE

ASTHMA PROFILE IN THE WORLD Globally, over 150 million people diagnosed with asthmaGlobally, the economic burden of asthma are estimated to be greater than TB and HIV/AIDS or combined Globally, over 180,000 people die from asthma each year Major factors contributing to asthma morbidity and mortality are underdiagnosis and inappropriate treatment

PATIENTS PROFILE( Yayasan Asma Indonesia Wilayah Sumatera Utara , 200, 93-95)More than one year 93 %Used anti inflammation25 %Used objective values 9 %Inhaller tehnique (poor )92 %Compliance 19 %Dose interval17 %

PATIENTS PROFILE( Yayasan Asma Indonesia Wilayah Sumatera Utara, 300, 96-99)More than one year 96 %Used anti inflammation32 %Used objective values 7 %Inhaller tehnique (poor )89 %Compliance 23 %Dose interval21 %

Reflected in Indonesian Asthma Market (IPMG Nov 2001)

World Asthma Market (IMS 2000)

Change paradigm of asthmaTo/SymptomscontrolTo/Diseasescontrol

Anti Inflammations is the mainstay therapy

InflammationBronchial hyperreactivitySymptomsControllerRelieverPathogenesis of asthma

AIRWAY REMODELLING IN ASTHMADesquamation of epitheliumIncrease in airway smooth muscleVascular proliferationCollagen depositionThickening of basement membraneIncrease in bronchial glandsVascular congestionOedema formationCellular infiltration

Natural History of Asthma

UNCORRECT TREATMENTCURECHRONIC ASTHMAAIRWAY REMODELLING

PERSISTENCE OF INFLAMMATIONAIRWAY REMODELLING

CHRONIC ASTHMA

MBP, ECPEosinophilEpitheliumPharmacokinetic ?AIRWAY REMODELLING IN ASTHMADesquamation of epitheliumThickening of basement membraneIncrease in airway smooth muscle

Epithelial Damage

P Jeffery, in: Asthma, Academic Press 1998

FEV1SymptomSymptomExacerbationRemodellingTime

Era of Asthma management1930th : Xanthin 1960th : Beta2-agonist1970th : Steroid inhallation2000th : Combination2003th : Single inhaler combinationSteroid depo ?

Evolving treatment options197519801985199019952000Large use of short-acting 2-agonists Fear of short-acting 2-agonistsSingle inhaler therapy (Symbicort)ICS treatment introduced1972 Adding LAA to ICS therapy Kips et al, AJRCCM 2000 Pauwels et al, NEJM 1997 Greening et al, Lancet 1992

BronchospasmInflammationRemodelling

Controller: Anti inflammationbudesonide (Pulmicort) (Inflamid)beclomethasone dipropionate (Becotide) triamcinolone acetonidefluticasone(Flexotide)sodium chromoglicate (Intal)ketotifensodium nedocromilSteroidNon steroid

Bronchodilator2 - agonist XanthinAnticholinergicReliever

BRONCHODILATORShort Acting 2 AGONIST (SABA):* salbutamol/albuterol (Ventolin )* terbutaline (Bricasma)* procaterol* fenoterol* orciprenaline, etcANTICHOLINERGIC:* atropine sulfate * ipratropium bromide, etcOTHER SYMPHATOMIMETIC: * ephedrine* adrenaline, etcXANTHINE:* theophyllineLong Acting 2 AGONIST:(LABA)salmoterolformoterol

45% said they just forgot

42% said that they felt wellADULT PATIENTS & CAREGIVERS OF CHILDREN WITH ASTHMA WERE ASKED WHY THEY DID NOT TAKE THEIR INHALED CORTICOSTEROID AS PRESCRIBED?Stahl AJRCCM, 2002

Combination therapy

SymbicortBudesonide + Formoterol

SeretideFluticasone + Salmoterol

The Beginning of Treatment

ExacerbationThe beginning of treatment?Stable condition

Peak flow meter600-700 0300( normal )Objective value

PEFR Monitoring:A Major Tool in Asthma Self-ManagementChronic DiseasesMonitorHypertension

Diabetes

AsthmaBlood pressure

Serum glucose

PEFR

THE GOALS FOR SUCCESSFUL MANAGEMENT OF ASTHMA( NHLBI / WHO, 1995)Prevent asthma exacerbations Achieve and maintain control of symptomsPrevent asthma mortalityPrevent development of irreversible airflow limitationAvoid adverse effect for asthma medicationsMaintain normal activity levels, including exercise Maintain pulmonary function as close to normal levels as posible

MANAGEMENT

ANTI INFLAMMATION, FIRST LINE, EARLYTRIGGER FACTORS, AVOIDREHABILITATION, DO TECHNIQUE, PROPERLYTIME, PROPERLY MEDICINE , SELECTIVEBRONCHODILATOR, OBJECTIVE VALUE

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