Guidance Based Asthma Management : twinning access with quality Chakaya J.M. Chief Research Officer, Centre for Respiratory Diseases Research, Kenya Medical Research Institute Technical Advisor, Kenya Association for the Prevention of Tuberculosis and Lung Disease Launch of the Ugandan Thoracic Society, Kampala, September 9,2011

Outline Justification for “ local guidelines” Guideline development Process Guideline Contents Burden of Disease Basic Pathophysiology Diagnosis Treatment Service Organization: the Practical Approach to Lung Monitoring and Evaluation

Justification for “Local Guidelines” Need to define: The peculiarities that may be important and likely to impact on asthma treatment outcomes. The deviations that may need to be made to internationally recommended interventions but ensuring that patients do not receive sub standard care nor are they ( or the health system) subjected to excessively costly care Need to ensure that recommendations assure most patients receiving care have the best possible outcomes Local guidelines development constrained by Paucity of robust local scientific data on the disease burden, risk factors, interventions and outcomes/impact of those interventions

Guideline Development Processes- Weighing the Evidence Evidence Categories A: Rich body of data from high quality Randomized Clinical Trials showing consistent effects B: Limited body of data from Randomized Clinical Trials which may be small in size, or used a population that is somewhat different from the population where the recommendation will be applied or the results of these trials are somewhat inconsistent C: Results from non randomized trials or observational studies D: Expert opinion/Panel Consensus judgment

Grading of Recommendations Assessment Development and Evaluation(GRADE)

The Outcomes of Interest Reduction in morbidity and mortality Improvement in quality of life Reduction in the burden of treatment ( monitoring tests, number of pills) Reduced resource expenditures

GRADE SYSTEM’s STRONG RECOMMENDATION

GRADE SYSTEM’s WEAK ECOMMENDATION

Disease Burden

Epidemiologic Studies Scanty for most of Africa Standardization of methods for measuring disease burden critical International Study of Asthma and Allergic Disease in Childhood

Prevalence of asthma in Africa Addis Ababa, Ethiopia 10.7* Ibadan, Nigeria 10.7* Jima, Ethiopia 1.9* Eldoret, Kenya 10.4* Nairobi, Kenya 17.1* Cape Town, South Africa 16.1* ISAAC. Eur Respir J 1998;12:315–335 *% of study population

Asthma: A multi factorial disease Non Modifiable Factors Gender: early M>F; Later F>M Atopy AHR Modifiable Factors Allergen Exposure Infections and Infestations Breastfeeding Air pollution HIV infection Occupational Exposures Tobacco smoking including environmental tobacco smoke( passive smoking)

Vehicular Traffic Pollution and Wheeze in Jimma, Ethiopia A Venn, H Yemaneberhan, S lewis et al. Occupp. Environ Med 2005; 62: 376 -380

Duration of Breastfeeding and allergic disease, hay fever, asthma and eczema CC Obihara, BJ Marais, RP Gie et al. Eur Respir J 2005; 25: 970-977

Tuberculous Infection and Allergic Disease C.C Obihara, J.L.L Kimpen, R.P Gie et al. Clinical and Experimental Allergy, 2006; 36: 70-76

The Asthma Continuum Stephen T Holgate et al. Clinical Science 2010; 118: 439-450

Epithelial – Mesenchymal – Immune System Interaction Stephen T Holgate et al. Clinical Science 2010; 118: 439-450

Time for Paradigm Change? Participating Cells Airway Epithelial Cells Antigen Presenting Cells T – Lymphocytes Eosinophils Mast Cells Airway smooth muscles Endothelium Fibroblasts and Myofibroblast Mediator Soup Chemokines Cytokines Cystenyl Leukotrienes Nitric Oxide Prostaglanding D2 Others Effects Broncho-constriction Vascular leakage Increased airway secretions Air way Hyper responsiveness

Asthma Diagnosis

Diagnostic Step 1 Listen to the patient Is there recurrent or episodic wheeze, cough, chest tightness or shortness of breath? Are the symptoms particularly troublesome at night or early morning? Are the symptoms triggered by factors such as dust, cold exposure, strong smells or exercise? Is there a consistent response to asthma specific treatment?

Diagnostic Step 2 Obtain a lung function Test (measure FVC, FEV1 and PEF) Is there airflow limitation (FEV1/FVC% less than 70?) Is there a bronchodilator response (FEV1 or PEF improved by greater that 12% or 15%, 30 minutes after inhalation of a short acting bronchodilator)? Measure PEF variability ( wide swings in the PEF between morning and evening or when at work and off work)

Diagnostic Step 3 Measure airway hyperresponsiveness. Does the FEV1 drop below 20% with only small doses of an inhaled bronchoconstrictor such as methacholine, histamine or with exercise?

Consider Asthma Mimics Hyperventilation syndrome and panic attacks Upper airways obstruction and inhaled foreign bodies Vocal cord dysfunction Other forms of airways obstruction especially Chronic Obstructive Pulmonary Disease (COPD) Non pulmonary causes of symptoms especially left ventricular failure Non obstructive forms of lung disease such as diffuse parenchymal lung disease

Spirometers From To Simple hand held manual and digital devices Complex computer based tests 29

Peak Expiratory Flow Meters Hand Held Devices Digital Devices 30

Lung Function Testing in Kenya: the aspiration Level Facility Available Test 1 Community Units Awareness/Referrals 2 Dispensary Peak Expiratory Flow 3 Health Centre PEF and Basic Spirometry 4 Sub and District Hospital PEF, Spirometry, airway resistance and airway hyperresponsiveness 5 Regional Hospitals Above plus lung volumes and capacities, gas transfer 6 Referral Hospitals Above plus complex imaging and invasive tests

Treatment of Asthma

KAPTLD Asthma Symposia Education KAPTLD Asthma Symposia

KAPTLD Asthma Symposia

KAPTLD Asthma symposia

Beta2 agonists Short acting Fenoterol Salbutamol Terbutaline Pirbuterol Procaterol Long acting inhaled ( LABA) Long Acting and Fast Onset : Formoterol Long Acting and Slow Onset : Salmetrol Long LABA always used with

Methylxanthines Theophylline Low dose – some anti-inflammatory effect High Dose – bronchodilator effect Recommended as add – on medicines Recommended – sustained release preparations Have a narrow therapeutic window

Leukotriene modifiers Cysteinyl leukotriene receptor antagonist Montekulast Zafirlukast Pranlukast 5-Lipooygenase inhibitor Zileuton Recommended as alternatives to low dose ICS and as add on treatment to low dose ICS

Cautionary Note Inhaled Corticosteroids (especially Fluticasone) and Ritonavir based ART

Emphasize HCW familiarity with the use of various inhaler devices Emphasized the need to train patients on devices prescribed.

Meter Dose Inhalers Deliver a specific dose of a spray of medicine Maximum drug that is deposited in the lung is about 15% of inhaled dose About 10% of the adult population cannot grasp the technique Cheaper than dry powder devices 41

Volume Spacers Aid the inhalation of drug delivered via the MDI Very useful in the very young and very old Essential when high doses of inhaled steroids are used Patients should be reminded about the appropriate care of their devices May be used with a face mask 42

Dry Powder Devices Easier to use than MDIs Generally more expensive than the MDIs Require a minimum Peak Inspiratory Flow for drug delivery 43

The Famous Nebulizer Loved by health care workers but Wasteful Not better than an MDI with a large volume spacer Expensive way to deliver drug May create infectious aerosols and contribute to nosocomial transmission of infections 44

Asthma Control Assessed using Symptoms - frequency Exercise capacity Lung function Exacerbation rates Reliever medicine use - frequency

Level of Asthma Control Characteristic Controlled Partly Controlled( any measure present in last one week Uncontrolled Day time Symptoms None > twice/week Three or more features of partly controlled asthma present in any week Limitation of Activities Any Nocturnal Symptoms/Awakening Need for reliever/rescue medication >twice/week Lung Function(PEF or FEV1) Normal <80% of personal best Exacerbations One or more/year One in any week

Acute Severe Asthma Acute Severe Asthma

Monitoring and Evaluation Adopted the TB model Tools Patient cards Facility registers Flow of data Facility to District to Region to National Key information Patient numbers ( new and prevalent) Outcomes : Controlled , Uncontrolled, Lost to follow , died

Conclusion Asthma A common disease but burden of disease poorly characterized in Kenya Common sense approaches can diagnose and treat to control, most cases of asthma