The Modern Management of Asthma: Getting it right Dr Richard Russell Senior Lecturer Nuffield Department of Medicine University of Oxford

Who am I? Dr Richard Russell Respiratory Consultant Lymington New Forest Hospital Clinical Director West Hampshire Integrated Respiratory Service Senior Lecturer University of Oxford Editor in Chief Int J COPD

Normal versus asthmatic airways

Airway inflammation in asthma Fibrosis Neutrophil Mast Cell Epithelial shedding Airways constriction and Smooth muscle hyperplasia hypertrophy Eosinophil Antigen Mucus plug Oedema Macrophage T-Lymphocyte Goblet cell discharge Plasma leak

Sites of airway remodelling Epithelium & BM Airway smooth muscle Mucous glands E BM Extracellular matrix Small vessels Large vessels Cartilage LV EC SV C BM = Basement membrane.

Improving asthma control Patients who would benefit from a review of therapy 10,000 % patients not well controlled 8,000 6,000 54.6% Number of patients at each step 4,000 55.4% 2,000 67.6% (n = 15,649) 1 2 3 4 5 BTS guidelines steps Figure produced by Russell R using data from Neville R et al. Eur Respir J 1999;14:605-609.

What are the wishes of asthma patients? No ‘bad asthma days’ Free from restrictions on their life PEF not important to patients (but still essential to monitor control and exacerbations) Price D et al. Asthma J. 1999;4:74-8.

Treatment goal: to take control of asthma No chronic symptoms No asthma attacks No emergency visits Minimal need for quick relief (as needed) ß2-agonist Maintain normal physical activity including exercise Maintain lung function as close to normal as possible Minimal (or no) adverse effects from medicine Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org [Accessed Dec 2016]

A stepwise approach British Thoracic Society, Scottish Intercollegiate Guidelines Network. SIGN 153: British guideline on the management of asthma. A national clinical guideline 2016.

A stepwise approach

National Review of Asthma Deaths (NRAD) Why asthma still kills National Review of Asthma Deaths (NRAD) Mark L Levy FRCGP Clinical Lead, NRAD Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

Multidisciplinary confidential enquiry panels 37 panel meetings 174 volunteer assessors 9 cases per panel Two assessors per case Panel assessment form Consensus agreement 195/276 died from asthma 1000 panel recommendations Major factors in 67% deaths potentially avoidable Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

Mild / moderate asthma – 58% of those who died from asthma It is possible that many of those cases defined by their doctors as mild or moderate… …were more severe Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

Primary care of the 195 cases (in the 12 months before death) 64 (33%) - no details on asthma diagnosis 84 (43%) - no record of asthma review 12 mths 37 (19%) - had assessment of asthma control 33 (17%) - given Personal Asthma Action Plans (PAAP) 112 (57%) - not under specialist supervision Please present data in a clearer way (table?) Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

Excessive GP prescribing of Short Acting Beta-Agonist Bronchodilators (SABAs) Excess need for reliever medication (SIGN/BTS) = poor asthma control Numbers of SABA inhalers prescribed during final year > 6: 92/165 patients > 12: 65/165 patients (39%) > 50: 6/165 patients (4%) Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

Potential avoidable factors identified by panels in routine medical care and ongoing supervision and monitoring Primary Care (n=195) n (%) Secondary Care (n=83) One or more avoidable factors 137 (70) 24 (29) Avoidable prescribing factor 92 (47) 12 (14) Lack of adherence to guidelines 115 (59) 19 (23) NRAD recommendation: “Health professionals must be aware of the features that increase the risk of asthma attacks and death, including the significance of concurrent psychological and mental health issues.” Table reproduced with permission from Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

Failure by doctors, nurses, patients and carers to identify risk – missed opportunities Prescribing Excess relievers; insufficient preventers Health care utilisation 10% recent admission 21% ED NRAD recommendations: Electronic monitoring prescriptions; earlier specialist referral; follow-up; named clinician responsible in hospital and primary care Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

Guided self-management The evidence… “Education in asthma self-management which involves self-monitoring by either peak expiratory flow or symptoms, coupled with regular medical review and a written action plan improves health outcomes for adults with asthma.” Gibson PG et al. The Cochrane Library, Issue 3, 2002.

Guided self-management The recommendation… “Every asthma consultation is an opportunity to review, reinforce and extend both the patient’s knowledge and skills.” British Thoracic Society, Scottish Intercollegiate Guidelines Network. SIGN 153: British guideline on the management of asthma. A national clinical guideline 2016.

Guided self-management The reality… UK surveys Survey of people with asthma in the UK 3% Price et al, Asthma J 2000; 5: 141-4 Patients who had had an acute attack 28% Pinnock et al. Asthma J 2000; 5: 130-2 Survey of 517 people with asthma throughout the UK 20% Haughney et al. Prim Care Respir J 2004; 13: 28-35 had a written asthma action plan

Telephone asthma reviews

Guided self-management What does an action plan look like? Meta-analysis: components of a written asthma action plan “Individualised written action plans based on personal best PEF, using 2–4 action points, and recommending both ICS and OCS for treatment of exacerbations consistently improve asthma health outcomes” Gibson PG, Powell H. Thorax 2004; 59: 94-9

Guided self-management What does an action plan look like? Asthma UK. Asthma Action Plan. https://www.asthma.org.uk/globalassets/health-advice/resources/adults/adult-asthma-action-plan.pdf [Accessed Dec 2016]

Inhaled corticosteroids are the anti-inflammatory treatment of choice Outcome: Asthma control Outcome: Best possible results Reliever: Rapid-acting inhaled β2-agonist as needed Controller Daily inhaled corticosteroid Daily long-acting inhaled β2-agonist Plus (if needed) Theophylline-SR Leukotriene Long-acting inhaled β2-agonist Oral corticosteroid When asthma is controlled, reduce therapy Monitor STEP 1: Intermittent STEP 2: Mild persistent STEP 4: Severe persistent None STEP 3: Moderate persistent STEP down Figure adapted from GINA Teaching Slide Set. 2003.