Lečenje i kontrola bronhijalne astme

Slides:



Advertisements
Similar presentations
Respiratory Prescribing in Tower Hamlets Bill Sandhu Head of Medicines Management, Tower Hamlets Medicines Management Team.
Advertisements

Speaker declaration Dr Christopher Worsnop Respiratory and Sleep Physician Austin Hospital, Melbourne. Conflict of interest – I’m an Aussie OPTIMIZING.
OBESITY AND ASTHMA Dr. Enrico Heffler MD, Specialist in Allergy and Clinical Immunology Allergy and Clinical Immunology - University.
Asthma Diagnosis Prescribing Acute Management Tracey Bradshaw Respiratory Consultant RIE.
1 British Guideline on the Management of Asthma BTS/SIGN British Guideline on the Management of Asthma, May 2008 Introduction Diagnosis Non-pharmacological.
Impact of Montelukast on Symptoms of Mild-to-Moderate Persistent Asthma and Exercise-Induced Asthma: The ASTHMA Survey The ASTHMA* survey was supported.
Asthma Management Fine Tuning  Maximum control with minimum medication  Start with mild asthma and work up the scale (BTS/SIGN 2004)
Bronchial Asthma  Definition  Patho-physiology  Diagnosis  Management.
Bronchial Asthma  Definition  Patho-physiology  Diagnosis  Management.
SGA 2003-W SS Slide 1 Dual Pathways of Asthmatic Inflammation Montelukast with Inhaled Corticosteroids.
SGA 2003-W SS Slide 1 Capacity of Oral SINGULAIR to Prevent Asthma Exacerbations CApacidad de SIngulair ™ Oral en la Prevencion de Exacerbaciones.
Assessing Control & Adjusting Therapy in Youths > 12 Years of Age & Adults *ACQ values of 0.76–1.4 are indeterminate regarding well-controlled asthma.
AHEAD COSMOS and COMPASS Studies. The AHEAD Study.
Strategies for asthma management VARIABLE ! Prof Huib Kerstjens Groningen Research Institute for Asthma and COPD University Medical Center Groningen.
What makes difficult asthma difficult? SCH Journal Club Nicki Barker 2012 June 2012 Dysfunctional breathing in children1.
Component 4 Medications.
Asthma Management and the Allergist: Better Outcomes at Lower Cost.
Anti-IgE Use in Allergy
P RACTICAL ISSUES IN L ONG T REM M ANAGEMENT OF A STHMA DESPITE REGULAR FOLLOW UP Dr kondekar Santosh TN Medical college Mumbai
Component 4 Medications. Key Points - Medications  2 general classes: – Long-term control medications – Quick-Relief medications  Controller medications:
Advances in Pediatric Asthma Care Keyvan Rafei, MD, MBA Division Head, Pediatric Emergency Medicine Chairman, Pediatric Asthma Program.
Asthma Guidelines, Diagnosis and Management Alison Hughes Respiratory Specialist Nurse Solent NHS Trust.
Prescribing for patients with COPD Evidence Update Emma Blanden- Pharmacist.
Linda Rogers and Joan Reibman Curr Opin Pulm Med. (2012) January Vol. 18 Stepping down asthma treatment: how and when Journal club R4. Yoo,
Dr Mazen Qusaibaty MD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital Ministry of Syrian health – Dr Mazen.
Asthma Kills Sophie Toor
Budesonide/Formoterol in a Single Inhaler for Maintenance and Relief in Mild-to-Moderate Asthma* A Randomized, Double-Blind Trial Klaus F. Rabe, MD, PhD;
Wheeze and Asthma Key Facts and Updates Dr Reena Bhatt, Paediatric Darzi Fellow in Asthma.
GOLD 2017 major revision: Summary of key changes
Bronchial Asthma Definition Patho-physiology Diagnosis Management.
Johnathan Grant D.O. FACOI
Asthma and Small Airway Inflammation
Asthma HESS 509 CHAPTER SEVENTEEN
COPD – Primary Care Update
Importance of guidelines in the management of Asthma
Bronchial Hyperresponsiveness in the Assessment of Asthma Control
Bronchial Hyperresponsiveness in the Assessment of Asthma Control
Research where it is most needed National Respiratory Strategy
Asthma Case Study – Module 9.
Adult Asthma Report 5 Coles Lane, Oakington, Cambridge, CB24 3BA.
Child Asthma Report 5 Coles Lane, Oakington, Cambridge, CB24 3BA.
The Modern Management of Asthma: Getting it right
Alan Kaplan MD CCFP(EM) FCFP Family Physician Airways Group of Canada
Monitoring asthma in primary care
Patterns of asthma medications prescriptions among adult patients in the chest and accident and emergency units of a tertiary health care facility in Uganda.
Global Initiative for Asthma (GINA) What’s new in GINA 2015?
The Role of the Primary Care Physician in Helping Adolescent and Adult Patients Improve Asthma Control  Barbara P. Yawn, MD, MSc  Mayo Clinic Proceedings 
Il ruolo dell’infiammazione nella BPCO
Severe Asthma in Primary Care: Identification and Management
The Modern Management of Asthma: Getting it right Part 2
Lečenje hronične opstruktivne bolesti pluća Prof
Šta sve biljke i bakterije mogu učiniti za vaš gastrointestinalni trakt? dr Jasna Jović.
Preporuke za lečenje alergijskog rinitisa kod dece
The Aerosol Drug Management Improvement Team
Evidence-Based Asthma Guidelines
Global Initiative for Asthma (GINA) What’s new in GINA 2015?
Drugs Affecting the Respiratory System
Airway inflammation in asthma and its consequences: Implications for treatment in children and adults  Ratko Djukanovic, MD  Journal of Allergy and Clinical.
The efficacy and safety of omalizumab in pediatric allergic asthma
Effects of β2-agonists on airway tone and bronchial responsiveness
Chronic Obstructive Pulmonary Disease
The Aerosol Drug Management Improvement Team
Effects of cysteinyl leukotrienes and leukotriene receptor antagonists on markers of inflammation  Anthony P. Sampson, PhDa, Emilio Pizzichini, MD, PhDb,
The Aerosol Drug Management Improvement Team
The paradoxes of asthma management: time for a new approach?
Efficacy and safety overview of a new inhaled corticosteroid, QVAR (hydrofluoroalkane- beclomethasone extrafine inhalation aerosol), in asthma  Jennifer.
Asthma Education for Families and HCPs
Introduction Project At Crown Street Surgery:
Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification based on symptom and risk evaluation. a) GOLD model of symptom/risk evaluation.
Study designs for double-blind single maintenance and reliever therapy (SMART) studies. Study designs for double-blind single maintenance and reliever.
Presentation transcript:

Lečenje i kontrola bronhijalne astme Prof. dr Zorica Lazić Fakultet medicinskih nauka, Univerzitet u Kragujevcu Klinika za pulmologiju,Klinički centar,Kragujevac

Karakteristike astme Hronična inflamacija disajnih puteva Hiperreaktivnost disajnih puteva Reverzibilna opstrukcija Ponavljene epizode vizinga, osećaja nedostatka vazduha, teskobe u grudima i kašalj

Evolulucija saznanja o astmi 1980s–1990s Inflamacija (PC20, Inflam ćelije, FeNO) 1990s–2000s Remodelovanje 1970s–1980s Bronhokonstrikcija (Spirometrija) Bronhijalna Hiperreaktivnost Trajna opstrukcija Simptomi Prevenirati simptome Prvenirati napade Prevenirati simptome Prvenirati napade Prevenirati remodelovanje Smanjiti simptome Wright, 2009 3

Uvodjenje antiasmatskih lekova fiksna kombinacija IKS/LABA GINA Uvodjenje antiasmatskih lekova Potpuna kontrola velika upotreba SABA IKS 1972 Beklometazon dipropionat isoprenalin 1940 salbutamol 1968 1975 1980 povećanje upotrebe IKS fiksna kombinacija IKS/LABA Anti-IgE Anti IL-4,5 1985 Asthma management guidelines and pharmacotherapy have evolved in parallel as new products have been developed. The introduction of ICS in 1972 led to the need to categorise medicines as either controllers or relievers; however, this did not happen until more than 20 years later. The introduction of the long-acting bronchodilator, formoterol, has led to some difficulties in classification as it is both a long-acting (controller) medication and a rapid-acting (reliever) medication. The addition of a long-acting 2-agonist to a low dose of ICS has been shown to provide better asthma control than a higher dose of ICS alone. The introduction of the first combination product, Seretide™, was a combination of two controller medications: salmeterol and fluticasone. Symbicort®, which contains both budesonide and formoterol, is a combination product containing both controller and potential reliever medications. 2004 1997 LTRA 1990 LABA 1995 Novi IKS bronhospazam inflamacija remodelovanje

Inflamacija u astmi Koncept Minimalne Perzistentne inflamacije Akutna inflamacija Simptomi Steroidni odgovor Hronična inflamacija Asthma is a chronic inflammatory disease with episodic attacks, involving acute inflammation on top of persistent inflammation Acute inflammation in asthma is associated with bronchoconstriction, plasma exudation / oedema, vasodilatation and mucus hypersecretion Chronic inflammation in asthma is associated with subepithelial fibrosis, smooth muscle hyperplasia / hypertrophy, mucus gland hyperplasia and new vessel formation If asthma remains uncontrolled or poorly controlled, the underlying persistent inflammation in the airways leads to structural changes (remodelling) that reduce the extent of airway response to therapy Hronična i akutna inflamacija su udružene sa fluktuiranjem hronične inflamacije usled delovanja različitih pokretača, šro izaziva akutnu inflamaciju. Hronična inflamacija vodi do progresivnih strukturnih promena. Sreoidi to mogu sprečiti Strukturne promene Steroidi to mogu sprečiti Vreme

Sadašnji vodiči terapiju astme zasnivaju na simptomatologiji Simptomi astme Kontrolišemo simptome, da li i inflamaciju ? Inflamacija disajnih puteva

Inflamatorni markeri kao terapijski vodiči (eozinofili u sputumu) Terapija zasnovana na broju eozinofila u sputumu bila je uspešnija (manje egzacerbacija) u poređenju sa terapijom koja se bazirala na simptomima i preporukama BTS 120 100 80 60 40 20 0 1 2 3 4 5 6 7 8 9 10 11 12 BTS terapija (n=37) Terapija zasnovana na nalazu sputuma (n=37) 35 vs. 109 p = 0,01 Egzacerbacije Slide 7. Sadašnji vodiči terapiju zasnivaju na simptomatologiji. Imajući u obzir značaj inflamacije u patogenezi astme, od koristi može biti praćenje markera inflamacije. U ovoj studiji 74 pacijenata sa astmom je randomizacijom podeljeno u dve grupe: terapija u jednoj grupi je bila zasnovana na preporukama BTS, a u drugoj na osnovu broja eozinofila u sputumu. Pacijenti su praćeni 12 meseci. Primarni cilj je bio broj teških egzacerbacija i kontrola inflamacaji putem merenja eozinofila u sputumu U BTS grupi terapija je zasnovana na tradicionalnoj proceni simptoma, vrednostima vršnog protoka i korišćenju SABA, i terapija se menjala u skladu sa preporukama BTS. U drugoj grupi odluka o antiinflamatornoj terapiji je zasnovana na broju eozinofila u sputumu Na slici je prikazan kumulativni broj egzacerbacija tokom 12 ,meseci. Značajno manji broj egzacerbacija je zabeležen u ovoj drugoj terapijskoj grupi (35 vs. 109, p=0.01). Autori sugerišu da je praćenje i kontrola inflamacije vazdušnih puteva može biti od pomoći za terapijski izbor i prevenciju egzacerbacija. Nameće se pitanje? Meseci Održanja eozinofilia 1-3% sa najmanjom dozom antiiinflamatornog leka < 1% prekid terapije; >3% veće doze antiinflamatornog leka Steroidi per os 24 vs. 73 (p = 0,008) Hospitalizacija zbog egzacerbacije (1 vs. 6; p = 0,047) Green RH et al Lancet 2002;360:1715–1721. SGA-2004-W-6869-SS 7

Terapijski ciljevi (Šta želimo) Prekidanje akutnog napada β2 agonisti kratkog dejstva Inhalacioni kortikosteroidi (IKS) Antileukotrijeni (LTRA) Dugo delujući β2 agonisti (LABA) Sporooslobađajući teofilin Oralni kortikosteroid (najniža doza) Anti-IgE Prevencija novih napada Supresija inflamacije

Cilj lečenja astme je postizanje kontrole Bez dnevnih simptoma (ili minimalno*) Bez ograničenja aktivnosti Bez noćnih simptoma Bez (ili minimalna) potrebe za lekovima za otklanjanje simptoma Normalna funkcija pluća Bez egzacerbacija *minimalno = dva puta nedeljno ili ređe

Delimično kontrolisana (jedan od pokazatelja u bilo kojoj nedelji) Pokazatelji Kontrolisana (sve od sledećeg) Delimično kontrolisana (jedan od pokazatelja u bilo kojoj nedelji) Nekontrolisana Dnevni simptomi Nema (≤ 2x nedeljno) > 2 x nedeljno Tri ili više pokazatelja delimično kontrolisane astme u toku bilo koje nedelje Ograničena aktivnost Nema Neka Noćni simptomi /buđenje Neki Potreba za lekovima za otklanjanje simptoma /hitno lečenje Plućna funkcija (PEF ili FEV1) Normalna <80% predviđenog ili najbolje lične (ako se zna) Egzacerbacije Jedna ili više/ godišnje Bilo koje nedelje ‡

Stepenasti pristup u lečenju astme GINA 2013 Smanjiti Stepenast pristup Povećati Korak 1 Korak 2 Korak 3 Korak 4 Korak 5 Edukacija Po potrebi brzode- lujući β2-agonist Po potrebi brzodelujući β2-agonist Izaberi jedan Izaberi jednu Dodati jedan ili više Dodati jedan ili oba Niska doza IKS Niska doza IKS plus dugodelujući β2-agonist Srednja ili visoka doza IKS plus dugodelujući β2-agonist Oralni kortikosteroid (najniža doza) Opcije lekova za kontrolu Modifikatori leukotriena** Srednja ili visoka doza IKS Modifikatori leukotriena Lečenje sa Anti-IgE Niska doza IKS plus modifikator leukotriena Sporooslobađajući teofilin Niska doza IKS plus sporooslobađajući teofilin

u Astmi Zlatni standard inhalacioni kortikosteroidi Kod svih oblika perzistentne astme Maksimalna korist/minimalni rizik U kombinaciji sa drugim lekovima Modifikatori leukotriena, dugodelujući beta 2 agonisti ...) primeniti najmanju dozu Zlatni standard

Mehanizam dejstva kortikosteroida Suprimiraju inflamatorni odgovor Smanjuju infiltraciju i aktivnost inflamatornih ćelija Smanjuju edem mukoze disajnih puteva Smanjuju sintezu i oslobadjanje inflamatornih medijatora Suprimiranjem inflamacije redukuju BHR

Kortikosteroidi - supresija inflamacije Rezistencija kod pušača sa astmom Duvanski dim Oksidativni stres acetilacija histona Peroxynitrite Pušači  HDAC2 NF-B GM-CSF IL-8 eotaxin Inflamatorni stumulusi GR  HDAC2  acetilacija histona Kortikosteroidi Steroidni odgovor Nepušači NF-B acetilacija histona rezistencija na steroide GM-CSF IL-8 eotaxin GM-CSF IL-8 eotaxin

Efekti kortikosteroida u astmi Redukuju težinu simptoma astme Popravljaju plućnu funkciju Redukuju primenu SABA Redukuju egzacerbacije/ hospitalizacije/ mortalitet Usporavaju pogoršanje plućne funkcije Mogu prevenirati remodelovanje disajnih puteva Popravljaju kvalitet života

Lekovi za kontrolu astme Bez noćnih simptoma Bez primene SABA 100% PEF FEV1 BHR % poboljšanje …….Egzacerbacije…… Stalna potreba za korišćenjem lekova za brzo otklanjanje simptoma je znak da inflamacija nije pod kontrolom Dani Nedelje Meseci Godine

IKS smanju smrtnost u astmi ERS/ATS Joint Course on Basics in Asthma – Oslo June 8-10 2005 2.5 Stepen smrtnosti zbog astme bio je 2.25 puta viši ukoliko IKS nisu korišćeni. 2.0 Stepen smrtnosti smanivao se za 21% sa svakim dodatnim kanisteron IKS upotrebljenim tokom godine 1.5 Rate ratio for death from asthma 1.0 0.5 Redovna primena redukuje rizik 4 puta 0.0 1 2 3 4 5 6 7 8 9 10 11 12 No. of canisters of inhaled corticosteroids per year Suissa S et al., N Engl J Med 2000;343:332-336

Manje od 50% pacijenata koristi inhalacione kortikosteroide. ? Manje od 50% pacijenata koristi inhalacione kortikosteroide. *IKS – Inhalacioni kortikosteroidi

Prihvatanje terapije

Razlozi su brojni , najčešće neopravdani, ali ......

Razlozi da bolesnici sami promene ili prekinu terapiju 50 40 30 20 10 45% Saopštena incidenca (%) 21% 18% 13% 9% Speaker Notes Patients who reported not being compliant with treatment all of the time were asked what factors contributed to them either discontinuing or switching medication 45% of patients report having switched or discontinued treatment because their asthma symptoms had lessened or disappeared, highlighting a lack of patient awareness on the need for continuous asthma therapy Aside from a perceived improvement in symptoms: If you look at the yellow bars, either experienced side effects or concern about the potential for side effects were cited by a total of 39% of patients as reasons they switched/discontinued their medication This highlights that side effects are a serious issue for patient compliance and also patient outcomes which we will explore further shortly Prestanak tegoba Osetili neželjene efekte Zabrinutost zbog mogućuh neželjenih efekata Lek je bio previše skup Lek nezgodan za uzimanje Since being diagnosed with asthma, have you ever switched from one asthma medication to another or discontinued an asthma medication because…? Base: Currently or Has Ever Used Asthma Medication (Patients) 21

Inflamacija disajnih puteva perzistira uprkos primene IKS Klinička studija 74 bolesnika p<0.001 20,000 10,000 1,000 100 10 1 p<0.001 Eozinofili  103/g sputum p<0.01 Kontrolna grupa IKS mala doza (n=10) IKS visoka doza (n=15) OKS (n=10) OKS ± IKS (n=7) Blaga i srednje teška teška astma Louis R et al Am J Respir Crit Care Med 2000;161:9-16.

Zašto se inflamacija održava i pored primene IKS?

Dvostruki put inflamacije u astmi Source: SGA 2004-W-6776-SS (Slide 25) Dvostruki put inflamacije u astmi Steroid-senzitivni medijatori (npr. citokini) Cisteinil leukotrijeni LTRA IKS Slide 24. Inhibicija steroid-senzitivnih medijatora Blokada efekta leukotrijena The slide represents an artistic rendition. Adapted from Diamant Z, Sampson AP Clin Exp Allergy 1999;29:1449–1453; Barnes PJ Am J Respir Crit Care Med 1996;154:S21–S27; Claesson H-E, Dahlén S-E J Intern Med 1999;245:205–227; Price DB et al Thorax 2003;58:211–216. 24

Stepenasti pristup u lečenju astme GINA 2013 Smanjiti Stepenast pristup Povećati Korak 1 Korak 2 Korak 3 Korak 4 Korak 5 Edukacija Po potrebi brzode- lujući β2-agonist Po potrebi brzodelujući β2-agonist Izaberi jedan Izaberi jednu Dodati jedan ili više Dodati jedan ili oba Niska doza IKS Niska doza IKS plus dugodelujući β2-agonist Srednja ili visoka doza IKS plus dugodelujući β2-agonist Oralni kortikosteroid (najniža doza) Opcije lekova za kontrolu Modifikatori leukotriena** Srednja ili visoka doza IKS Modifikatori leukotriena Lečenje sa Anti-IgE Niska doza IKS plus modifikator leukotriena Sporooslobađajući teofilin Niska doza IKS plus sporooslobađajući teofilin

Lečenje za postizanje kontrole astme Korak 3 – Lek za otklanjanje simptoma plus jedan ili dva za kontrolu Za odrasle i adolescente, primeniti nisku dozu inhalacionih kortikosteroida sa inhalacionim dugodelujućim β2-agonistom u fiksnoj kombinaciji ili odvojene komponente (Kategorija A) Inhalacija dugodelujućeg β2-agonista se ne sme koristiti kao monoterapija

Kombinacija IKS + LABA + Kortikosteroid β2-agonist β2-adrenoreceptor Bronhodilatacija Antiinflamacijski efekat Glukokortikoidni receptor Fiksna kombinacija ICS+LABA deluje efikasnije nego istovremena primena pojedinačnih lekova koji čine tu fiksnu kombinaciju (ev.A).

Dva koncepta u terapiji astme

Edukacija, Akcioni plan, praćenje Prilagodjavanje terapije OKS Postepeno povećanje IKS SABA po potrebi Dodatna terapija Niske Umerene Visoke Inhalacioni kortikosteroidi Brzo delujući bronhodilatator SABA po potrebi Faktori okruženja Edukacija, Akcioni plan, praćenje Guidelines Summary of Recommendations from the Canadian Asthma Consensus Guidelines, 2003 & Canadian Pediatric Asthma Consensus Guidelines, 2003 (updated to December 2004) pg S3 Handouts Continuum of Asthma Management Key Points -the minimal amount of medication needed to control the asthma may vary through different seasons and at different ages: it is variable and individual Intermitentna Laka Umerena Teška Vrlo teška

Edukacija, Akcioni plan, praćenje Prilagodjavanje terapije OKS fiksna kombinacija IKS/formoterol i za kontrolu i za otklanjanje simptoma Dodatna terapija SMART MART Niske Umerene Visoke Inhalacioni kortikosteroidi Brzo delujući bronhodilatator SABA p.p. SABA ili ICS/formoterol p.p. Faktori okruženja Edukacija, Akcioni plan, praćenje Guidelines Summary of Recommendations from the Canadian Asthma Consensus Guidelines, 2003 & Canadian Pediatric Asthma Consensus Guidelines, 2003 (updated to December 2004) pg S3 Handouts Continuum of Asthma Management Key Points -the minimal amount of medication needed to control the asthma may vary through different seasons and at different ages: it is variable and individual Intermitentna Laka Umerena Teška Vrlo teška

Preporuka SABA umesto fiksne kombinacije IKS/LABA kao reliever se preporučuje kod bolesnika sa blagom astmom koji su na monoterapiji IKS. Kod bolesnika starijih od 12 godina sa umereno teškom astmom koja je nekontrolisana primenom fiksne kombinacije IKS/LABA , preporučuje se primena fiksne kombinacije budesonid/formoterol kao lek za otklanjanje simptoma u istoj dozi koja se primenjuje za postizanje kontrole

’09. GINA preporuka: Inhalator u kome se nalazi kombinacija formoterola i budesonida može da se koristi i za brzo olakšanje disanja i za kontrolisanje bolesti. Pokazano je da ovo rezultira redukcijom egzacerbacija i poboljšanjem kontrole astme odraslih i adolescenta malim dozama lekova. (DOKAZ A)

Astma je dinamična bolest Loša kontrola Dobra kontrola Vizing Dispneja Kašalj Upotreba SABA Asthma Is Not a Static Disease Key Point: Symptoms of asthma in any given patient will change over time. Thus, asthma control can be expected to change over time as well. It is important to understand that asthma is not a static disease. For this reason, it is important to understand the way that a patient’s disease varies over time and to employ the strategies of chronic disease management. It’s also important to seek and understand what underlying triggers and causes make a patient’s disease shift to poor control. Asthma is not a static disease – each patient reacts differently to medication, the environment, triggers, and changing allergens that impact symptoms Asthma therapy and control should be assessed at each and every visit Asthma management must be individualized, because each patient responds to medication in a unique way Effective control requires an ongoing relationship and good communication between doctor and patient Decisions related to managing the patient’s asthma should be driven by the level of asthma control. When it is completely controlled or well-controlled, patients may need less medication. Uncontrolled asthma requires a step-up in therapy, which could mean an increase in medication, more frequent physician visits, etc FEV1 PEF varijabilnost

Da li je postignuta kontrola astme prema GINA smernicama?

Kontrola astme nije zadovoljavajuća Eur Resp Rev 2012 Patients with poorly controlled asthma Patients with well-controlled asthma Also been shown by Rabe et al across the world that asthma control remains poor alot of this has been attributed to poor inhaler competence and adherence / ASTHMA COMORBIDITIES /

Kod nekontrolisanih pacijenata: 58% ima noćna buđenja najmanje jednom nedeljno 70% ima nedostatak daha više nego 3–6 puta nedeljno 80% koristi lekove za otklanjanje simptoma najmanje 2–3 puta nedeljno Key message: In Europe today, most asthma patients are not controlled and experience symptoms. The National Health & Wellness Survey (NHWS) was a population based cross-sectional survey carried out in 2006 in France, Germany, Italy, Spain and the UK. A detailed questionnaire was administered to a sample of individuals drawn from an Internet Panel.(1) The Asthma Control Test (ACT™) was used to assess the level of control: Total Control (TC, score 25), Well Controlled (WC, score 20–24) and Not Well-Controlled (NWC, score <20). The ACT has been validated previously and is recommended in the Global INitiative for Asthma (GINA) 2006 guidelines as a tool for assessing asthma control.(2,3) NHWS results: 37,476 participants, 2337 (mean age 44 years) had been diagnosed with asthma by a physician: France (n=476), Germany (n=486), Italy (n=223), Spain (n=227) and the UK (n=915).(1) Of the NWC patients: 58% woke up ≥1 times/week owing to asthma, 70% had shortness of breath >3–6 times/week and 80% used rescue medication ≥2–3 times/week in response to asthma symptoms.(1) Conclusions: this recent survey suggests that most asthma patients remain uncontrolled, are experiencing frequent symptoms and continue use of rescue medication.(1) References Desfougeres JL et al. Accepted. ERS 2007 Nathan R et al. J Allergy Clin Immunol 2004;113:59–65 GINA 2006 (www.ginasthma.org) Desfougeres JL et al. Accepted. ERS 2007

9 od 10 pacijenata veruje da je normalno 90 % pacijenata koji boluju od astme veruje da su simptomi sastavni deo njihovog života i da im niko ne može pomoći4. Pacijenti se na žalost nisu svesni da sa astmom mogu da žive normalno bez simptoma 9 od 10 pacijenata veruje da je normalno što im astma ometa svakodnevni život Bellamy D et al. Prim Care Respir J, 2005; 14: 252-258

Gde je problem? Pogrešna dijagnoza Neredovna kontrola Neadekvatna promena terapije. Loša saradnja Neadekvatna procena

Odgovor na terapiju Varijabilan Većina inhalatora ne stiže do malih disajnih puteva 11

Mali disajni putevi značajni u patogenezi astme Highlight difficulties in the techniques and the current challenges regards assessment of this region Relatively inaccesible Majority tests are indirect markers or surrogate parameters of small airways < 2mm Teško se procenjuju

Od čega zavisi depozicija u plućima? Karakteristike aerosola Veličina čestica Gustina Lipofilnost Higroskopnost Karakteristike pacijenata Inhalacioni manevar Inspirijumski volumen inspirijumski protok Zadržan dah Težina bolesti Vrsta inhalatora

Male čestice – veća depozicija u plućima i malim disajnim putevima The size of inhaled particles directly impacts their distribution in the lungs. Small particles have greater lung deposition and small airway deposition than large particles. The penetration index and small airway distribution increase with smaller particle size.3 References Leach CL, et al. Lung deposition of hydrofluoroalkane-134a beclomethasone is greater than that of chlorofluorocarbon fluticasone and chlorofluorocarbon beclomethasone : a cross-over study in healthy volunteers. Chest 2002;122:510-6. Newman S, et al. High lung deposition of 99mTc-labeled ciclesonide administered via HFA-MDI to patients with asthma. Respir Med 2006;100:375-384. Usmani OS, et al. Regional lung deposition and bronchodilator response as a function of beta2-agonist particle size. Am J Respir Crit Care Med 2005;172:1497-504. Veličina čestica: 6µm 3µm 1.5µm Ukupna plućna depozicija: 46% 51% 56.3% Depozicija u malim dis. put.: 24.6% 34.3% 43.9% Leach CL et al. Chest 2002;122:510-516. Newman S et al. Respir Med 2006;100:375-384. Usmani OS et al. Am J Respir Crit Care Med 2005;172:1497-504.

MMAD (µm) 3 ITW - Dutch Task Inhalation Technology Working group (Adapted from Newhouse MT. J aërosol Med 1998; 11: S122)

MMAD (µm) 3 2 ITW - Dutch Task Inhalation Technology Working group (Adapted from Newhouse MT. J aërosol Med 1998; 11: S122)

MMAD (µm) 3 2 1.5 ITW - Dutch Task Inhalation Technology Working group (Adapted from Newhouse MT. J aërosol Med 1998; 11: S122)

Gde su steroidni receptori ? generacije 1 2 3 4 5 15 23 Alveole Vaskularni endotel Vaskularni glatki mišići Epitel disajnih puteva Inflamatorne ćelije Adcock I.M. et al; Am J Respir Crit Care Med 1996;154:771-82 Courtesy ITW – Dutch Inhalation Technology Working Group

Gde su beta-2 receptori ? Glatki mišići disajnih puteva Epitelne ćeije Vaskularni endotel i glatki mišići Presinaptički završeci Inflamatorne ćelije (eoz, limfocit, mastociti makrofagi) Generacije 1 2 3 4 5 15 23 ITW - Dutch Task Inhalation Technology Working group (Barnes PJ, Nature 1982:299;444)

Preporuke za lečenje astme Proceniti kontrolu astme Lečiti do postizanja kontrole Pratiti radi održavanja kontrole Proceniti, lečiti i pratiti prema stepenu kontrole astme, a ne stepenu težine GINA 2006 (www.ginasthama.org)