The Modern Management of Asthma: Getting it right Part 2 Dr Richard Russell Senior Lecturer Nuffield Department of Medicine University of Oxford

Step 1: Mild intermittent asthma Prescribe inhaled SABA as short term reliever therapy for all patients with symptomatic asthma Good asthma control is associated with little or no need for SABA Using > 1 canister of SABA per month or > 8 puffs per day is a marker of poorly controlled asthma that puts individuals at risk of fatal or near-fatal asthma Patients with high SABA use should have their asthma management reviewed Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org [Accessed Dec 2016]

Daily dose of budesonide (µg) Rapid improvements of symptoms and lung function even at low doses of corticosteroids Daily dose of budesonide (µg) Symptoms FEV1 Exercise FEV1 NO FEF25%-75% Percent of maximum 100 200 300 400 500 600 700 800 10 20 30 40 50 60 70 80 90 Figure reproduced with permission from Barnes PJ, et al. Am J Respir Crit Care Med. 1998;157:S1-S53.

Underuse of inhaled corticosteroids Quick-relief Intermittent medications Inhaled corticosteroids Mild, persistent Moderate, persistent Severe, persistent AIRE total AIRE = Asthma Insights & Reality in Europe. 20 40 60 80 100 Patients, % Figure adapted with permission from Rabe KF et al. Eur Respir J. 2000;16(5):802-7.

Few patients regularly use inhaled corticosteroids 30 Irregular ICS use Regular ICS use 25 20 ICS use (%) 15 10 5 All patients Hospitalised Figure produced by Russell R using data from Suissa S et al. Thorax. 2002;57:880-884.

Treatment-related barriers to adherence Method of administration1,2 Frequent dosing1,2 Multiple different inhalers2 Fear of, or experience of, side effects1,2 Lack of understanding of asthma or treatment1,2 Denial about asthma or treatment2 Forgetfulness1,2 1. Jin et al. Ther Clin Risk Manag. 2008;4(1):269-86. 2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org [Accessed Dec 2016]

Step 2: Who gets inhaled corticosteroids? 1 severe exacerbation of asthma in last year Using SABA more than twice a week Symptoms more than twice a week Waking once a week or more Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org [Accessed Dec 2016]

Step 3 A proportion of patients may not be adequately controlled at step 2 First choice as add-on therapy is an inhaled long-acting β2 agonist (LABA) If still not controlled increase steroids as well Consider: LTRA, Theophyllines Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org [Accessed Dec 2016]

Long-acting beta2 agonists Walters EH et al. Cochrane Database Syst Rev. 2003;(4):CD001385 “Long acting beta2 agonists are highly effective in chronic asthma” 85 studies: 34 as add-on therapy Fewer asthma symptoms by day or night Less relief bronchodilator medication requirement Better lung function Lower risk of acute worsening of asthma Better quality of life

Long-acting beta2 agonists In the UK, prescribers are being reminded that: “Patients treated with long-acting beta2 agonists (salmeterol/formoterol) should always be prescribed an inhaled corticosteroid” The Pharmaceutical Journal, Vol. 277, p155. URI- 10001823. 2006

FACET study – severe exacerbations: % reductions versus BUD 200 µg 1.0 0.5 BUD 800 µg > BUD 200 µg/FORM 12 µg Exacerbations per patient per year 26% 49% 63% BUD 200 µg BUD 200 µg/FORM 12 µg BUD 800 µg BUD 800 µg/FORM 12 µg 1 2 BUD = Budesonide; FORM = Formoterol P < 0.001 vs BUD 200 µg P < 0.03 vs BUD 200 µg / FORM 12 µg Figure produced by Russell R using data from Pauwels RA et al. N Engl J Med. 1997;337:1405-1411.

Stepping down Stepping down therapy once asthma is controlled is recommended Regular review of patients as treatment is stepped down is important Patients should be maintained at the lowest possible dose of inhaled steroid Reductions should be slow, decreasing dose by ~25-30% every three months When deciding which drug to step down first and at what rate, the severity of asthma, the side effects of the treatment, time on current dose, the beneficial effect achieved, and the patient’s preference should all be taken into account. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org [Accessed Dec 2016]

How do you get buy in? Language Education: Pictures Stories Colour Disease Drug Device Pictures Stories Colour

Self management You can do this! All patients should be offered SMP and educations: Personalised Written Structured You can do this!

Evidence base for asthma action plans Cochrane review1 demonstrates use of patient education and self-management associated with reductions in: Unscheduled GP visits Number of patients who were hospitalised Number of days off work or school Nocturnal asthma Improvements in compliance2 and reduction in deaths also demonstrated3 Gibson PG et al. The Cochrane Library, Issue 3, 2002. Boychuck et al. Ann Emerg Med. 2004;44(Supplement 4):S38. (3) Abramson MJ et al. Am J Respir Crit Care Med. 2001;163(1):12-8.

Few other bits and bobs Fatal asthma Acute attacks Associated with severe asthma and “adverse behavioural or psychosocial features” Acute attacks Oral steroids: 40-50mg for min 5 days or until recovered Continue Inhaled therapy British Thoracic Society, Scottish Intercollegiate Guidelines Network. SIGN 153: British guideline on the management of asthma. A national clinical guideline 2016.

So how do we do this? Stage 1: (no such thing!) Stage 2: Inhaled steroids Stage 3: 1. Add Long acting beta agonist 2. Increased dose of inhaled steroids Stage 4: High dose steroids plus others Stage 5: The Kitchen Sink

Asthma summary Treat each patient as an individual Right drug Right dose Right device Self management plans work!