CHRONIC ASTHMA GUIDELINES IN ADOLESCENTS & ADULTS 2007 Gillian Ainslie, Elvis Irusen, Bob Mash, Michael Pather, Angeni Bheekie, Pat Mayers, Hilary Rhode Asthma Guidelines Implementation Project

Guidelines for the management of chronic asthma in adolescents and adults Lalloo U, Ainslie G, Wong M, Abdool-Gaffar S, Irusen E, Mash R, Feldman C, O'Brien J and Jack C Working Group of the South African Thoracic Society S.A. Fam Pract 2007;49(5):

Levels of Evidence

Aims of the Guideline to improve asthma care for the greatest number through uniform treatment protocols to use the most efficacious and cost-effective drug combinations to facilitate teaching of doctors and other health care workers to empower patients to understand their disorder, and the types & goals of therapy

Key Features of New Guidelines Emphasis on defining & achieving control of asthma The positioning of leukotriene blockers in the treatment of chronic asthma New evidence on the safety & optimal use of asthma medications The ongoing need to emphasize the use of anti-inflammatory medication as the foundation of asthma treatment

2006 GINA Goals of Asthma Management Achieve and maintain control of symptoms Maintain normal activity levels including exercise Maintain pulmonary function as close to normal as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality abcdefabcdef

Essential steps in the Management of Asthma to Achieve Control: Establish the diagnosis of asthma Assess severity Implement asthma treatment Set goals for control of asthma Prevent/avoidance measures Pharmacotherapy Achieve and monitor control abcdabcd

A. ASTHMA DIAGNOSIS

STEP 1 Suspect asthma on basis of symptoms and signs, particularly if there is variability

STEP 2 Search for associated factors such as: a. Atopy - allergic rhinitis, conjunctivitis, eczema b. Family history of asthma or other allergic disorders c. Onset of, or presence of, symptoms during childhood d. Identifiable triggers for symptoms and relieving factors such as improvement with a bronchodilator or deterioration with exercise e. Exposure to known asthma sensitizers in the workplace f. Reversibility shown on lung function tests g. Optional tests include: Full blood count to check the eosinophil count Total serum IgE Skin prick tests or RAST in blood to look for evidence of atopy Methacholine or histamine or exercise challenge tests

Diagnostic lung function values Reversibility: An increase of FEV1 of > 12% and 200ml, 15-30min after the inhalation of mcg salbutamol, or a 20% improvement in PEF from baseline. Hyper-responsiveness: Methacholine/histamine challenge Exercise: A fall of 20% in PEF (or 15% in FEV1) measured 5-10 minutes apart – before and then after cessation of exercise (e.g. running for 6 minutes) Diurnal Variation: Diurnal Variation in PEF of more than 20% Distinguishing between COPD and asthma when FEV shows obstruction: Improvement of FEV1 from baseline ( > 12% and 200ml) after a 2 week trial of oral prednisone (40mg daily)

Differentiating asthma and COPD

Other causes of airway obstruction

Causes of occupational asthma

B. ASSESSMENT OF SEVERITY OR CONTROL

C. ASTHMA TREATMENT Preventative/Avoidance Measures Pharmacotherapy

Preventative/Avoidance Measures A. Avoid exposure to personal and second-hand tobacco smoke B. Avoid contact with furry animals C. Reduce pollen exposure D. Reduce exposure to house dust mite E. Avoid sensitisers and irritants (dust and fumes) which aggravate or cause asthma, especially in the workplace F. Avoid food and beverages containing preservatives G. Avoid drugs that aggravate asthma such as beta-blockers (including eye drops) and aspirin and non-steroidal anti- inflammatory drugs

PHARMACOTHERAPY (A) RELIEVERS : Act only on airway smooth muscle spasm i.e. Cause BRONCHODILATION symptoms acutely - cough - SOB - wheeze/tightness Take when necessary

PHARMACOTHERAPY (B) CONTROLLERS : underlying INFLAMMATION and/or cause prolonged bronchodilation i.e. mucosal swelling secretions irritability of smooth muscle Take regularly, even when well For ALL asthmatics, except mild intermittent

ASTHMA DRUG CLASSIFICATION

All patients should be prescribed inhaled, short-acting ß 2 agonists such as salbutamol; 200mcg (2 puffs) as needed for use as symptom relief for acute asthma symptoms (Evidence A). All patients should receive inhaled corticosteroids as baseline asthma treatment except those classified as mild intermittent asthma (Evidence A). Key prescribing recommendations

Inhaled Corticosteroids Mainstay of Rx of chronic asthma symptoms & lung function decline give twice daily regularly direct lung delivery = lower dose use of spacers ­ delivery & side effects safe 1000µg BDP/day (800µg Bud/day)

Inhaled Corticosteroids Beclomethasone Beclate Becotide Becloforte Clenil Viarox Aerobec Budesonide Inflammide Budeflam Fluticasone Flixotide Flomist

Equivalent doses of inhaled steroid

RECOMMENDED ADD-ON Rx 1. Add a LABA if asthma is not well controlled on low dose ICS (Evidence A). This option is preferred to doubling the dose of ICS; however, not all patients respond to LABAs. Never use LABAs alone. 2. An alternative is to double the dose of ICS or add leukotriene modifiers (Evidence A) or slow-release theophyllines (Evidence B) 3. Oral corticosteroids should only be used as a maintenance treatment with extreme caution. 4. Referral to a specialist is recommended when asthma is difficult to control

Long-Acting Beta-2 Agonists Salmeterol Formoterol Combined with steroid Serevent Oxis Foradil Foratec Seretide Symbicord

Long-Acting Beta-2 Agonists cause bronchodilation for 12+ hours give twice daily regularly delayed onset of action - Salmeterol

Patients with poor control despite moderate dose of inhaled steroids especially when: They should not be used as monotherapy but in combination with inhaled steroids. Indications for Long-Acting Beta-Agonists nocturnal asthma wide variation in am & pm PEF exercise-induced asthma

Leukotriene Receptor Antagonists Montelukast - Singulair Zafirlukast - Accolate Advantages: Unique mode of action Oral form and “one dose fits all” Add-on effect when used with inhaled steroids Anti-inflammatory and anti-bronchoconstrictor

STEP-WISE Rx of ASTHMA Only an option for those with mild intermittent asthma at diagnosis or who remain consistently well-controlled and treatment is progressively reduced STEP 1: Inhaled beta-agonist PRN

STEP-WISE Rx of ASTHMA Start patients with mild chronic persistent asthma at this step STEP 2: Inhaled beta-agonist PRN Low dose inhaled corticosteroid ug/day (BDP equivalent)

STEP-WISE Rx of ASTHMA STEP 3: Inhaled beta-agonist PRN & Low dose inhaled corticosteroid ug/day (BDP equivalent) & Inhaled long-acting beta-agonist (PREFERRED) OR Low dose inhaled corticosteroid ug/day (BDP equivalent) & Oral leukotriene modifier OR Moderate dose inhaled corticosteroid ug/day (BDP equivalent)

STEP-WISE Rx of ASTHMA STEP 4: Inhaled beta-agonist PRN & Moderate dose inhaled corticosteroid ug/day (BDP equivalent) & Inhaled long-acting beta-agonist (PREFERRED) OR Moderate dose inhaled corticosteroid ug/day Oral leukotriene modifier OR Moderate dose inhaled corticosteroid ug/day & Oral SR theophylline BD

STEP-WISE Rx of ASTHMA STEP 5: Inhaled beta-agonist PRN & High dose inhaled corticosteroid > 1000ug/day (BDP equivalent) & Inhaled long-acting beta-agonist AND Oral leukotriene modifier OR Oral SR theophylline BD

STEP-WISE Rx of ASTHMA STEP 6: Inhaled beta-agonist PRN & High dose inhaled corticosteroid > 1000ug/day (BDP equivalent) & Inhaled long-acting beta-agonist PLUS Oral leukotriene modifier PLUS Oral SR theophylline BD AND/OR Long term oral corticosteroids PLUS SPECIALIST REFERRAL

Treatment Choices Depend on: availability cost efficacy in individual patients patient preference side effect profile

Cost Compromises oral steroids vs. inhaled steroids ~ long-term side effects: “save now, pay later” oral theophylline vs. inhaled beta-agonists ~ less effective, more side effects, titration difficult short-acting vs. long-acting theophyllines short-acting vs. long-acting beta-agonists oral vs. inhaled long-acting beta-agonists ~ less effective, more side effects MDIs ± spacers vs. dry powder devices

Therapy to avoid! sedatives & hypnotics cough syrups anti-histamines duplication of same type (eg. Ventolin + Berotec) combination tablets immunosuppressive drugs immunotherapy maintenance oral prednisone > 10mg/day

Asthma Treatment Algorithm

D. ACHIEVE AND MONITOR CONTROL

Routine Asthma Questions 1) How many times/week do asthma symptoms (cough, wheeze, SOB) affect you during the day? 2) How many times/week do asthma symptoms disturb your sleep? 3) How many times/week do you use your relievers? 4) Has asthma caused time off work/school or interfered with your usual activities? 5) Have you needed to attend as an emergency since your last visit / over the last year?

Assessing control

Monitor Asthma Control

Managing partly/uncontrolled patients Check the inhaler technique Check adherence and understanding of medication Consider aggravation by: –Exposure to triggers/allergens at home or work –Co-morbid conditions: GI reflux, rhinitis/sinusitis, cardiac –Medications: Beta-blockers, NSAIDs, Aspirin Consider stepping up treatment Consider need for short course oral steroids Review self-management plan

ASSESS GOOD INHALER TECHNIQUE RINSE MOUTH AFTER INHALATION OF CORTICOSTEROIDS

ASSESS GOOD SPACER TECHNIQUE RINSE MOUTH AFTER INHALATION OF CORTICOSTEROIDS

PREDICTED PEF RATES IN ADULT WOMEN

PREDICTED PEF RATES IN IN ADULT MALES

Self-management plan Realistic goals of treatment in terms of symptom relief and/or PEF Advice on how to recognise changes in the asthma (via symptoms and/or peak flow rates) and when to make adjustments to treatment according to a predetermined schedule Written instructions on treatment which include the class, name, strength, dose and frequency of each of the asthma medications prescribed Instruction on when and how to initiate short courses of oral prednisone Details on how to obtain access to medical care in emergencies The use of a PEF meter and chart, particularly in those requiring stabilisation or patients who have had a recent exacerbation or deterioration Arrangements for a Medic-Alert bracelet for patients on high-dose inhaled or oral corticosteroids, known drug hypersensitivities (like aspirin and penicillin) and brittle asthma

Indications for Oral Steroid Short Course progressive worsening over days acute deterioration repeated night wakening failure of maximum other Rx

Oral Steroid Short Course prednisone 30-40mg x 7-14 days once daily morning dose no weaning of dose unless long term use inhaled steroids maintained or started step up maintenance Rx

Reasons for referral to a specialist

Managing the well controlled patient As soon as good control: Reduce oral steroids first, then stop Reduce relievers before controllers When good control for 3+ months: Reduce inhaled steroids

Contacts and resources National Asthma Education Programme (South Africa) PO Box 72128, Parkview, 2122 Fax: Tel: Mail: Other sites offering educational material include: Full text of guidelines on chronic adult asthma ~ SA Thoracic Society ~ Allergy Society of South Africa (ALLSA) ~ The Global Initiative for Asthma ~ National Asthma campaign (UK) ~ National Heart, Blood and Lung Institute (US) ~ Medic Alert ~ Asthma Guidelines Implementation Project (South Africa) Ms Hilary Rhode, Family Medicine and Primary Care PO Box 19063, Tygerberg, 7505 Fax: Tel: Mail:

This 2007 asthma guideline update was developed following a meeting with a working group constituted by the S.A. Thoracic Society. The working group was chaired by Prof. U.G. Lalloo. The contribution by the working group is gratefully acknowledged. –Meetings were held with the working group, 2-3 July 2005, subsequently the editorial board was convened and met on 30 March 2007 to develop and finalise this guideline document. –The meetings were sponsored by the National Asthma Education Programme (NAEP) of the S.A. Thoracic Society. This was possible through unrestricted educational grants to NAEP from the S.A. Thoracic Society, GSK, Astra-Zeneca, MSD, Altana Madaus and Boeringher Ingelheim. –The document is viewed as a living document that will be updated periodically.