Asthma Diagnosis and Treatment PDF

How is Asthma diagnosed? History of characteristic symptom patterns and evidence of variable expiratory airflow limitation. This should be documented from bronchodilator reversibility test or other tests. Test before treating, whenever possible i.. document the evidence for the dia...

How is Asthma diagnosed? History of characteristic symptom patterns and evidence of variable expiratory airflow limitation. This should be documented from bronchodilator reversibility test or other tests. Test before treating, whenever possible i.. document the evidence for the diagnosis of asthma before starting ICS-containing treatment , as it is often more difficult to confirm the diagnosis once asthma control has improved Diagnostic Criteria 1. HISTORY OF TYPICAL VARIABLE RESPIRATORY SYMPTOMS 2. CONFIRMED VARIABLE EXPIRATORY AIRFLOW LIMITATION Diagnostic Criteria Diagnostic Criteria Ex. FEV1 increases by >200mL and >12% of the baseline value ( or in children , increases by >12% of the predicted value) after inhaling bronchodilator FEV1 increases by more than 12% and 200mL from baseline after 4 weeks of inflammatory treatment Diagnostic Criteria  Assessment of Asthma Control 1. Symptom control - Assess symptom control over the last 4 weeks - Identify any modifiable risk factors for poor outcome -measure lung function before starting treatment, 3-6 months later and then periodically  Risk factors for future poor outcomes Assess risk factors at diagnosis and periodically at least every 1-2 years, particularly for patients experiencing exacerbations Measure FEV1 at the start of treatment , after 3-6 months of controller treatment to record personal best lung function, then periodically Management of Asthma Long Term Goal 1. Risk reduction 2. Symptom control General Principles 3. Partnership 4. Communication skills 5. Health literacy Adults & adolescents Confirmation of diagnosis if necessary Symptom control & modifiable 12+ years risk factors (see Box 2-2B) Comorbidities Inhaler technique & adherence Patient preferences and goals Symptoms Exacerbations Side-effects Treatment of modifiable risk factors Lung function and comorbidities Patient Non-pharmacological strategies satisfaction Asthma medications (adjust down/up/between tracks) Education & skills training STEP 5 Add-on LAMA STEP 4 Refer for assessment STEP 3 Medium dose of phenotype. Consider CONTROLLER and Low dose maintenance high dose maintenance STEPS 1 – 2 ICS-formoterol PREFERRED RELIEVER maintenance ICS-formoterol, As-needed low dose ICS-formoterol (Track 1). Using ICS-formoterol ICS-formoterol ± anti-IgE, anti-IL5/5R, as reliever reduces the risk of anti-IL4R, anti-TSLP exacerbations compared with See GINA RELIEVER: As-needed low-dose ICS-formoterol severe using a SABA reliever asthma guide STEP 5 STEP 4 Add-on LAMA Medium/high Refer for assessment STEP 3 of phenotype. Consider Low dose dose maintenance CONTROLLER and STEP 2 high dose maintenance maintenance ICS-LABA ALTERNATIVE RELIEVER STEP 1 Low dose ICS-LABA, ± anti-IgE, (Track 2). Before considering a Take ICS whenever maintenance ICS ICS-LABA anti-IL5/5R, anti-IL4R, regimen with SABA reliever, SABA taken anti-TSLP check if the patient is likely to be RELIEVER: As-needed short-acting beta2-agonist adherent with daily controller Add azithromycin (adults) or Other controller options for either Low dose ICS whenever Medium dose ICS, or Add LAMA or LTRA or HDM SLIT, or switch to LTRA. As last resort consider track (limited indications, or less SABA taken, or daily LTRA, add LTRA, or add high dose ICS adding low dose OCS but or add HDM SLIT HDM SLIT evidence for efficacy or safety) consider side-effects  Adults & adolescents Confirmation of diagnosis if necessary Symptom control & modifiable 12+ years risk factors (see Box 2-2B) Comorbidities Personalized asthma management Inhaler technique & adherence Patient preferences and goals Assess, Adjust, Review for individual patient needs Symptoms Confirmation of diagnosis if necessary Exacerbations Side-effects Symptom control & modifiable Lung function risk factors (seeTreatment Box 2-2B)of modifiable risk factors and comorbidities Patient Comorbidities Non-pharmacological strategies satisfaction Inhaler technique & adherence Asthma medications (adjust down/up/between tracks) Education & skills training Patient preferences and goals STEP 5 Add-on LAMA STEP 4 Refer for assessment STEP 3 Medium dose of phenotype. Consider CONTROLLER and Low dose maintenance high dose maintenance STEPS 1 – 2 ICS-formoterol PREFERRED RELIEVER maintenance ICS-formoterol, Symptoms As-needed low dose ICS-formoterol (Track 1). Using ICS-formoterol ICS-formoterol ± anti-IgE, anti-IL5/5R, Exacerbations as reliever reduces the risk of anti-IL4R, anti-TSLP Side-effects exacerbations compared with Lung RELIEVER: As-needed low-dose ICS-formoterol See GINA using a SABA reliever severe function Treatment of modifiable risk factors and asthma guide Patient comorbidities STEP 5 satisfaction Non-pharmacological strategiesSTEP 4 Add-on LAMA Asthma medications STEP 3 (adjust down/up/between Medium/high tracks) Refer for assessment of phenotype. Consider CONTROLLER and STEP 2 EducationLow & skills dose training dose maintenance high dose maintenance maintenance ICS-LABA ALTERNATIVE RELIEVER STEP 1 Low dose ICS-LABA, ± anti-IgE, (Track 2). Before considering a Take ICS whenever maintenance ICS ICS-LABA anti-IL5/5R, anti-IL4R, regimen with SABA reliever, SABA taken anti-TSLP check if the patient is likely to be RELIEVER: As-needed short-acting beta2-agonist adherent with daily controller Add azithromycin (adults) or Other controller options for either Low dose ICS whenever Medium dose ICS, or Add LAMA or LTRA or HDM SLIT, or switch to LTRA. As last resort consider track (limited indications, or less SABA taken, or daily LTRA, add LTRA, or add high dose ICS adding low dose OCS but or add HDM SLIT HDM SLIT evidence for efficacy or safety) consider side-effects GINA 2023, Box 3-5A, 2/4 © Global Initiative for Asthma, www.ginasthma.org  Starting Asthma Treatment For best outcome, ICS containing treatment should be initiated as ASAP after diagnosis of asthma is made because: 1. even mild asthma can have severe exacerbations 2. Low dose ICS reduces asthma hospitalizations and death 3. Low dose ICS is very effective in preventing severe exacerbations, reducing symptoms, improving lung function, and preventing exercise induced bronchoconstriction  Starting Asthma Treatment 4. Early treatment with low dose ICS leads to better lung function 5. Patients not taking ICS who experience a severe exacerbations have a lower long term lung function than those who have started ICS  THANK YOU FORR LISTENING!  Other controller options at Step 1 Low dose ICS taken whenever SABA is taken ( off label) Daily low dose ICS Important Considerations in this recommendation Patients with few interval asthma symptoms can have severe or fatal exacerbations 64% reduction in severe exacerbations was found in step 2 study with as needed low dose budesonide- formoterol compared with SABA only The priority to avoid past conflicting messages in which patients were iniatially told to use SABA for symptom relief but later to be told that they needed to reduce there SABA use by taking a daily controller The fact that adherence with ICS is poor in patients with STEP 2 Preferred controllers: Daily low dose ICS plus as needed SABA , OR as needed low dose ICS formoterol ( off label)  Other controller options at Step 2 Low dose ICS taken whenever SABA is taken Leukotriene receptor antagonist (LTRA) -are less effective than regular ICS Daily low dose ICS LABA- faster improvement in symptoms but more costly and exacerbation rate is similar Reviewing response and adjusting treatment How often should asthma be reviewed? 1-3 months after treatment started, then every 3-12 months During pregnancy, every 4-6 weeks After an exacerbation, within 1 week Stepping up asthma treatment Sustained step-up, for at least 2-3 months if asthma poorly controlled Important: first check for common causes (symptoms not due to asthma, incorrect inhaler technique, poor adherence) Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen May be initiated by patient with written asthma action plan Day-to-day adjustment For patients prescribed low-dose ICS/formoterol maintenance and reliever regimen* Stepping down asthma treatment Consider step-down after good control maintained for 3 months Find each patient’s minimum effective dose, that controls symptoms and General principles for stepping down controller treatment Aim To find the lowest dose that controls symptoms and exacerbations, and minimizes the risk of side-effects When to consider stepping down When symptoms have been well controlled and lung function stable for ≥3 months No respiratory infection, patient not travelling, not pregnant Prepare for step-down Record the level of symptom control and consider risk factors Make sure the patient has a written asthma action plan Book a follow-up visit in 1-3 months  Step down through available formulations Stepping down ICS doses by 25–50% at 3 month intervals is feasible and safe for most patients (Hagan et al, Allergy 2014) Stopping ICS is not recommended in adults with asthma because of risk of exacerbations (Rank et al, JACI 2013) Treating modifiable risk factors Provide skills and support for guided asthma self-management This comprises self-monitoring of symptoms and/or PEF, a written asthma action plan and regular medical review Prescribe medications or regimen that minimize exacerbations ICS-containing controller medications reduce risk of exacerbations For patients with ≥1 exacerbations in previous year, consider low-dose ICS/formoterol maintenance and reliever regimen* Encourage avoidance of tobacco smoke (active or ETS) Provide smoking cessation advice and resources at every visit  For patients with severe asthma Refer to a specialist center, if available, for consideration of add-on medications and/or sputum-guided treatment For patients with confirmed food allergy: Appropriate food avoidance Ensure availability of injectable epinephrine for anaphylaxis Non-pharmacological interventions Avoidance of tobacco smoke exposure Provide advice and resources at every visit; advise against exposure of children to environmental tobacco smoke (house, car) Physical activity Encouraged because of its general health benefits. Provide advice about managing exercise-induced bronchoconstriction Occupational asthma Ask patients with adult-onset asthma about work history. Remove sensitizers as soon as possible. Refer for expert advice, if available Avoid medications that may worsen asthma Always ask about asthma before prescribing NSAIDs or beta-blockers  Remediation of dampness or mold in homes Reduces asthma symptoms and medication use in adults Sublingual immunotherapy (SLIT) Consider as add-on therapy in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite ICS treatment, provided FEV1 is 70% predicted Thank you!