Asthma_new-1.pdf

Asthma PADMAVATHY RAMASWAMY, PHD, MPH, APRN, FNP-BC What is Asthma v Chronic inflammatory, disease of the airways characterized by variable levels of airway expiratory obstruction and hyperresponsiveness v Affects approximately 8-10% of the population v Slightly more common in male children (younge...

Asthma PADMAVATHY RAMASWAMY, PHD, MPH, APRN, FNP-BC What is Asthma v Chronic inflammatory, disease of the airways characterized by variable levels of airway expiratory obstruction and hyperresponsiveness v Affects approximately 8-10% of the population v Slightly more common in male children (younger than 14 years) and in female adults v Each year, approximately 10 million office visits, 1.8 million ER visits and more than 3500 deaths in the U.S. due to Asthma v Prevalence, hospitalizations, and fatal asthma have all increased in the U.S. over the last 20 years Pathology of Asthma Asthma involves inflammation of the airways Normal Asthma Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995 Pathogenesis of Asthma v Airway inflammatory cell infiltration with eosinophils, neutrophils, and lymphocytes (esp T cells); v Goblet cell hyperplasia; v Plugging of small airways with mucus; v collagen deposition beneath the basement membrane; v bronchial smooth muscle hypertrophy; v Airway edema; mast cell activation; and v denudation of airway epithelium Clinical Presentation v Clinical presentation varies and depends whether is it an acute attack or if patient is seeking help to manage chronic asthma. v Not all people with asthma wheeze and not everyone who wheezes has asthma Subjective Objective Breathlessness Reversible airflow limitation and diurnal variation, as measured by peak expiratory flow rate (PEFR) Unable to talk, or only short sentences Nasal discharge, mucosal swelling, frontal facial tenderness, nasal polyps, and allergic “shiners” may be noted Profuse sweating and c/o air hunger Atopic dermatitis or eczema may be noted Cough only or wheezing Audible expiratory and inspiratory wheezes may be present. Tightness in chest Use of accessory muscles Diagnostic Tests v Pulmonary function testing with either spirometry or peak expiratory flow measurements are important for diagnosis and management v Important spirometry measurements include: v Forced expiratory volume in 1 second (FEV1) v Forced vital capacity (FVC) and v FEV1/FVC before and after the administration of a short-acting bronchodilator (SABA) v Airway obstruction is indicated by a reduced FEV1/FVC ratio below 0.7 or lower limit of normal v Diagnosis is made by demonstrating reversibility of airway obstruction defined as a 10% or greater increase in FEV1 after 2 puffs of a SABA Representative spirograms (upper panel) and expiratory flow-volume curves (lower panel) for normal (A), obstructive (B), and restrictive (C) patterns. Citation: 9-02 Pulmonary Function Tests, Papadakis MA, McPhee SJ, Rabow MW, McQuaid KR, Gandhi M. Current Medical Diagnosis & Treatment 2024; 2024. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=3343&sectionid=279902320 Accessed: February 18, 2024 Copyright © 2024 McGraw-Hill Education. All rights reserved Additional Testing v Chest X-Ray – indicated when Pneumonia or a complication of asthma is suspected v Skin or in vitro allergy testing for environmental allergens in patients with persistent asthma v Evaluation for GERD or paranasal sinus disease in patients with persistent, severe or refractory symptoms v Absolute eosinophil count to identify patients eligible for anti-IL-5 therapy to manage eosinophilic airway disease v Fractional nitric oxide concentration in exhaled breath condensates (FENO) to assess underlying airway inflammation (conflicting data on asthma outcomes) v >50 ppb makes eosinophilic inflammation and treatment response to ICS more likely Differential Diagnosis v Upper airway disorders that mimic asthma: vocal cord paralysis, laryngeal mass or dysfunction v Lower airway disorders: foreign body aspiration, tracheal masses or narrowing, airway edema, cystic fibrosis, sarcoidosis, COPD etc. v Systemic vasculitis v Cardiac disorders: CHF, pulmonary HTN v Psychiatric causes: conversion disorders, emotional laryngeal wheezing, panic disorders,  Classification of Asthma Severity Classification Clinical Features before treatment Intermittent Intermittent symptoms less than 2 days per week Nighttime asthma symptoms less than twice per month Asymptomatic and normal peak expiratory flow (PEFR) between exacerbations PEFR or forced expiratory volume in 1 second (FEV1) greater than 80% predicted; pulmonary function test (PFT) variability greater than 20% Mild Persistent Symptoms more than 2 days per week but not daily; may be several times at night per month PEFR or FEV1 greater than 80% predicted; PFT variability 20% to 30% Moderate Persistent Symptoms daily, but not continual; nighttime symptoms more than once a week, but not nightly Exacerbations affect activity and sleep PEFR or FEV1 60% to 80% predicted; PFT variability greater than 30% Severe Persistent Continuous daily symptoms; frequent nighttime symptoms Frequent exacerbations Physical activities limited by asthma PEFR or FEV1: less than 60% predicted; PFT variability greater than 30% Management of Asthma Guidelines recommended by two organizations: v Global Strategy for Asthma Management and Prevention (GINA) v Established by WHO and NHLBI in 1993 vPublishes annual updates on asthma management based on new literature for global audience v Latest update is GINA 2023 v National Heart, Lung, and Blood Institute (NHLBI)’ National Asthma Education and Prevention Program (NAEPP) v Latest update 2020 titled NAEPP – 2020 Focused Asthma Update v Created for U.S. audience GINA 2023 Recommendations  Goals of asthma treatment § Few asthma symptoms § No sleep disturbance Symptom control (e.g. ACT, ACQ) § No exercise limitation § Maintain normal lung function § Prevent flare-ups (exacerbations) Risk reduction § Prevent asthma deaths § Minimize medication side-effects (including OCS) § The patient’s goals may be different § Symptom control and risk may be discordant § Patients with few symptoms can still have severe exacerbations ACQ: Asthma Control Questionnaire; ACT: Asthma Control Test; OCS: oral corticosteroids © Global Initiative for Asthma, www.ginasthma.org GINA 2023 Box 3-2 © Global Initiative for Asthma, www.ginasthma.org  Initial Asthma Treatment for Adults and Adolescents (GINA 2023) Presenting Symptoms Preferred Initial Treatment (Track Alternative initial treatment (Track 1) 2) Infrequent asthma symptoms (less than 2x month As-needed low-dose ICS Low-dose ICS taken whenever SABA & no risk factors for exacerbations & no Formoterol is taken, in combination or separate exacerbations in the last 12 mo inhalers Asthma symptoms or need for reliever twice a As-needed low-dose ICS Low-dose ICS plus as-needed SABA. month or more Formoterol Before choosing option consider likely adherence with daily ICS Troublesome asthma symptoms most days (4-5 Low-dose ICS-formoterol Low-dose ICS-LABA plus prn SABA or days/week) or walking due to asthma once a maintenance and reliever therapy plus prn ICS-SABA or medium dose week or more, esp. if risk factors exist (MART) ICS + prn SABA or + prn ICS-SABA Initial asthma presentation is with severely Medium-dose ICS-Formoterol Medium- or high-dose ICS-LABA plus uncontrolled asthma, or with an acute maintenance and reliever therapy prn SABA or plus prn ICS-SABA. A exacerbation (MART). A short course of oral short course of oral corticosteroids corticosteroids may also be needed may also be needed *Anti-inflammatory reliever (AIR) Box 3-12 © Global Initiative for Asthma, www.ginasthma.org  GINA 2023 – Adults and adolescents Track 1 Maintenance and reliever therapy (MART) with ICS-formoterol As-needed-only ICS-formoterol (‘AIR-only’) *An anti-inflammatory reliever (AIR) Box 3-12 (2/4) Track 1 © Global Initiative for Asthma, www.ginasthma.org  GINA 2023 – Adults and adolescents Track 2 *An anti-inflammatory reliever (Steps 3–5) Box 3-12 (3/4) Track 2 © Global Initiative for Asthma, www.ginasthma.org  GINA 2023 – Adults and adolescents Box 3-12 4/4) © Global Initiative for Asthma, www.ginasthma.org  Terminology n Reliever § For symptom relief, or before exercise or allergen exposure n Controller § Function: targets both domains of asthma control (symptom control and future risk) § Mostly used for ICS-containing treatment n Maintenance treatment § Frequency: regularly scheduled, e.g. twice daily ICS: inhaled corticosteroid; SABA: short-acting beta2-agonist GINA 2023 Box 3-4 © Global Initiative for Asthma, www.ginasthma.org  Terminology n Anti-Inflammatory Reliever = AIR § e.g. ICS-formoterol, ICS-SABA § Provides rapid symptom relief, plus a small dose of ICS § Reduces the risk of exacerbations, compared with using a SABA reliever Regimens with ICS-formoterol anti-inflammatory reliever n As-needed-only ICS-formoterol = AIR-only § The patient takes low-dose ICS-formoterol whenever needed for symptom relief n Maintenance And Reliever Therapy with ICS-formoterol = MART § A low dose of ICS-formoterol is used as the patient’s maintenance treatment, plus whenever needed for symptom relief n ICS-formoterol can also be used before exercise or allergen exposure ICS: inhaled corticosteroid: SABA: short-acting beta2-agonist; MART is sometimes also called SMART © Global Initiative for Asthma, www.ginasthma.org How to prescribe low-dose ICS-formoterol in GINA Track 1 Example: budesonide-formoterol 200/6 mcg [160/4.5 delivered dose] n Steps 1–2: take 1 inhalation whenever needed for symptoms n Step 3: take 1 inhalation twice a day (or once a day) PLUS 1 inhalation whenever needed for symptoms n Steps 4–5: take 2 inhalations twice a day PLUS 1 inhalation whenever needed for symptoms n As-needed doses of ICS-formoterol can also be taken before exercise (Lazarinis et al, Thorax 2014) or before allergen exposure (Duong et al, JACI 2007) See following slides for medications, doses, and maximum number of inhalations in any day for GINA Track 1 © Global Initiative for Asthma, www.ginasthma.org Box 3-13 © Global Initiative for Asthma, www.ginasthma.org Box 6-6 © Global Initiative for Asthma, www.ginasthma.org NAEPP 2020 Guidelines https://www.lung.org/get media/e6be8c67-a793- 44a8-bd7c- 96629e57c20d/respirator y-medication-chart.pdf Principles on stepping down asthma treatment v Consider stepping down when asthma symptoms have been well controlled and lung function has been stable for 3 or more months v Patients with risk factors for exacerbations (poor adherence, incorrect inhaler use, obesity, smoking, air pollution..), step down with close supervision v Choose an appropriate time (no respiratory infection, not pregnant or travelling) v Approach each step as a therapeutic trial: v Engage patient (and parents in children) in the process v Document their asthma status v Provide clear instructions v Provide a written asthma action plan v Ensure patient has enough medications and v Schedule a follow-up visit Other Therapies v Allergen Immunotherapy: v Subcutaneous immunotherapy (SCIT) v Sublingual immunotherapy (SLIT) v Vaccinations v Recommend influenza vaccination annually v Advise patients to be up to date with COVID-19 vaccines v Bronchial Thermoplasty v Procedure that uses heat to remove muscle tissue from the airways of adults with moderate to severe asthma (not recommended by NAEPP or GINA) (GINA 2023, NAEPP,2020) Non-pharmacological strategies v Cessation of smoking, environmental tobacco exposure and vaping v Physical activity v Avoidance of occupational or domestic/indoor exposure to allergens or irritants v Avoidance of medications that may worsen asthma (e.g. NSAIDS, oral beta blockers) v Healthy diet v Weight reduction v Dealing with emotional stress (GINA 2023) When to Refer v Difficulty confirming the diagnosis of asthma v Suspected occupational asthma v Persistent or severely uncontrolled asthma or frequent exacerbations v Any risk factors for asthma-related death v Evidence of, or risk of, significant treatment side-effects v Symptoms suggesting complications or sub-types of asthma v Concerns about child’s well-being or welfare (6-11 years) (GINA 2024) Inhaler choice and environmental considerations n First, what is the right medication for this patient? § Control symptoms and reduce exacerbations § Urgent healthcare and hospitalization have a heavy environmental burden n Which inhaler(s) can the patient access for this medication? § Low/middle income countries often have limited choice and access § Cost of inhalers is a major burden n Which of these inhalers can the patient use correctly? § Incorrect technique à more exacerbations n What are the environmental implications of these inhaler(s)? § Manufacture § Propellant (for pMDIs) § Recycling potential n Is the patient satisfied with the treatment and the inhaler? § Consider the patient’s environmental priorities § Avoid ‘green guilt’, which may contribute to poor adherence § Check inhaler technique frequently © Global Initiative for Asthma, www.ginasthma.org GINA 2023 from Box 3-21 © Global Initiative for Asthma, www.ginasthma.org GP OR SPECIALIST CARE Investigate and manage difficult-to-treat asthma in adults and adolescents Consider referring to specialist or severe asthma clinic at any stage DIAGNOSIS: “Difficult- to-treat 1 (asthma/differential Confirm the diagnosis 3 Optimize including: management, 4 Review response after ~3-6 months asthma” diagnoses) For adolescents and adults with symptoms 2 Look for factors contributing to symptoms, Asthma education Optimize treatment (e.g. check and correct inhaler technique and Is asthma still uncontrolled? yes DIAGNOSIS: “Severe If not done by now, refer to asthma” a specialist, if possible and/or exacerbations adherence; switch to ICS-formoterol despite medium or exacerbations and poor maintenance and reliever therapy, high dose ICS-LABA, quality of life: if available) or taking maintenance Incorrect inhaler technique Consider non-pharmacological OCS no Suboptimal adherence interventions (e.g. smoking cessation, exercise, weight loss, Comorbidities including obesity, mucus clearance, influenza and GERD, chronic rhinosinusitis, OSA COVID-19 vaccination) Modifiable risk factors and Treat comorbidities and Consider stepping down triggers at home or work, including modifiable risk factors Restore previous dose treatment, OCS first smoking, environmental exposures, Consider non-biologic add-on (if used) allergen exposure (if sensitized); medications such as beta-blockers therapy (e.g. LABA, LAMA, and NSAIDs LM/LTRA, if not used) Consider trial of high dose ICS- Does Overuse of SABA relievers LABA, if not used asthma become yes Medication side effects uncontrolled when Anxiety, depression and social treatment is stepped difficulties down? Key no decision, filters Continue optimizing management intervention, treatment diagnosis, confirmation © Global Initiative for Asthma 2022, www.ginasthma.org SPECIALIST CARE; SEVERE ASTHMA CLINIC IF AVAILABLE Assess and treat severe asthma phenotypes Continue to optimize management as in section 3 (including inhaler technique, adherence, comorbidities, non-pharmacologic strategies) 5 Investigate further and 6 Assess the severe asthma phenotype 7 Consider other treatments provide patient support Is add-on Investigate for comorbidities/differential Could patient Type 2 biologic yes yes diagnoses and treat/refer as appropriate have Type 2 airway Type 2 airway inflammation therapy available/ - Consider: CBC, CRP, IgG, IgA, IgM, inflammation? affordable? Consider adherence tests IgE, fungal precipitins; CXR and/or HRCT chest; DLCO; DEXA scan Type 2 inflammation Consider increasing the ICS dose for 3-6 months no no - Skin prick testing or specific IgE for Consider add-on non-biologic treatment for relevant allergens, if not already done Blood eosinophils ≥150/µl specific Type 2 clinical phenotypes, e.g. AERD, and/or ABPA, chronic rhinosinusitis, nasal polyposis, If add-on Type 2-targeted biologic therapy is - Consider screening for adrenal FeNO ≥20 ppb and/or atopic dermatitis NOT available/affordable insufficiency in patients taking maintenance OCS or high dose ICS Sputum eosinophils ≥2%, and/or Consider higher dose ICS, if not used - If blood eosinophils ≥300/μl, look for Asthma is clinically allergen- Consider other add-on therapy and treat non-asthma causes, includ- driven (e.g. LAMA, LM/LTRA, low dose azithromycin) ing parasites (e.g. Strongyloides (Repeat blood eosinophils and As last resort, consider add-on low dose OCS, but serology, or stool examination) FeNO up to 3x, at least 1-2 implement strategies to minimize side-effects - If hypereosinophilia e.g. ≥1500/μl, weeks after OCS or on lowest Stop ineffective add-on therapies consider causes such as EGPA possible OCS dose) - Other directed testing (e.g. ANCA, CT Go to section 10 sinuses, BNP, echocardiogram) Note: these are not the criteria for No evidence of Type 2 airway inflammation based on clinical suspicion add-on biologic therapy (see 8) Consider need for social/psychological Review the basics: differential diagnosis, inhaler technique, adherence, support comorbidities, side-effects Involve multidisciplinary team care Avoid exposures (tobacco smoke, allergens, irritants) (if available) Consider investigations (if available and not done) Invite patient to enroll in registry (if - Sputum induction available) or clinical trial (if appropriate) - High resolution chest CT - Bronchoscopy for alternative/additional diagnoses Consider trial of add-on treatments (if available and not already tried) - LAMA Not currently eligible - Low dose azithromycin for T2-targeted biologic * - Anti-IL4R if taking maintenance OCS therapy - Anti-TSLP* (but insufficient evidence in patients on maintenance OCS) - As last resort, consider add-on low dose OCS, but implement strategies to minimize side-effects Consider bronchial thermoplasty (+ registry) *Check local eligibility criteria for specific biologic Stop ineffective add-on therapies Go to section 10 therapies as these may vary from those listed © Global Initiative for Asthma 2022, www.ginasthma.org SPECIALIST CARE; SEVERE ASTHMA CLINIC IF AVAILABLE Assess and treat severe asthma phenotypes cont’d Continue to optimize management as in section 3 (including inhaler technique, adherence, comorbidities, non-pharmacologic strategies) 8 Consider add-on biologic Type 2-targeted treatments Eligibility Predictors of asthma response Consider add-on Type 2- Anti-IgE (omalizumab) What factors may predict good targeted biologic therapy Is the patient eligible for anti-IgE for severe allergic asthma?* asthma response to anti-IgE? Extend trial to for patients with Blood eosinophils ≥260/µl ++ 6-12 months* Sensitization on skin prick testing or specific IgE exacerbations or poor Total serum IgE and weight within dosage range FeNO ≥20 ppb + symptom control on high dose ICS-LABA, who have Exacerbations in last year Allergen-driven symptoms + unclear evidence of Type 2 Childhood-onset asthma + Choose one inflammation* no no if eligible*; Good yes Consider local payer trial for at least asthma eligibility criteria*, Anti-IL5 / Anti-IL5R (benralizumab, mepolizumab, reslizumab) What factors may predict good 4 months and response?* Good response comorbidities and to T2-targeted therapy Is the patient eligible for anti-IL5 / anti-IL5R for severe eosinophilic asthma?* asthma response to anti-IL5/5R? assess response predictors of response Exacerbations in last year Higher blood eosinophils +++ when choosing between no available therapies Blood eosinophils, e.g. ≥150/µl or ≥300/µl More exacerbations in previous year +++ Also consider cost, dosing no Adult-onset of asthma ++ frequency, route (SC or IV), STOP add-on patient preference Nasal polyposis ++ no Consider switching to a different Type Anti-IL4R (dupilumab) What factors may predict good 2-targeted therapy, Is the patient eligible for anti-IL4R for severe eosinophilic/Type 2 asthma?* asthma response to anti-IL4R? if eligible* Exacerbations in last year Higher blood eosinophils +++ no Blood eosinophils ≥150 and ≤1500/μl, or FeNO ≥25 ppb, Higher FeNO +++ Which biologic or taking maintenance OCS is appropriate to start first? no no Little/no response to T2-targeted therapy Anti-TSLP (tezepelumab) What factors may predict good Is the patient eligible for anti-TSLP for severe asthma?* asthma response to anti-TSLP? Exacerbations in last year Higher blood eosinophils +++ Higher FeNO +++ Eligible for none? Return to section 7 No evidence of Type 2 airway inflammation No evidence of Type 2 airway inflammation. Go to section 10 *Check local eligibility criteria for specific biologic therapies as these may vary from those listed © Global Initiative for Asthma 2022, www.ginasthma.org SPECIALIST AND PRIMARY CARE IN COLLABORATION Monitor / Manage severe asthma treatment Continue to optimize management 9 Review response 10 Continue to optimize management as in section 3 including:, Asthma: symptom control, exacerbations, lung function Type 2 comorbidities e.g. nasal polyposis, atopic dermatitis Inhaler technique Medications: treatment intensity, side-effects, affordability Adherence Patient satisfaction Comorbidity management Non-pharmacologic strategies Patients’ social/emotional needs If good response to Type 2-targeted therapy Re-evaluate the patient every 3-6 months* Two-way communication with GP for ongoing care yes For oral treatments: consider decreasing/stopping OCS first (and check for adrenal insufficiency), then stopping other add-on medication For inhaled treatments: consider decreasing after 3-6 months; continue at least moderate dose ICS-LABA Re-evaluate need for ongoing biologic therapy Notes: Order of reduction of treatments based on observed benefit, potential side-effects, cost and patient preference If no good response to Type 2-targeted therapy Stop the biologic therapy Review the basics: differential diagnosis, inhaler technique, adherence, comorbidities, side-effects, emotional support Consider high resolution chest CT (if not done) Reassess phenotype and treatment options no - Induced sputum (if available) - Consider add-on low dose azithromycin - Consider bronchoscopy for alternative/additional diagnoses - As last resort, consider add-on low dose OCS, but implement strategies to minimize side-effects - Consider bronchial thermoplasty (+ registry) Stop ineffective add-on therapies Do not stop ICS No evidence of Type 2 airway inflammation. Go to section 10 *Check local eligibility criteria for specific biologic therapies as these may vary from those listed © Global Initiative for Asthma 2022, www.ginasthma.org References v American Lung Association. Asthma and COPD medicines. https://www.lung.org/getmedia/e6be8c67-a793-44a8-bd7c-96629e57c20d/respiratory- medication-chart.pdf v Cloutier, M. M., Baptist, A. P., Blake, K. V., Brooks, E. G., Bryant-Stephens, T., DiMango, E., Dixon, A. E., Elward, K. S., Hartert, T., Krishnan, J. A., Lemanske, R. F., Ouellette, D. R., Pace, W. D., Schatz, M., Skolnik, N. S., Stout, J. W., Teach, S. J., Umscheid, C. A., & Walsh, C. G. (2020). 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. Journal of Allergy and Clinical Immunology, 146(6), 1217–1270. https://doi.org/10.1016/j.jaci.2020.10.003 v Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2023. www.ginasthma.org