1 Pulmonary Diseases, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul,

1. CONTROL OF ASTHMA AT THE 3RD-LINE PULMONARY DISEASES CLINICS (3RD LINE PDC) ACCORDING GINA (GLOBAL INITIATIVE FOR ASTHMA) PARAMETERS BİLUN GEMİCİOĞLU 1 FÜSUN YILDIZ 2 MEHMET POLATLI 3 SİBEL ATIŞ 4 A.BERNA DURSUN 5 FERDA ÖNER ERKEKOL 5 HATİCE TÜRKER 6 BİRSEN OCAKLI 6 GÜNGÖR ÇAMSARI 7 AYGÜN GÜR 7 SEÇİL KEPİL ÖZDEMİR 8 ÖMÜR AYDIN 8 ÖZNUR ABADOĞLU 9 ARİF ÇIMRIN 10 MUSTAFA LEVENT ERKAN 11 HAKAN GÜNEN 12 ÖZLEM GÖKSEL 13

2. Study Centers 1Pulmonary Diseases, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul, 2Pulmonary Diseases, Kocaeli University, Faculty of Medicine, Kocaeli, 3Pulmonary Diseases, Adnan Menderes Univerity, Faculty of Medicine, Aydin, 4Pulmonary Diseases, Mersin Univerity, Faculty of Medicine, Mersin 5Allergy, Ataturk Chest Diseases and Thoracic Surgery Education and Research Hospital, Ankara 6Pulmonary Diseases, Sureyyapasa Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul 7Pulmonary Diseases, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, 8Allergy, Ankara University, Faculty of Medicine, Ankara 9Allergy, Cumhuriyet University, Faculty of Medicine, Sivas 10Pulmonary Diseases, Dokuz Eylul University, Faculty of Medicine, Izmir 11Pulmonary Diseases, Ondokuz Mayis University, Faculty of Medicine, Samsun 12Pulmonary Diseases, Inonu University, Faculty of Medicine, Malatya 13Pulmonary Diseases, Izmir Ataturk Education and Research Hospital, İzmir

3. GINA 2007 and Control Concept ≥ 3 features of partly controlled asthma present in any week

4. TESTS NUMERICALLY EVALUATING ASTHMA CONTROL

5. AIMS • Preparing an easily understandable form (AACT1) questionning GINA 2007 symptom control citeria and determining some reasons for uncontrolled disease through AACT2 form. • Validation of the new form; eatablishing its correlation with Astma Control Test (ACT) and FEV1 • Establishing some reasons for lack of control in asthma and compliance with GINA 2007 criteria in Turkish asthmatic patients at 3rd line PDC, through AACT total score.

6. METHOD 810 asthmatics on treatment (13 3rd line PDC) Information about demographic information, treatment, allergy ACT,AACT questionnaires, PFT expert opinion on 100 cases Statistical evaluation .

7. ASTHMA CONTROL TEST™ (ACT) • 1) In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? • All of the time • Most of the time • Some of the time • A little of the time • None of the time • 2) During the past 4 weeks, how often have you had shortness of breath? • More than once a day • Once a day • 3 to 6 times a week • Once or twice a week • Not at all • 3) During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? • 4 or more nights a week • 2 or 3 nights a week • Once a week • Once or twice • Not at all

8. Asthma Control Test™ (ACT) • 4) During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? • 3 or more times per day • 1 or 2 times per day • 2 or 3 times per week • Once aweek or less • Not at all • 5) How would you rate your asthma control during the past 4 weeks? • Not controlled at all • Poorly controlled • Somewhat controlled • Well controlled • Completely controlled • Total Score:

9. Achieving Asthma Control Test (AACT) • 1. In the past week, how often did you have day time asthma symptoms (dyspnea, cough, wheezing)? • None of the time (10) • 1 or 2 days (8) • 3 or more days (2) • Every day (0) • 2. In the past week, how often did your asthma symptoms (dyspnea, cough, wheezing, awakening ) wake you up at night or earlier than usual in the morning? • None of the time (10) • One night (4) • 2 to 6 times (2) • Every day (0) • 3. In the past week, how often have you used your rescue bronchodilator medication (relieving dypnea) in addition to your regular daily treatment? • None of the time (10) • 1 or 2 days (8) • 3 or more days (2) • Every day (0)

10. 4. In the past week, how much of the time have you experienced any limitation in your daily activities (work, school, exercise and house work etc.) due to asthma symptoms? • None of the time (10) • 1 or 2 days (6) • 3 or more days (2) • Every day(0) • 5. Did you have any unplanned office/emergency room visits since your last visit? • No (10) b) Yes (0) • 6.Does your asthma symptoms remain contolled (asymptomatic) despite being exposed to triggering factors (smoking, perfumes, allergens, having cold, stress)? • a) No (10) b) Yes (0)

11. 7.Do you have any accompanying diseases such as allergic/non allergic rhinitis or reflux (heartburn, gastric symptoms)? If your answer is’no’, please answer question 9? • a) No (10) b) Yes (0) • 8. If your answer to question 7 is ‘yes’, has your accompanying disease been controlled? • a) Yes (10) b) No (0) • 9. Have you used your treatment regularly since your last visit (especially in the past week)? • a) Yes (10) b) No (0) • 10. Would you please show me the way you use your inhaler device(s)? • a) Tecnic is correct (10) b) Tecnic is incorrect (0) • Total score:

12. BIOMETRIC AND FUNCTIONAL PARAMETERS

13. Validations of AACT and ACT

14. ACT and AACT RESULTS Uncontrolled Partly controlled Controlled AACT1 ACT MEAN±SD 18,8±5.4 36,2±14,8 Best 25 50

15. Correlation between ACT & AACT1 ACT Total Score R=0,846 p<0,001 AACT Total Score (first 5 questions)

16. Total correlation between ACT & AACT ACT Total Score R=0,758 p<0,001 AACT Total Score

17. Correlation of ACT & AACT1 with FEV1 < 80 % ACT Total Score R=0,847 p<0,001 AACT Total Score (first 5 questions)

18. Correlation of ACT & AACT1 with FEV1> 80% ACT Total Score R=0,781 p<0,001 AACT Total Score (first 5 questions)

19. ACT RESULTS ACCORDING TO SEX Uncontrolled Controlled ACT Female ACT Male ACT P<0,003

20. AACT RESULTS ACCORDING TO SEX Uncontrolled Partly controlled Controlled AACT AACT Female AACT Male P<0,009

21. Skin Prick Test Findings % positive negative 42,7 % not performed % ACT and AACT showed no siginificant difference between skin prick test (+) and (-) subjects.

22. ACT; Consistency with GINA (%) Consistent ACT1 ACT2 ACT3 ACT4 ACT5

23. AACT 1; Consistency with GINA (%) Consistent AACT1 AACT2 AACT3 AACT4 AACT5

24. Consistency of ACT– AACT with GINA (%) ACT AACT Nocturnal Activity Daytime

25. AACT 1 + FEV1 ; GINA consistency(%) 67,9% , 60 % and 34,4% of those who are controlled, partly controlled and uncontrolled respectively, had FEV1 >80%.

26. AACT 6-10 answers (%) present Incorrect inhaler tecnnic Hyperreactivity Comorbidity Irregular treatment Comorbidities were reported to be controlled in only 47% of patients having these diseases

27. Consistency between AACT 6 and AACT (%) Hyperreactivity (+) Hyperreactivity (-) Controlled Partly controlled Uncontrolled

28. CONCLUSION • ACT is a practical test recommended in GINA, • but AACT questionnaire includes more precise data in demonstrating parameters that may represent reason for lack of control and GINA compliance.