The Saudi Initiative for Asthma Guidelines for the Diagnosis and Management of Asthma in Adults and Children 2013 update

1. The Saudi Initiative for AsthmaGuidelines for the Diagnosis and Management of Asthma in Adults and Children2013 update Out-patient Management of Asthma in Adults On behalf of the SINA panel Mohamed S. Al-Moamary, FRCP (Edin) FCCP Dep. of Medicine, King Abdulaziz Medical City-Riyadh King Saud bin Abdulaziz University for Health Sciences

2. Out-patient Management of Asthma in Adults Enter presenter name Enter the presenter’s institute

3. What is SINA? • SINA is developed by a task force originated from the Saudi Initiative for Asthma Group under the umbrella of the Saudi Thoracic Society • SINA is a practical approach for a comprehensive management of asthma in adults and children and when to refer to a specialist. • International recommendations were customized to the local setting for asthma diagnosis and management • Directed to HCW dealing with asthma who are not specialists in the field.

4. Purpose of SINA • To provide a document that is easy to follow, simple to understand yet totally updated and carefully prepared for use by non-asthma specialist including primary care doctors and general practice physicians

5. Where do you find SINA? • The SINA guideline was published in the Annals of Thoracic Medicine (www.thoracicmedicine.org): Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, Al-Ghobain MO, Idrees MM, Zeitouni MO, Al-Harbi AS, Al Dabbagh MM, Al-Matar H, Alorainy HS. The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2012;7:175-204 • The SINA guidelines booklet is available at: www.sinagroup.org

6. Saudi Thoracic Society commitment • The STS is committed to improve the care of asthma by a long term plan: • Periodic scientific meetings • Annual asthma meeting (since 2001) • Frequent asthma courses • Educational brochures • Publishing new and updated asthma guidelines

7. What is new in SINA-2012 • Comprehensive revision with the addition of new 125 references • Addition of charts and algorithms for asthma diagnosis and management • Updating asthma management • Rewritten “asthma in children” section • New section on “difficult to treat asthma”

8. SINA Panel • Mohamed S. Al-Moamary (Chairman), King Saud bin Abdulaziz University for Health Sciences, Riyadh • Sami Alhaider, King Faisal Specialist Hospital and Research Center, Riyadh • Mohamed S. Al-Hajjaj, King Saud University, Riyadh • Mohammed O. AlGhobain, King Saud bin Abdulaziz University for Health Sciences, Riyadh • Majdy M. Idrees, Military Hospital, Riyadh • Mohamed O. Zeitouni, King Faisal Specialist Hospital and Research Center, Riyadh • Adel S. Alharbi, Military Hospital, Riyadh •  Hussain Al-Matar, Imam Abdulrahman Al Faisal, Dammam • Maha M. Al Dabbagh, King Fahd Armed Forces Hospital, Jeddah •  Hassan S Alorainy, King Faisal Specialist Hospital and Research Center, Riyadh

9. Acknowledgment The SINA panel would like to thank the following reviewers : • Prof. J. Mark FitzGerald from the University of British Columbia, Vancouver, BC, Canada • Prof. Qutayba Hamid from the Meakins-Christie Laboratories, and the Montreal Chest Research Institute • Prof. Sheldon Spier, the University of British Columbia, Vancouver, Canada • Prof. Eric Bateman from the University of Cape Town Lung Institute, Cape Town, South Africa (SINA 2009) • Prof. Ronald Olivenstein from the Meakins-Christie Laboratories and the Montreal Chest Research Institute, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada. (SINA 2009)

10. SINA Documents • Published manuscript • Booklet • Electronic version • Slides kit • Flyers • Website: www.sinagroup.org

11. Sections of SINA – update cover • Epidemiology • Pathophysiology • Diagnosis • Medications • Approach to Management • Treatment Steps • Special Situations • Acute Asthma

12. Prevalence • Prevalence of asthma has increased between 1986 – 1995 Alfrayyah et al. Ann Allergy Asthma Immunol 2001;86:292–296

13. Burden of Asthma • Asthma is among the most common chronic illnesses in Saudi Arabia • 53% had missed school or work (AIRKSA-2007) • 35% attempted Unconventional therapy (Al Moamary, ATM 2008) • 46% were controlled in Riyadh (AIRKSA-2007) • 36% were controlled in 5 tertiary care centers in Riyadh (Aljahdali SMJ-2008) • 48% were controlled in one center (Al Moamary, ATM 2008)

14. AIRKSA report (Ministry of Health) • 78 % of adults & 84% of kids reported acute asthma over 12 months (AIRKSA) • 54 % of adults & 80% of kids reported ER over 12 months (AIRKSA) • 45-68% of adults & 37-56% of kids reported limitation of activity over 12 months (AIRKSA) • 76 % of adults & 78% of kids never had spirometry(AIRKSA)

15. The prevalence of wheeze and associated symptoms in the study group Al-Ghobain et al, NBC Pulm Med 2012;12:39

16. Pattern of asthma treatment Al-Shimemeri, Ann Thorac Med 2006;1:20-5

17. Pathology of Asthma Inflammation Airway Hyper-responsiveness Airway Obstruction Symptoms of Asthma

18. Pathophysiology

19. Inflammation  Remodeling • Inflammation • Airway Hypersecretion • Subepithelial fibrosis • Angiogenesis

20. Diagnosis - History • Episodic attacks: • Cough • Breathlessness • Wheezing • Nocturnal symptoms • Patient could be asymptomatic between attacks • co-existent conditions: GERD, rhinosinusitis.

21. Relevant Questions • Does the patient or his/her family have a history of asthma or other atopic conditions, such as eczema or allergic rhinitis? • Does the patient have recurrent attacks of wheezing? • Does the patient have a troublesome cough at night? • Does the patient wheeze or cough after exercise? • Does the patient experience wheezing, chest tightness, or cough after exposure to pollens, dust, feathered or furry animals, exercise, viral infection, or environmental smoke?

22. Relevant Questions • Does the patient experience worsening of symptoms after taking aspirin/nonsteroidal inflammatory medication or use of B-blockers? • Does the patient's cold “go to the chest” or take more than 10 days to clear up? • Are symptoms improved by appropriate asthma treatment? • Are there any features suggestive of occupational asthma

23. Physical Examination • Normal between attacks • Bilateral expiratory wheezing • Examination of the upper airways • Other allergic manifestations: e.g., atopic dermatitis/eczema • Consider alternative Dx when there is localized wheeze, crackles, stridor, clubbing

24. Investigations • Measurements of lung function: • Spirometry • Peak expiratory flow (PEF) • Normal Spirometry does not role out asthma • Spirometry is superior to PEF

25. Bronchodilator response • Proper instructions on how to perform the forced expiratory maneuver must be given to patients, and the highest value of three readings taken. • The degree of significant reversibility is defined as an improvement in FEV1 ≥12% and ≥200 ml from the pre-bronchodilator value.

26. Clinical Assessment • Measurements of allergic status to identify risk factors (if indicated) • Chest X-ray is not routinely recommended • Routine blood tests are not routinely recommended • IgE measurement is indicated in severe cases

27. Assessment of Asthma Control

28. Asthma Control Test Level of Control: • Total: 25 • Control: 20-24 • Partial control: 16-19 • Uncontrolled: < 16

29. Differential Diagnosis • Upper airway diseases • Allergic rhinitis and sinusitis • Obstructions involving large airways • Foreign body in trachea or bronchus • Vocal cord dysfunction • Vascular rings or laryngeal webs • Laryngotracheomalacia, tracheal stenosis, or bronchostenosis • Enlarged lymph nodes or tumor • Obstructions involving small airways • Viral bronchiolitis or obliterative bronchiolitis • Cystic fibrosis • Bronchopulmonary dysplasia • Heart disease • Other causes • Recurrent cough not due to asthma • Aspiration from swallowing mechanism dysfunction or GERD

30. Differential Diagnosis • COPD (e.g., chronic bronchitis or emphysema) • Congestive heart failure • Pulmonary embolism • Mechanical obstruction of the airways (benign and malignant tumors) • Pulmonary infiltration with eosinophilia • Cough secondary to drugs (e.g., angiotensin-converting enzyme (ACE) inhibitors) • Vocal cord dysfunction

31. Management

32. Patient/Dr Partnership • Enhance the chance of disease control • Agreed goals of management • Guided self-management plan

33. Asthma Education • Creation of partnership between patient and healthcare worker • Understanding clinical presentation of asthma and diagnosis • Ability to differentiate between “relievers” and “controllers” medications and their appropriate indications • Recognition of potential side effects of medications and the appropriate action to minimize them • Performance of the proper technique of devices • Identification of symptoms and signs that suggest worsening of asthma control and the appropriate action to be taken • Understanding the approach for monitoring asthma control • Recognition of the situations that need urgent medical attention • Ability to use a written self-management plan

34. Drugs: Poor technique of inhaler devices. Regimen with multiple drugs. Occurrence of Side effects from the drugs. Cost of medications. Non-drugs Lack of knowledge about asthma. Lack of partnership in the management. Inappropriate expectations. Underestimation of severity. Cultural issues. Non-Adherence

35. Precipitating Factors • Indoor Allergens and Air Pollutants • Outdoor Allergens • Occupational Exposure • Food and Drugs

36. Self-management plan

37. Self-management plan لكل مريض خطة علاجية ذاتية خاصة به توضع تحت إشراف الطبيب المختص حسب حالته

38. Asthma Medications • Controllersare medications taken daily on a long-term basis to keep asthma under clinical control chiefly through their anti-inflammatory effects. • Relieversare medications used on an as-needed basis that act quickly to reverse bronchoconstriction and relieve symptoms.

39. Controller Medications • Inhaled glucocorticosteroids • Long-acting inhaled B2-agonists • Leukotriene modifiers • Long-acting anticholenergics • Theophylline • Anti-IgE • Systemic glucocorticosteroids

40. Inhaled Corticosteroids • The most effective antiinflammatory medications for asthma treatment • Benefits of ICS: • reduce symptoms • improve quality of life • improve lung function • decrease airway hyperresponsiveness • control airway inflammation • reduce frequency and severity of exacerbations, and reduce mortality.

41. Inhaled Corticosteroids • When ICS discontinued, deterioration of clinical control may follow within weeks • Most of the benefits from ICS are achieved in adults at relatively low doses • Increasing to higher doses may provide further benefits in terms of asthma control but increases the risk of side effects • Tobacco smoking reduces the responsiveness to ICS

42. Inhaled Corticosteroids • To reach control, add-on therapy with another class of controller is preferred to increasing the dose of ICS • ICS are generally safe and well-tolerated • Though low-medium dose of ICS may affect growth velocity, this effect is clinically insignificant and may be reversible.

43. Inhaled Corticosteroids • Local adverse effects: • oropharyngeal candidiasis • dysphonia – may be e reduced by using MDI with spacer devices and mouth washing • Systemic side effects are occasionally reported with high doses and long-term treatment

44. Inhaled Corticosteroids

45. Leukotriene modifiers (LTRA) • LTRA reduces airway inflammation, improve asthma symptoms and lung function • It has less consistent effect on exacerbations when compared to ICS. • Alternative treatment to ICS for patients with mild asthma, especially in those who have clinical rhinitis • Some patients with aspirin-sensitive asthma respond well to the LTRA

46. Leukotriene modifiers (LTRA) • Available as montelokast in Saudi Arabia • Their effects are generally less than that of low dose ICS • When added to ICS, LTRA may reduce the dose of ICS required by patients with uncontrolled asthma, and may improve asthma control • LTRA are generally well-tolerated. There is no clinical data to support their use under the age of six months.

47. LABA • LABA: (formoterol and salmeterol) • Should not be used as monotherapy • Combination with ICS lead to: • improves symptoms • decreases nocturnal asthma • improves lung function • decreases the use of rapid-onset inhaled B2-agonists • reduces the number of exacerbations • achieves clinical control of asthma in more patients, more rapidly, and at a lower dose of ICS

48. Dual Pathways of Inflammation Steroid-sensitive mediatorsplay a key role in asthmatic inflammation CysLTsplay a key role in asthmatic inflammation Montelukast Inhaled steroids blocks the effects of CysLTs block steroid-sensitivemediators DUAL PATHWAY The slide represents an artistic rendition. Adapted from Peters-Golden M, Sampson AP J Allergy Clin Immunol 2003;111(1 suppl):S37-S42; Bisgaard H Allergy 2001;56(suppl 66):7-11.

49. Long acting anti-chlenergics • It was superior to a doubling of the dose of an inhaled glucocorticoid for patients at step 3 • It was non-inferior to LABA • It improves lung function in patients with severe uncontrolled asthma • It is effective as add-on therapy to combination devices at step 4 • Daily home peak expiratory flow measurements were higher with tiotropium doses Peters et al. N Engl J Med 2010; 363:1715-1726

50. Combination devices • Sympicort turbohaler: • Combination of budesonide/formeterol: 160/4.5 • Seretide: • Combination of fluticasone/salmeterol • Evohaler: 50/25 125/25 250/25 • Diskus: 100/50 250/50 500/50