Clinical Conversations : Primary Care Management of Patients With Asthma

1. Clinical Conversations:Primary Care Managementof Patients With Asthma

2. Faculty Stephen A. Brunton, MD, FAAFP (moderator) Adjunct Clinical Professor of Family Medicine University of North Carolina, Chapel Hill, North Carolina LeRoy M. Graham, MD, FCCCP Georgia Pediatric Pulmonary Associates, PC Associate Clinical Professor of Pediatrics, Morehouse School of Medicine Founder and Medical Director, Not One More Life, Inc. Atlanta, Georgia

3. CME information Please review CME information at: www.jfponline.com

4. Trends in Asthma Management(1998 vs 2009) Acute care for asthma in past 12 months N=1788; age ≥16 y N=2294; age ≥16 y Asthma Insight & Management Survey 2010. http://www.takingaimatasthma.com/pdf/executive-summary.pdf.

5. Case: Brian C-ACT, childhood asthma control test; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroid; SABA, short-acting inhaled -agonist. • 8-year-old male diagnosed with mild persistent asthma at age 3 years • Current assessment of asthma control: • FEV1 68% predicted; FEV1/FVC 79% • Often feels short of breath after recess or when playing outdoors; responds to SABA (uses more than twice a week) • 5-6 nighttime awakenings/month • Experiences an exacerbation every month that requires nebulized albuterol in the office/ED • C-ACT score 15 • Presently treated with low-dose ICS and prn SABA

6. Case: Brian(cont) • Asthma not well controlled • Important questions • Is he adherent? • Is he being treated appropriately based on asthma control?

7. Evaluating Treatment Adherence Ask in a non-threatening manner Ask how many times a week he is using his ICS Inquire about inhaler technique and, if appropriate, use of spacer

8. Evaluating Current Treatment and Symptom Control • Asthma is a disease of chronic inflammation • Is the anti-inflammatory dose correct? • Is anti-inflammatory therapy being delivered to both large and small airways? • Importance of air trapping

9. Role of Small Airways in Asthma BDP, beclomethasone dipropionate; CFC=chlorofluorocarbon; HFA, hydrofluoroalkane. Role of small airways not entirely clear Deposition of ICS into the small airways appears to be inversely related to steroid particle size Lung deposition studies show that small particles (eg, BDP HFA and ciclesonide) are deposited deeper into smaller airways compared to larger particles (eg, CFC formulation)

10. ICS Particle Size FP, fluticasone propionate. Price et al. J Allergy Clin Immunol. 2010;126:511-518. • Relevance of ICS particle size to clinical outcomes not entirely clear • Real-world clinical trial in primary care compared BDP HFA to FP HFA/CFC over 1 year as initial or step-up therapy • BDP HFA patients • 30% more likely to achieve control as initial therapy • 22% more likely to achieve control as step-up therapy • Similar exacerbation rates

11. Therapy Considerations Asthma Severity Asthma Control Initiate Therapy (Not currently on controller therapy) Adjust Therapy (Currently on controller therapy) Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. ICS remain as initial anti-inflammatory therapy for persistent asthma Obtaining objective lung function is essential

12. Case: Brian, Step-up Options LABA, long-acting -agonist. 3 choices: •  ICS to medium dose (good option) • Add LABA (good option) • Add a different anti-inflammatory (reasonable option) • Cromolyn, nedocromil, leukotriene receptor antagonist, 5-lipoxygenase inhibitor • Symptom control may be less than with medium-dose ICS

13. Long-Acting -Agonists • The FDA recently concluded that there is an increased risk of severe exacerbation of asthma symptoms leading to hospitalizations in children and adults, as well as of death in some patients with asthma treated with a LABA • Labeling changes, risk and evaluation mitigation strategies • However, some experts question FDA actions • Conclusion: LABAs • Do have a role in moderate or severe persistent asthma • Do not have a role in mild persistent asthma

14. Case: Brian, Next Steps First, ensure adherence and appropriate inhaler technique Step up to medium-dose ICS Adding LABA to low-dose ICS an equally good option Reevaluate in 2 to 6 weeks Review environmental control, early recognition of exacerbation, overall self-management

15. How to recognize and handle worsening asthma Daily management to keep asthma controlled Action Plans Principal objectives

16. Communicating With the Patient Should be seamless Determine what is important to patient, and identify shared values and goals Emphasize that patient can control symptoms

17. Communicating With the Patient • Communicate in simple, straightforward terms • Tell patient how response to therapy will be assessed • Exercise tolerance, nighttime awakening, other symptoms • Peak expiratory flow/spirometry

18. Action Plan Appropriate therapy Assess limitations Ongoing education

19. Implementing Action Plan Written/printed out Involve staff to talk through action plan with patient Have patient repeat plan to staff Have patient demonstrate inhaler technique

20. Summary Incidence of asthma-related morbidity has changed little over past decade Effective treatments are available Clinicians should set expectations very high Patients should not accept significant symptoms or functional impairment

21. Faculty Stephen A. Brunton, MD, FAAFP (moderator) Adjunct Clinical Professor of Family Medicine University of North Carolina, Chapel Hill, North Carolina LeRoy M. Graham, MD, FCCCP Georgia Pediatric Pulmonary Associates, PC Associate Clinical Professor of Pediatrics, Morehouse School of Medicine Founder and Medical Director, Not One More Life, Inc. Atlanta, Georgia

22. Clinical Conversations:Primary Care Managementof Patients With Asthma Please visit www.pceconsortium.org/asthmawebcast to complete the evaluation and receive your CME certificate of participation.