Asthma- A Clinical Review

and its Management

K V GOPINATH M Pharm(PhD)CPhTHospital Pharmacist

Tirumala Tirupati DevasthanamsTirupati -517 501

gopinath.karnam@gmail.com

Magnitude of the problem

>5000 patients die from asthma

1.9 million ER visits (1995)

Self reported asthma in the US was 14.6 million

Estimated patients rose to 17 million (1998)

Overall asthma health expenditure was at $6.2 billion (1990)

Indian Scenario 15- 20 million asthmatics

Asthma prevalence to be 12% in school children

Significant cause of school/work absence

Health care expenditures very high

Morbidity and mortality are on the rise JAPI 2002; Vol 50: 462

The Treatment Gap in Asthma

Patients are not detected

Do not seek medical attention

No access to health service

Missed diagnosis (bronchitis, LRTI)

Definition

“A chronic inflammatory disorder of the airways”

NAEPP.Expert Panel Report 2. Guidelines for the diagnosis and management of asthma: NIII publication, 1997.

Risk Factors that Lead to Asthma Development

Respiratory infections

Allergens

Environment

Emotions

Exercis

Drugs/preservatives

Occupational Stimuli

Pathophysiology

Risk Factor

Inflammation

Airway Hyper responsiveness

Airflow limitation

Risk Factor Symptoms

Current Understanding of Asthma

A chronic inflammatory disorder of the airway

Infiltration of mast cells, eosinophils and lymphocytes

Airway hyperresponsiveness

Recurrent episodes of wheezing, coughing and shortness of breath

Widespread, variable and often reversible airflow limitation

DIAGNOSIS OF ASTHMA

Detailed History of Asthma & Physical examination

X-Ray

Blood & sputum test

Allergy prick skin testing & Challenge tests

Differential diagnosis

A trial use of asthma medications

Pulmonary Function Test

Diagnostic testing

E.g. A patient with 35 yrs;M; Height 149 cm, and Weight 49kgs

Pred: FEV1 =1.555 L Pre =1.231L

Post =1.369 L % Change = 11.21

Peak Flow Meter/Spiro meter

Classification of Asthma Severity

Step 4 Severe persistent

FEV1 or PEF<60% Predicted

Step 3Moderate Persistent

FEV1orPEF>60%<80% Predicted

Step 2Mild

FEV1 or PEF >80% predicted

Step1:Intermittent FEV1 or PEF >80% predicted

Goals to Be Achieved in Asthma Control Achieve and maintain control of symptoms

Prevent asthma episodes

Minimal use of reliever medication

No emergency visits to doctors or hospitals

Maintain normal activity levels and Maintain pulmonary function

Minimal /No adverse effects from medicine

Tool Kit for Achieving Management Goals

Preventers

Peak Flow meter

Patient education

What are Preventers?

Prevent future attacks

Long term control of asthma / regular use only

Prevent airway remodeling

Anti-inflammatory

Takes time to act (1-3 hours)

Long-term effect (12-24 hours)

PREVENTERS

CORTICOSTEROIDS ANTI LEUCOTRIENES Prednisolone, Betamethasone Montelukast, Beclomethasone, Budesonide Zafirlukast, Fluticasone

XANTHINESTheophylline SR

LONG ACTINGS 2 AGONISTS MAST CELL STABILIZERESBambuterol, Salmeterol SodiumcromoglycateFormoterol

COMBINATIONSSalmeterol/Fluticasone Formoterol/Budesonide Salbutamol/Beclomethasone

What Are Relievers?

Rescue medications Quick relief of symptoms Used during acute attacks

Action lasts 4-6 hrs

Not for regular use

Rescue Medication

SALBUTAMOL INHALER

100 mcg: 1 or 2 puffs as necessary

LEVOSALBUTAMOL INHALER

50 mcg : 1 or 2 puffs as necessary

Ideal combination

Formoterol ( fast relief and SR ) + Budesonide

Dose: 1- 4 puffs ( OD/BD )

Another combination

Salmeterol + Fluticasone

All Asthma Drugs Should Ideally Be Taken Through The Inhaled Route

Oral Slow onset of action

Large dosage used

Greater side effects Not useful in acute symptoms

Inhaled route Rapid onset of action

Less amount of drug used

Better tolerated

Treatment of choice

In acute symptoms

Aerosol delivery systems

Metered dose inhalers

Dry powder inhalers (Rota haler)

Spacers / Holding chambers

Rota haler - The dry powder advantage

Overcomes hand-lung coordination problems that are encountered with MDIs

Can be easily used by children, elderly and arthritic

patients

Can take multiple inhalations if the entire drug has not

been inhaled in one

Advantages of Spacer

No co-ordination required

No cold - Freon effect

Reduced oropharyngeal deposition

Increased drug deposition

Age-wise selection of inhaler devices

< 3 years – MDI + Spacer + Mask or nebulisers

3 – 5 years – MDI + Spacer + Mask or Rotahaler

5 – 8 years – Rotahaler or MDI + Spacer

> 8 years – Rotahaler or MDI + Spacer

Patient Education

Patient Education Explain nature of the disease (i.e. inflammation) Explain action of prescribed drugs Stress need for regular, long-term therapy Allay fears and concerns Peak flow reading Treatment diary / booklet

Key Messages

It can happen to anybody It is not caused by supernatural forces Asthma is not contagious It produces recurrent attacks of cough with or without

wheeze Between attacks people with asthma lead normal lives

as anyone else In most cases there is some history of allergy in the

family.

Key Messages

Asthma can be effectively controlled, although it cannot be cured.

Effective asthma management programs include education, objective measures of lung function, environmental control, and pharmacologic therapy

. A stepwise approach to pharmacologic therapy is

recommended. The aim is to accomplish the goals of therapy with the least possible medication.

Objectives

To assess the health related quality of life with respect to the pulmonary function

To assess the knowledge, attitude and practices of asthmatics regarding their diseases, medication and its management.

To evaluate the patient adherence in asthmatics receiving medications.

To appropriately counsel patients on the proper use of medications for asthma and methods for prevention.

To evaluate the outcome of patient counseling.

Materials and Methods

Spirometer

Health related quality of life

Demographic data

Knowledge, attitude and practice

Compliance assessment

Statistical analysis

66.66

%

33.33

%

37.50

%

62.50

%

47.22

%

52.77

%

Male Female

Sex

% of

Patie

nts

Pharmaceutical care group n=12 Usual care group n=24 Total study population n=36

Demographic data based on sex

Demographic data based on age

16.6

6%

83.3

3%

0%

12.5

0%

75%

12.5

0%

13.8

8%

77.7

7%

33%

12 to 18 19 to 60 > 60

Age in Years

% o

f P

atie

nts

Pharmaceutical care group n=12 Usual care group n=24 Total study population n=36

Demographic data based on education

16.6

6%

25%

16.6

6%

8.33

%

33.3

3%

12.5

0% 16.6

6%

25%

25%

20.8

3%

13.8

8%

19.4

4%

22.2

2%

19.4

4% 25%

Illiterate Middle School High/higher Secondary College

Education

% o

f pat

ient

s

Pharmaceutical care group n=12 Usual care group n=24 Total study population n=36

Demographic data based on occupation

25%

33.3

3%

8.33

%

25%

8.33

%

20.8

3%

37.5

0%

16.6

6% 20.8

3%

4.16

%

22.2

2%

36.1

1%

13.8

8%

22.2

2%

5.55

%

Student House w ife Business Employee Labour

Occupation

% o

f P

atie

nts

Pharmaceutical care group n=12 Usual care group n=24 Total study population n=36

Demographic data based on social habits (Alcohol)

8.33

%

91.6

6%

12.5

0%

87.5

0%

11.1

1%

88.8

8%

Yes No

Alcohol - Status

% o

f P

atie

nts

Pharmaceutical care group n = 12 Usual care group n = 24 Total study population + 36

Demographic data based on social habits (Smoking)

8.33

%

91.6

6%

25%

75%

19.4

4%

80.5

5%

Yes No

Smoking status

% o

f P

atie

nts

Pharmaceutical care group n = 12 Usual care group n = 24 Total study population + 36

Demographic data based on treatment profile

16.6

6%

66.6

6%

16.6

6%25%

58.3

3%

0

22.2

2%

61.1

1%

25%

<3 3 to 5 >5

No. of drugs used

% o

f Pat

ient

s

Pharmaceutical care group n = 12 Usual care group n = 24 Total study population + 36

Drug Usage in Study Population

91.6

6%

41.6

6%

16.6

6%

0% 0%

33.3

3%

33.3

3%

8.33

%

33.3

3%

66.6

6%

16.6

6%

16.6

6%

0%

25%

25%

0%

8.33

%

79.1

6%

45.8

3%

20.8

3%

4.16

%

8.33

% 16.6

6%

4.16

%

4.16

%

25%

75%

0%

29.1

6%

8.33

%

12.5

0%

12.5

0%

8.33

%

4.16

%

Name of the drugs

% o

f Pat

ient

s

Pharmaceutical Care Group Usual care group

DIAGNOSIS OF ASTHMA: % REVERSIBILITY

Parameter Pharmaceutical Care

Group (%)

Usual Care Group (%)

Reversibility 23.01±16.73 15.03±12.14

Phauc Nguyen.Counseling Patients on Management of Asthma. J of Asthma.2001: 9-18.

Comparative Statement Of PFT Parameters, Percentage Predicted

Group PFT parameter

Base Line

Follow Up 1

Follow Up 3

Follow Up 6

Pharm. CareGroup

C 1.48 1.96 (32%)

2.31 (56%)

2.48 (67.56%)

FVC 2.01 2.40 (19%)

2.75 (37%)

2.87 (43%)

FEV1/FVC% 73.7 82 (11.3%)

85 (15.3%)

86 (17%)

PEF 254 357 (40.6%)

380 (49.7%)

396 (56%)

Usual careGroup

FEV1 1.63 1.65 (1.22%)

1.71 (8%)

1.78 (9.20%)

FVC 2.08 2.1 (0.23%) 2.1 (0.23)

2.12 (2%)

FEV1/FVC% 78.4 80 (2.1%)

83.5 (6.5%)

84.5 (7.7%)

PEF 302 279 (-7.8%)

290 (-3.99%)

303 (0.33%)

Mean Medication Knowledge Assessment score

Characteristic population

Base line Follow up-6 % Change p value

Pharma. care group

24.41+9.64 54.33+4.79 122.57 *p=<0.0001

Usual care group

14.30+8.18 20.87+16.00 45.94 p=<0.0868

Patient Compliance: Pill Count Method

The percentage of compliance was more in intervention 90.55

Health Related Quality Of Life

Characteristic population

Component

0-45th day 46th - 90th day

% *Change

P value

Pharmaceutical Care Group

Symptoms 45.40+22.96 9.644+7.90 -78.76 *P= <0.0001

Activity 46.74+28.69 4.14+8.51 -91.14 *P= <0.0001

Impact 37.02+16.08 4.33+8.03 -88.30 *P= <0.0001

Total score

41.31+18.50 5.19+7.30 -87.43 *P=<0.0001

Usual care Group

Symptoms 8.82+20.79 13.44+2.71 52.38 P=0.3792

Activity 21.79+23.60 12.63+17.02 -0.42 P=0.1472

Impact 18.68+18.72 15.76+13.85 -15.63 P=0.5598

Total score

17.89+18.71 14.42+12.15 -19.39 P=0.4689

-78.76

52.38

-100

-80

-60

-40

-20

0

20

40

60

Studypopulation

% o

f Sym

pto

m S

core

PharmaceuticalCare GroupUsual CareGroup

Percentage Improvement of SGRQ Symptom Scores

-91.14

-0.42

-100

-80

-60

-40

-20

0

Study population

% o

f SG

RQ

Act

ivity

sco

re

Pharmaceutical CareGroupUsual Care Group

Percentage Improvement of SGRQ Activity Scores

-88.3

-0.42

-100-90-80-70-60-50-40-30-20-10

0

Study population

% o

f SG

RQ

Imp

act

sco

rePharmaceuticalCare Group

Usual CareGroup

Percentage Improvement of SGRQ Impact Scores

-87.43

-19.39

-100

-90

-80

-70

-60

-50

-40

-30

-20

-10

0

Study population

% o

f S

GR

Q t

ota

l score

PharmaceuticalCare GroupUsual CareGroup

Percentage Improvement of SGRQ Total Scores

Conclusion

• The pharmaceutical intervention would improve the pulmonary function and HRQOL appears to hi-light different aspects of disease severity in asthma.

Future Action Plan

To assess the safe, appropriate, and cost effective management of asthma.

To compare the efficiency of bronchodilators used in practice.

Wheezing Disturbed sleep

Breathlessness Cough and Cold

How to use Rota haler

oral metered-dose inhalers

How to use Spacer