Asthma Treatment - PDF document

1 Update s in Asthma Treatment Laura Vaugh
Update s in Asthma Treatment Laura Vaughan, MD Clinical Assistant Professor of Medicine Stanford University GINA slides used in this presentation are reproduced with permission No

2 financial disclosures Serious Consequen
financial disclosures Serious Consequences • 9.8 million office visits • 1.8 million ER visits • 3,564 deaths • African - Americans 3X more likely to die Bronchospasm + In

3 flammation 5 SABA Short acting beta agon
flammation 5 SABA Short acting beta agonist albuterol, terbutaline LABA Long acting beta agonist formoterol, salmetorol ICS Inhaled corticosteroid budesonide, fluticasone

4 , beclomethasone, mometasone Asthma: P
, beclomethasone, mometasone Asthma: Pre - 2017 8 ICS - f orm o terol PRN ICS Containing Inhaler daily Revolution in Asthma: 2019 Why? 1 1 • Patient like the immediate eff

5 ects SABA • Providers use them for acu
ects SABA • Providers use them for acute treatment • More than bronchoconstriction A cute asthma exacerbations 30 - 37% “mild” Dying of asthma 15 - 20% “mild” Symptoms

6 eekly in previous 3 months Dusser , All
eekly in previous 3 months Dusser , Allergy 2007 1 2 The Risks of " Mild ” Asthma More SABA use… More adverse outcomes • ≥3 canisters per year (average 1.7 puffs/day) i

7 s associated with higher risk of ED vis
s associated with higher risk of ED visits 1 • ≥12 canisters per year is associated with higher risk of death 2 1 Stanford, AAAI 2012 2 Suissa, AJRCCM 1994 1 3 Regular or fre

8 quent use of SABA is associated with adv
quent use of SABA is associated with adverse effects − B - receptor down regulation − Decreased bronchodilator response 1 1 Hancox, Respir Med 2000 Risks with SABA - only Tr

9 eatment Regular or frequent use of SABA
eatment Regular or frequent use of SABA is associated with adverse effects − B - receptor down regulation − Decreased bronchodilator response 1 − Rebound hyper responsivene

10 ss − Increased allergic response and
ss − Increased allergic response and increased eosinophilic airway inflammation 2 1 Hancox, Respir Med 2000 2 Aldridge, AJRCCM 2000 Risks with SABA - only Treatment 3 , 849 pat

11 ients D ouble blind RCT Placebo controll
ients D ouble blind RCT Placebo controlled 52 weeks Symbicort Given as Needed in Mild Asthma SYGMA 1 Trial 1 7 Symbicort Given as Needed in Mild Asthma (SYGMA) 1 1 8 Budesonide + F

12 ormoterol PRN Terbutaline PRN Budesoni
ormoterol PRN Terbutaline PRN Budesonide daily + Terbutaline PRN SYGMA 1 Trial Findings 1 9 Budesonide + Formoterol PRN Terbutaline PRN Budesonide daily + Terbutaline PRN Be

13 tter asthma - symptom control weeks 44 %
tter asthma - symptom control weeks 44 % 31 % 34 % SYGMA 1 Trial Findings Budesonide + Formoterol PRN Terbutaline PRN Budesonide daily + Terbutaline PRN Better asthma - symptom

14 control weeks 44 % 31 % 34 % Annual rate
control weeks 44 % 31 % 34 % Annual rate of severe exacerbations 0.09 0.20 0.07 Findings SYGMA 1 Budesonide - Formoterol PRN v s Terbutaline PRN 64% lower rate of severe ex

15 acerbations 2 1 SYGMA 1 Trial Findings 2
acerbations 2 1 SYGMA 1 Trial Findings 2 2 Budesonide + Formoterol PRN Terbutaline PRN Budesonide daily + Terbutaline PRN Better asthma - symptom control weeks 44 % 31 % 34 % An

16 nual rate of severe exacerbations 0.09
nual rate of severe exacerbations 0.09 0.20 0.07 ICS 100 0 17% Findings SYGMA 1 Budesonide - Formoterol PRN vs Budesonide daily PRN associated with 83% lower cumulative dose

17 of ICS 4 , 215 patients D ouble blind
of ICS 4 , 215 patients D ouble blind 52 weeks • Similar reduction in the risk of severe exacerbations for PRN ICS - formoterol vs daily budesonide • 75% less c

18 orticosteroid in PRN budesonide - for
orticosteroid in PRN budesonide - formoterol vs daily budesonide SYGMA 2 Trial: Mild Asthma 2 4 More Supporting Evidence 2 5 Confirmed: Fewer Adverse Events For safety, do no

19 t use SABA - only treatment for Step 1
t use SABA - only treatment for Step 1 • SABA - only treatment increases the risk of severe exacerbations • Adding any ICS significantly reduces risk Global Initiative for Ast

20 hma (GINA 2019) Landmark Changes in Asth
hma (GINA 2019) Landmark Changes in Asthma Treatment Instead, use ICS - containing controller treatment: • ICS daily treatment or • In mild asthma, PRN ICS - formoterol Reduce

21 Serious Exacerbations © Global Initiativ
Serious Exacerbations © Global Initiative for Asthma, www.ginasthma.org 2 7 Starting Treatment © Global Initiative for Asthma, www.ginasthma.org GINA 2020, Box 3 - 5A Adjusting Tre

22 atment © Global Initiative for Asthma, w
atment © Global Initiative for Asthma, www.ginasthma.org GINA 2020, Box 3 - 5A Adjusting Treatment ICS Dosing − Low dose ICS provides most of the clinical benefit of ICS for m

23 ost patients with asthma Biologics 3 1 D
ost patients with asthma Biologics 3 1 Decreasing Oral Corticosteroid Dependence Asthma - COPD Overlap Asthma COPD Features of Both Asthma - COPD Overlap Asthma COPD Features of

24 Both Variable symptoms Triggers Earlier
Both Variable symptoms Triggers Earlier age onset Respond to BD in minutes Respond to ICS days to weeks Variable expiratory airflow limitation Age onset after 40 Persistent Dyspne

25 a Activity limited +/ - BD response Toxi
a Activity limited +/ - BD response Toxic exposure/hx smoking Persistent expiratory airflow limitation GINA recommendations: − Asthma: never treat with bronchodilators alone (r

26 isk of death, hospitalization, severe e
isk of death, hospitalization, severe exacerbations) Asthma - COPD Overlap Asthma COPD Features of Both GINA recommendations: − Asthma: never treat with bronchodilators alone

27 (risk of death, hospitalization, severe
(risk of death, hospitalization, severe exacerbations) − COPD: start treatment with LABA and/or LAMA without ICS Asthma - COPD Overlap Asthma COPD Features of Both GINA recomm

28 endations: − Asthma: never treat with
endations: − Asthma: never treat with bronchodilators alone (risk of death, hospitalization, severe exacerbations) − COPD: start treatment with LABA and/or LAMA without ICS

29 − Patients with both asthma and COPD a
− Patients with both asthma and COPD are more likely to die or be hospitalized if treated with LABA vs ICS - LABA (Gershon et al, JAMA 2014; Kendzerska et al, Annals ATS 2019

30 ) Asthma - COPD Overlap Asthma COPD Feat
) Asthma - COPD Overlap Asthma COPD Features of Both GINA recommendations: − Asthma: never treat with bronchodilators alone (risk of death, hospitalization, severe exacerbatio

31 ns) − COPD: start treatment with LABA
ns) − COPD: start treatment with LABA and/or LAMA without ICS − Patients with both asthma and COPD are more likely to die or be hospitalized if treated with LABA vs ICS - LAB

32 A (Gershon et al, JAMA 2014; Kendzersk
A (Gershon et al, JAMA 2014; Kendzerska et al, Annals ATS 2019) − High dose ICS may be needed for severe asthma, but should not be used in COPD (risk of pneumonia) Asthma - CO

33 PD Overlap Asthma COPD Features of Both
PD Overlap Asthma COPD Features of Both Real Practice: COST and COVERAGE • ICS - LABA: More expensive, often not fully covered by insurance or with higher co - pays 3 8 Real

34 Practice: COST and COVERAGE • ICS - L
Practice: COST and COVERAGE • ICS - LABA: More expensive, often not fully covered by insurance or with higher co - pays • B udesonide - f ormotero l covered by 9/10 insuran

35 ce types -- co - pays can be high 3 9
ce types -- co - pays can be high 3 9 Real Practice: COST and COVERAGE • ICS - LABA: More expensive, at times not fully covered by insurance or with higher co - pays • B

36 udesonide - f ormoterol advertises cov
udesonide - f ormoterol advertises covered by 9/10 insurance types -- co - pays can be high • Option to use SABA and take ICS - low dose any time SABA used 4 0 Black Box W

37 arning with Montelukast • March 2020
arning with Montelukast • March 2020 FDA boxed warning about risk of serious neuropsychiatric events, including suicidality, depression and agitation Black Box Warning with Mo

38 ntelukast • March 2020 FDA boxed warn
ntelukast • March 2020 FDA boxed warning about risk of serious neuropsychiatric events, including suicidality, depression and agitation • Before prescribing Montelukast, con

39 sider its benefits and risks and other
sider its benefits and risks and other alternatives and counsel patients about the risk of neuropsychiatric events • Continue ICS, OCS, biologics • Avoid nebulizers where pos

40 sible • Use MDI with spacer for severe
sible • Use MDI with spacer for severe exacerbations. • Avoid spirometry and peak flow in PUI or COVID COVID - 19 and Asthma 4 3 Clinical pearls • SABAs do not treat the

41 airway inflammation underlying asthma a
airway inflammation underlying asthma and are useful in the treatment of symptoms only 4 4 Key Points • SABAs do not treat the airway inflammation underlying asthma and are use

42 ful in the treatment of symptoms only â€
ful in the treatment of symptoms only • Avoid using short acting beta agonists alone in patients with mild asthma 4 5 Key Points • SABAs do not treat the airway inflammation u

43 nderlying asthma and are useful in the
nderlying asthma and are useful in the treatment of symptoms only • Avoid using short acting beta agonists alone in patients with mild asthma • Use ICS - containing inhaler