Update 2017 What we can do to prevent & treat Richard - - PowerPoint PPT Presentation

What we can do to prevent & treat

Richard Hendershot, M.D., FAAAAI Asthma & Allergy – Salt Lake Clinic

Asthma Exacerbations Update 2017

Asthma Exacerbations Update 2017

What we can do to prevent and treat

Richard Hendershot, M.D., FAAAAI Asthma & Allergy – Salt Lake Clinic

Asthma Exacerbations Update 2017

Etiology – increase in disease activity

Asthma exacerbations - explode

A pressure phenomenon +/-

• How much underlying disease/

inflammation:

• Physiologic severity, allergy, last exacerbation,

SABA use, functional capacity (exercise), ICS use.

• Severity of trigger (s)
• Rhinovirus vs RSV vs influenza, SMOG, allergy

J Allergy Clin Immunol 2008;122:697-9.

Virus is the major trigger of asthma exacerbations (70- 85% of the time based on age and risk). Note: allergy, atypical bacteria and SMOG frequently make this worse. OR 2.3 (virus only) OR 8.4 (virus + allergy)

Is there a role for macrolides in treating exacerbations? I routinely do not b/c data is not impressive, unless already failed OCS or very severe exacerbation.

JACI 2006;117:1233-6

278 pts w/ moderate to severe asthma exacerbations tx’d w/ telithromycin + prednisone vs placebo vs prednisone. Note increased time to improvement in symptoms and decreased symptoms with addition of telithromycin.

Asthma Exacerbations - etiology

URIs (virus) are the primary cause of an asthma exacerbation

• Rhinovirus is the leading cause in adults & children
• Huge seasonal peak – Fall/ September is the highest, lowest summer
• Allergy, pollution, non-adherence amplify this.
• Virus alone (OR 2.3) vs allergen (cat in home) exposure + virus (OR 8.4)
• Adherence to ICS is the most effective way to decrease this risk.
• OCS in the last 12 months highest predictor of repeat exacerbation
• High SABA use strong predictor of exacerbations

Asthma exacerbations – viral increase to inflammation & bronchial reactivity

URIs/ viral infections cause 85% of asthma exacerbations in peds (75% adults).

• Rhinovirus causes 2/3 of viral triggered

exacerbations

• Rhinovirus and/ or RSV and/or influenza all

trigger reactions but c/b SMOG, allergen, cold air, exercise, etc.

BMJ 1995;310:1225-8

Asthma exacerbations – viral increase to inflammation & bronchial reactivity

URIs/ viral infections cause 85% in peds (75% adults) of asthma exacerbations – responsible for seasonal variation.

• Rhinovirus causes 2/3 of viral triggered

infections

• Why September – kids & school
• Note: most studies indicate virus attenuates an

additional trigger.

BMJ 1995;310:1225-8

Asthma exacerbation seasonal

• Sept. peak is broken out by age
• Peds 2-15 show greatest variabilty
• Pts 16-49 yo still show a small Sept peak
• Adults >50 is this flu season or delay in

rhinovirus getting to the elderly (no data

• n adults over 50 for viral PCR)

Proc Am Thorac Soc 2007;4:591-6

Ideally – measure viral infection, inflammation & reactivity at home.

• PCR to nasal lavage is currently

impractical.

• eNO did not work well and too

expensive for home use.

• Home PEF failed to help as well.
• So we use surrogate markers & we

need to be able to measure it on a population basis.

Goal – reduce exacerbations & morbidity, use markers of significance to accomplish that.

• Controller:Reliever ratio >0.50,

patients use 2x as many controllers as relievers.

• High SABA use correlates w/

increased morbidity.

• Controller Rx (s) do not correlate

with exacerbations

Am J Manag Care. 2010;16(5):327-333

Asthma exacerbations – Update 2017

What we can do to prevent & treat.

• High use of ICS helps.
• High need/ use of SABA is a surrogate

marker for bronchial reactivity & inflammation.

• This is complex because it depends on the

patient/ parent’s priorities and beliefs.

• This is a system problem & challenge.
• There are tools available to help.

JACI 2008;122:741-7

ICS is more effective than LTRA or lower dose ICS/ LABA

Note BADGER study See table

JACI 2008;122:741-7 NEJM 2010;362:975-85

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Overall we are doing pretty good, but for some patients can we do better?

3 pts hospitalized, 13 pts in ER – 12 total not meeting HEDIS, 8 ended up in ER, some hospitalized

What do we do ? Utah stats per year:

• 40 deaths
• >1500

hospitalizations

• >7000 ED visits

Asthma exacerbations – key messages

Factors we CANNOT change.

• Before puberty boys exacerbate >

girls.

• After puberty, females exacerbate

more, get sicker, hospitalized longer

• Predictable seasonal epidemics
• Most exacerbations virally

triggered. Factors we CAN change

• Synergistic relationship between viral

infection/ allergy sensitization & exposure & exacerbations.

• Frequent exacerbations indicate

comorbidity especially psychosocial factors.

• ICS + LABA helps, LABA without ICS is
• inappropriate. Off-label of PRN ICS/

formoteral has proven efficacy.

• +LTRA in peds helps reduce fall

exacerbations.

JACI 2008;122:662-8

Am J Manag Care. 2010;16(5):327-333

Big Picture, the more controller med used regularly (ICS, ICS/LABA or LTRA taken) and less SABA required regularly to treat asthma the lower the risk of an exacerbation. Distribution of a controller does not help.

2 addressable problems:

• 1. Address comorbidities including

psycho-social.

• 2. Align goals & expectations

between docs & pts. **Key relationships

Asthma exacerbations – what can we do about them?

Comorbidities:

• 1. Psychosocial – cost, divorce, child

in charge, poor technique, etc.

• 2. Allergy – cat/dog/ guinea pig/ bird
• 3. Sinusitis
• 4. Tobacco/ SMOG
• 5. AERD
• 6. GERD
• 7. Hyper-eosinophilia, etc.

Asthma exacerbations – what can we do about them?

Psychosocial: Relationships, relationships, relationships (care manager to track), doctor to educate and create a plan Discussion on approaches

• Divorce?
• Cost?
• Child in charge of therapy?
• Poor technique?
• Other problems with discussion . . .

Asthma exacerbations – what can we do about them?

Other comorbidities:

• 1. Allergy – cat/dog/ guinea pig/ bird,
• nly about 5% get rid of their pets so

modify environment and trial AIT

• 2. Sinusitis – consider above too
• 3. Tobacco/ SMOG – quit, avoid, stay

indoors on bad days.

• 4. AERD – ASA desensitization, LTRA
• 5. GERD – rare, worth a trial
• 6. Hyper-eosinophilia, etc, new med, etc

Asthma exacerbations – what can we do about them?

Goals & Expectations/ pt perceptions:

• 1. Not allergic to my dog or cat
• 2. OCS 2-5 times a year OK.
• 3. ED/ hospitalization twice a year OK.
• 4. Fear of steroids – ICS vs OCS
• 5. SABA use 2-4 times a day OK.
• 6. Preference for naturopathic therapy,

standard medical care is harmful.

• 7. Coughing after exertion – normal.

**Relationships key to this

Asthma exacerbations – what can we do about them?

Another great idea: My brother in law worked with a farmer in upstate New York who did this with his tractor. It was terrifying and awesome at the same time.

Goals & Expectations/ pt perceptions:

• --OCS 2-5 times a year OK/ ED hospitalizations

OK. Peds OCS use:

• short term crazy & hyperactive (hangry)
• Long term – loss of height, see adult long

term Adult OCS use:

• Short term – cranky/ hungry (extra hangry)
• long term - DM-II, osteoporosis, compression

fractures, loss of FEV1

Asthma exacerbations – what can we do about them?

Goals & Expectations/ pt perceptions Fear of all steroids

• Yes, corticosteroids are bad – but dose

matters.

• Pred 60mg QD x 5 days = 300mg
• Fluticase ICS 200mcg QD x 365 days x

10% efficiency = 7300 mcg = 7.3mg

• 300mg/7.3mg = 41 fold higher dose per

year with 1 exacerbation per year for OCS

Asthma exacerbations – what can we do about them?

Goals & Expectations/ pt perceptions High SABA use OK

• Asthma is 3 things: bronchial

reactivity, inflammation, mucus

• SABA only treats bronchial

reactivity and leaves other alone

• Sole SABA use (no ICS) correlates

with increased risk of death, hospitalizations, ED, decreased exercise capacity

Asthma exacerbations – what can we do about them?

Goals & Expectations/ pt perceptions:

• 1. Preference for naturopathic

therapy, standard medical care is harmful – ideas? My experience supports patience and a good relationship is key here.

• 2. Coughing after exertion, I avoid or

have my child avoid exercise – education, all asthmatics should be so well treated they can exercise as much as they prefer.

Asthma exacerbations – what can we do about them?

Asthma Exacerbations Update 2017

Big picture: Intermountain Healthcare as a whole is doing well w/ HEDIS. However, pts are still severely exacerbating & those are the pts failing.

• Success = High ICS/ LTRA or ICS+LABA

use with low regular SABA use.

• Physician & care manager relationships

& communication are key to making this happen. Cute picture, but if this occurs it largely means we failed as a

• system. WE CAN DO BETTER.

Asthma Exacerbations Update 2017

• Discussion & questions & ideas.
• I want your ideas and your experience

with how this can be done better as individuals and as a system.