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Asthma Exacerbations Update 2017 What we can do to prevent & treat Richard Hendershot, M.D., FAAAAI Asthma & Allergy Salt Lake Clinic Asthma Exacerbations Update 2017 What we can do to prevent and treat Richard Hendershot, M.D.,

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  1. Asthma Exacerbations Update 2017 What we can do to prevent & treat Richard Hendershot, M.D., FAAAAI Asthma & Allergy – Salt Lake Clinic

  2. Asthma Exacerbations Update 2017 What we can do to prevent and treat Richard Hendershot, M.D., FAAAAI Asthma & Allergy – Salt Lake Clinic

  3. Asthma Exacerbations Update 2017 Etiology – increase in disease activity

  4. Asthma exacerbations - explode A pressure phenomenon +/- • How much underlying disease/ inflammation: o Physiologic severity, allergy, last exacerbation, SABA use, functional capacity (exercise), ICS use. • Severity of trigger (s) o Rhinovirus vs RSV vs influenza, SMOG, allergy J Allergy Clin Immunol 2008;122:697-9.

  5. 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)

  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. 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 JACI 2006;117:1233-6 severe exacerbation.

  7. 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. o Virus alone (OR 2.3) vs allergen (cat in home) exposure + virus (OR 8.4) o Adherence to ICS is the most effective way to decrease this risk. o OCS in the last 12 months highest predictor of repeat exacerbation o High SABA use strong predictor of exacerbations

  8. 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 o Rhinovirus and/ or RSV and/or influenza all trigger reactions but c/b SMOG, allergen, cold air, exercise, etc. BMJ 1995;310:1225-8

  9. 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 o Note: most studies indicate virus attenuates an additional trigger. BMJ 1995;310:1225-8

  10. 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 on adults over 50 for viral PCR) Proc Am Thorac Soc 2007;4:591-6

  11. Ideally – measure viral infection, Goal – reduce exacerbations & inflammation & reactivity at morbidity, use markers of home. significance to accomplish that. • PCR to nasal lavage is currently • Controller:Reliever ratio >0.50, impractical. patients use 2x as many controllers as relievers. • eNO did not work well and too • High SABA use correlates w/ expensive for home use. increased morbidity. • Home PEF failed to help as well. • Controller Rx (s) do not correlate o So we use surrogate markers & we need to be able to measure it on a with exacerbations population basis. Am J Manag Care. 2010;16(5):327-333

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

  13. ICS is more effective than LTRA or lower dose ICS/ LABA Note BADGER study See table JACI 2008;122:741-7

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

  15. Place slide text here. Resize shape behind text to properly fit content. Overall we are doing pretty good, but for some patients can we do better?

  16. 3 pts hospitalized, 13 pts in ER – 12 total not meeting HEDIS, 8 ended up in ER, some hospitalized

  17. What do we do ? Utah stats per year: • 40 deaths • >1500 hospitalizations • >7000 ED visits

  18. Asthma exacerbations – key messages Factors we CAN change Factors we CANNOT change. • Synergistic relationship between viral • Before puberty boys exacerbate > infection/ allergy sensitization & girls. exposure & exacerbations. • After puberty, females exacerbate • Frequent exacerbations indicate more, get sicker, hospitalized comorbidity especially psychosocial factors. longer • ICS + LABA helps, LABA without ICS is • Predictable seasonal epidemics inappropriate. Off-label of PRN ICS/ • Most exacerbations virally formoteral has proven efficacy. triggered. • +LTRA in peds helps reduce fall exacerbations. JACI 2008;122:662-8

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

  20. Asthma exacerbations – what can we do about them? 2 addressable problems: 1. Address comorbidities including psycho-social . 2. Align goals & expectations between docs & pts. **Key relationships

  21. 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.

  22. 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 . . .

  23. Asthma exacerbations – what can we do about them? Other comorbidities : 1. Allergy – cat/dog/ guinea pig/ bird, only 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

  24. 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

  25. 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.

  26. Asthma exacerbations – what can we do about them? 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

  27. 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

  28. 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

  29. 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.

  30. 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. Cute picture, but if this occurs • Physician & care manager relationships it largely means we failed as a & communication are key to making this system. WE CAN DO BETTER. happen.

  31. 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.

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