amr and respiratory paediatrics

AMR and Respiratory Paediatrics

Richard Goodwin

Paediatric Integrated Care Pharmacist, Evelina London Children’s

Hospital

Pharmacy Lead, Children & Young People's Health

Partnership

Teacher Practitioner, University College London: School of Pharmacy

#PharmacyTogether2018

Declaration of Interest


I received no funding from the pharmaceutical industry

Currently employed by Great Ormond Street Hospital

Undertake primary care teaching funded through CCGs

Nothing else to declare

Todays session


Identifying which wheeze is which disease

Treatments for viral induced wheeze

Consider AMR in paediatric respiratory

Asthma isn’t serious is it?

How to monitor asthma

Treatments for asthma

Supporting holistic care

Wheezing in preschool childWheezing in preschool childWheezing in preschool childWheezing in preschool child

• Common presentation to both GP & General Paediatrics

• Significant winter burden on A&E

• 1/3 of preschool school children experience wheeze

• ~20% of these will be diagnosed as asthmatic

• Tucson Children’s Respiratory Study: 1980 to present1

Most preschool wheeze is not linked to atopy and for the vast majority will resolve by school age

The right wheeze for the right diseaseThe right wheeze for the right diseaseThe right wheeze for the right diseaseThe right wheeze for the right diseaseCommon causes of childhood wheeze:

Respiratory tract infections

GORD Asthma

Croup Bronchiolitis

ENT abnormalities Foreign body

Cystic fibrosis Bronchiectasis

Tracheobronchomalacia CHD

Tumours / vascular rings Immunodeficiency

Tracheoesphageal fistula

Asthma diagnosis red flags2

Upper Upper Upper Upper RRRRespiratory Infections / ENTespiratory Infections / ENTespiratory Infections / ENTespiratory Infections / ENTChildren > adults to receive antibiotics for self-limiting illness

• Acute otitis media in over 2 years olds: 4 days

• Acute sore throat, pharyngitis, tonsillitis 1 week

• Common cold 10 days

• Acute rhinosinusitis 18-20 days

• Acute cough/ acute bronchitis 3 weeks

Strongly consider no treatment for delayed prescribing3,4,5

Lack of confidence in treating children and risk aversion• RCGP & RCPCH provide online training

• Access to localised Antibiotic Guidance Across Primary & Secondary Care

• Public health educating families on the risk of AMR

CQUIN Paediatric Serious InfectionsCQUIN Paediatric Serious InfectionsCQUIN Paediatric Serious InfectionsCQUIN Paediatric Serious InfectionsPaediatrics is based on Days on Therapy rather than Daily Dose Units

• Ensure you are reporting the correct data

• Review process & reporting systems to reduce double reporting

• Consider increased AMS for Hospital@Home and OPAT

• Restrictive supplies of board spectrum antibiotics

• Focus on paediatric antibiotic guidance

• Tackle inappropriate post op prophylaxis

• Junior doctors & NMP more likely to prescribe Abx in children than consultants

Technology to support Sepsis 6 triggers:

Treating viral induced wheezeTreating viral induced wheezeTreating viral induced wheezeTreating viral induced wheeze

No robust evidence on when to initiate treatment

No robust evidence on initiating preventer therapy

Inhaled Salbutamol6

Prescribe

Good evidence base for reducing

hospitalisation, healthcare unitisation and

symptomatic relief.

Oral Steroids7

Avoid routine prescribingDoes not: reduce hospitalisations, GP attendance, improve

symptoms, reduced SABA use, improve self report scores or reduce

missed school days.

Reserve for severe exacerbations

Inhaled ICSPrescribe in caution

50% reduction in oral steroid requirement but no

effect on hospitalisation or duration of symptoms

with high dose budesonide 1600-3200mcg8

No benefit of lower dose ICS9

Review regularly to assess improvements

MontelukastPrescribe in caution

Recommended in BTS/SIGN Guidance2

Continuous therapy

Vs.

Pulse therapy

MontelukastMontelukastMontelukastMontelukast for Viral Induced Wheezefor Viral Induced Wheezefor Viral Induced Wheezefor Viral Induced WheezeEvidence in viral induced wheeze patients10: Montelukast Vs. Placebo

Treatment

with oral

steroids

Reduction in

wheeze

episodes

Reduced A&Eattendance

Reduced

hospital

admission

Reduce access

to healthcare

Decreased use

of reliever

Continuous

MontelukastX X X X X X

Intetmittent

MontelukastX X X X X X

Evidence in preschool wheeze11: Montelukast Vs. PlaceboContinuous Montelukast

No: change in frequency wheezy episodes, no ss difference in adverse events

Intermittent Montelukast

No: change in frequency wheezy episodes, no ss difference in adverse events

Is asthma a condition or a group of conditions

‘Phenotypes’ or reasons for asthma: patients may have more than one:

Mainly academic interest at the moment but could revolutionise paediatric

asthma care!

Inflammatory markers

of asthma:

9.Eosinophilic and

neutrophilic asthma

Asthma is Asthma RightAsthma is Asthma RightAsthma is Asthma RightAsthma is Asthma Right

Clinical presentation:

6. Pre-asthma wheezing in

infants

7. Exacerbation-prone

asthma

8. Asthma with limited

reversibility

Trigger induced:

1. Allergic

2. Non-allergic

3. Aspirin-NSAID induced

4. Infection

5. Exercise

Asthma shouldn’t killAsthma shouldn’t killAsthma shouldn’t killAsthma shouldn’t kill

0

5

10

15

20

25

30

0.00

0.05

0.10

0.15

0.20

0.25

Proportion (%)10 year mortality rate per

100,000 population

10 year mortality rate

Proportion aged 6-7 with wheeze

Proportion aged 6-7 with asthma

Proportion aged 13-14 with wheeze

Proportion aged 13-14 with asthma

Directly standardised asthma mortality rate in children aged 0-14 years and proportion aged 6-7 and 13-14 Source: WHO European Mortality

Database (2000-10) and the International Study of Asthma and Allergies in Childhood (2000-03)

7 children in a capital

died from asthma in

2017

How do children talk about their asthmaHow do children talk about their asthmaHow do children talk about their asthmaHow do children talk about their asthma

Young Children Under 5

years

Children 5 – 11 years old Teenagers

(>12 years)

How do children talk about their asthmaHow do children talk about their asthmaHow do children talk about their asthmaHow do children talk about their asthmaYoung Children Under 5 years Children 5 – 11 years old Teenagers

(>12 years)

Struggle to verbalise that that their

asthma is active. Will request medicine

or provide non-specific symptoms.

‘I need my puffer’

‘My tummy hurts | My chest hurts’

‘I’m tired’

Sit very quietly

Naughty cough

Request drink after exercise

Able to verbalise specific symptoms but

struggle with change over time.

‘I feel like an elephant I sitting on my chest’

‘My throat / neck gets itchy’

‘It feels like ants tickling me’

I can’t breathe’ or ‘I can’t get enough air in’

‘I feel wheezy’ or ‘I cough’

Sense of invincibility.

Unable to explain but may answer specific

closed questions.

‘It stops me doing things like sport and I

cannot play

‘It’s not my asthma, it’s just a cough’

‘I cough and then I start getting wheezy’

‘My chest is bad’

Speaking the same language: asthma symptoms Speaking the same language: asthma symptoms Speaking the same language: asthma symptoms Speaking the same language: asthma symptoms

RCGP 3 Questions:

• Difficulty sleeping

• Daytime symptoms

• Interfered with work or school

Peak flow monitoring:

• Evidence of impact is mixed

• Poor compliance to daily continued monitoring

• Consider for targeted monitoring or diagnosis

Thinking holistically: Emotional HealthThinking holistically: Emotional HealthThinking holistically: Emotional HealthThinking holistically: Emotional HealthAsthmatic children say:

• 98% stops them doing something

• 51% had problems visiting friends

• 40% felt it stopped them having fun

Missing out – UK Wide Report. Asthma UK 2009

• 87% miss school due to asthma

• 73% struggled to engage in PE session

• 49% struggled in lessons

• 48% avoided school trips

Always think is this Asthma symptoms or Anxiety symptoms

Utilise Peak flow

Asthma action plans

Support exploring anxiety

Therapeutic

trial with

moderate

dose of ICS

Consider

salbutamol

mono-

therapy if few

symptoms

All ages Low

dose ICS

<5 years refer to

tertiary care

>5 years

Add a LABA and

increase ICS to

medium dose

Consider MART

therapy

All ages

add LTRA

Mirrors

BTS/SIGN

Guidance

Mirrors

BTS/SIGN

Guidance

NIC

E G

uid

an

ce1

2B

TS

/ S

IGN

Gu

ida

nce

2

MART Therapy in ChildrenMART Therapy in ChildrenMART Therapy in ChildrenMART Therapy in Children• Combination of a quick onset LABA and ICS

• Symbicort 100/6 & 200/6 licenced >12 years as SMART13,14

• BTS/SIGN2 not recommended for children

• NICE12 recommends in over 5 years with caveat of licensing and prescribers risk

Comparing SMART therapy, ICS and ICS/LABA fixed dose combinations14

Outcome SMART therapy Symbicort fixed dose

100/6

Budesonide

320micrograms

Exacerbation % 14 38 26

Exacerbations requiring medical attention % 8 31 20

Night-time awaking % 2.4 4.6 4.4

Symptom free days % 63.4 68.0 56.2

Asthma control days % 57.0 60.6 50.8

Corticosteroid: the good, the bad, the uglyCorticosteroid: the good, the bad, the uglyCorticosteroid: the good, the bad, the uglyCorticosteroid: the good, the bad, the ugly

Corticosteroids remain the most cost effective intervention for improving asthma2

Patents and parents concerns: I will look like a ‘shot putter’ ‘I will get fat’ ‘what about basketball!’

‘Causing shortness’ what does the evidence say16:

• Cochrane review of 25 studies totalling 8471 children were included

• Included studies of Low or Medium dose ICS over 3months

• ICS reduce growth: mean reduction of 0.61cm in year one with a mean reduction of 0.48cm/yr

Take home messages:

• Use effective doses don’t be scared

• Pick a device which works for the patient

• Don’t switch all patients to the newest therapeutic choice

• More research is needed

Thinking holistically Thinking holistically Thinking holistically Thinking holistically Child don’t smoke do they!

1%

96%

3%Don't know

No

Yes 0.0%

5.0%

10.0%

15.0%

20.0%

13 14 15 16 17 18

2%

75%

23%Don't know

No

Yes

Percentage of children who smoke

Children in smoking homes

Thinking holistically Thinking holistically Thinking holistically Thinking holistically

Weight and exercise

• Obesity contributes to poor asthma control

• Promote exercise (asthmatics should be able to undertake similar exercise to their peers) and healthily lifestyle

Vaccinate to protect

• Check vaccines on every contact

• Promote annual flu vaccine

• Check pneumococcal vaccine

Personalised asthma action plan

• Ensure every patient has one

• Use one design across the STP: Asthma UK

ReferencesReferencesReferencesReferences1. Taussig LM, Wright AL, Holberg CJ, et al. Tucson Children’s Respiratory Study: 1980 to present. J Allergy Clin Immunol 2003;111:661-75

2. British Thoracic Society and Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma – A National Clinical Guideline. Edinburgh2016

3. Spurling GKP, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotic prescriptions for respiratory infections. Cochrane Database of Systematic Reviews 2017, Issue 9. Art. No.:

CD004417. DOI: 10.1002/14651858.CD004417.pub5

4. Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.:

CD000219. DOI: 10.1002/14651858.CD000219.pub4

5. Niamh M Redmond, Sophie Turnbull, Beth Stuart, Hannah V Thornton, Hannah Christensen, Peter S Blair, Brendan C Delaney, Matthew Thompson, Tim J Peters, Alastair D Hay and

Paul Little. Br J Gen Pract 2018; 68 (675): e682-e693. DOI: https://doi.org/10.3399/bjgp18X698873

6. Baraldi BP, Bisgaard H, Boner A ,et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. E Respir J. 2008;32(4)1096-

1110

7. Panickar J, Lakhanpaul M, Lambert PC et al. Oral Prednisolone for Preschool Children with Acute Virus-Induced Wheezing. NEJM, 2009 Volume 360:329-338

8. Kaditis AG, Winnie G, Syrogiannopoulos GA. Anti-inflammatory pharmacotherapy for wheezing in preschool children. Pediatr Pulmonol 2007;42:407–420.

9. McKean M, Ducharme F. Inhaled steroids for episodic viral wheeze of childhood. Cochrane Database Syst Rev 2000;Issue 1:CD001107

10. Brodlie M, Gupta A, Rodriguez-Martinez CE, Castro-Rodriguez JA, Ducharme FM, McKean MC. Leukotriene receptor antagonists as maintenance and intermittent therapy for

episodic viral wheeze in children. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD008202. DOI: 10.1002/14651858.CD008202.pub2.

11. Hussein, H.R., Gupta, A., Broughton, S. et al. Eur J Pediatr (2a017) 176: 963. https://doi.org/10.1007/s00431-017-2936-6

12. National Institute for Health and Care Excellence (2017) Asthma: diagnosis, monitoring and chronic asthma management (NICE Guideline N80). Available at:

https://www.nice.org.uk/guidance/ng80 [Accessed 01 Jan 2018].

13. Electronic medicines compendium (2017) Symbicort Turbohaler 100/6 dry powder SPC. Available at: https://www.medicines.org.uk/emc/product/1326 [Accessed 01 Jan 2018].

14. Electronic medicines compendium (2017) Symbicort Turbohaler 200/6 dry powder SPC. Available at: https://www.medicines.org.uk/emc/product/1326 [Accessed 01 Jan 2018].

15. Bisgaard H, Le Roux P, Bjamer D, Dymek A, Vermeulen JH, Hultquist C. 1 Budesonide/formoterol maintenance plus reliever therapy: a new strategy in paediatric asthma. Chest.

2006; 130(6):1733-1743

16. Zhang L, Prietsch SOM, Ducharme FM. Inhaled corticosteroids in children with persistent asthma: effects on growth. Cochrane Database of Systematic Reviews 2014, Issue 7. Art.

No.: CD009471. DOI: 10.1002/14651858.CD009471.pub2

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