asthma long term treatment

7/26/2019 Asthma Long Term Treatment

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ASTHMAASTHMAMANAGEMENTMANAGEMENT

LONG-TERM THERAPY


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Inhalation therapy isInhalation therapy is

the mainstay therapythe mainstay therapy


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Gaps between treatment goal and the

reality

no chronic symptoms

no asthma attacks

no emergency visits

no need for quick relief (asneeded) 2-agonist

normal physical activity

including exercise

lung function as close tonormal as possible

no adverse effects from

medicine

Frequent chronic symptoms

Some asthma attacks

Some emergency visits

Excessive use of 2-agonist

as reliever

Impaired physical activity

including exercise

Some ups and do!ns in

lung function

Frequent adverse effects from

medicine

"#E $%&'"#E $%&' "#E (E&'I")"#E (E&'I")


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Pathogenesis of asthmaPathogenesis of asthma


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Pathogenesis ofPathogenesis of

asthmaasthma

(NHLBI/WHO 199!(NHLBI/WHO 199!

InflammationInflammation

"n#ironmental ris$ %a&tor"n#ironmental ris$ %a&tor

'irway'irwayhyperresponsi#enesshyperresponsi#eness

riggersriggers

'ir%low limitation'ir%low limitation

)ymptoms)ymptoms


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Asthma is an inflammatoryAsthma is an inflammatory

diseasedisease


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*ormal &sthma

Inflammation()(!)

+ronchial hyperreactivity+ronchial hyperreactivity ,-

Symptoms ,.Symptoms ,-

"r

iggers


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Ig "Ig "

AgAg

**

#ethyl#ethyl

transferasetransferase$hospholipid$hospholipid $hosphatidyl$hosphatidyl

ethanolamineethanolamine

$hosphatidyl$hosphatidyl

cholinecholine

$hospho$hospholipase Alipase A22

%a%a &istamin&istamin

%a%a &istamin&istamin

"%' %'"%' %'Arachidonic acidArachidonic acid

lypoxygenaselypoxygenase cyclooxygenasecyclooxygenase

*-&"+"*-&"+",eucotrienes,eucotrienes

,+,+..,+%,+%..,+/,+/..,+",+"..

+hromboxanes+hromboxanes

+0A+0A22

$rostaglandins$rostaglandins

$1/$1/$1'$1'22

#ediator release inasthma reactions


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+iagnosis

+ata

'nalisis

,lanning


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+iagnosis+ata-

'nalisis

,lanning

'sma

Bat.$

)esa$engi

0el.arga asma

Obat asma

,em2isi$

)pirometri

',"

es ,ro#o$asi


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'% 3 4$

the total volume forcibly exhaled

'"5 3 "$5

the amount exhaled in the first second


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3

4

5

6

1

7

'"5 '%

1 6 5 4 3

ime (se&!

8

ol.me(liters!

Fig 2. Normal forced expiration curve


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,ea$ 2low eter /,"2/',"


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ASTHMA PROFILEASTHMA PROFILE


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ASTHMA PROFILE IN THE WORLDASTHMA PROFILE IN THE WORLD

$lo/ally0 over$lo/ally0 over 13 million13 millionpeople diagnosed !ith asthmapeople diagnosed !ith asthma

$lo/ally0 the economic /urden of asthma are estimated$lo/ally0 the economic /urden of asthma are estimated

to /e greaterto /e greaterthan "+ and #I45&I6S or com/inedthan "+ and #I45&I6S or com/ined

$lo/ally0 over$lo/ally0 over 1730333 people1730333 peoplediedie from asthma each yearfrom asthma each year

8a9or factors contri/uting to asthma mor/idity and mortalityare underdiagnosisand inappropriate treatment


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PATIENTSPATIENTS

PROFILEPROFILE, )ayasan &sma Indonesia :ilayah Sumatera;tara 0 2330


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PATIENTS PROFILEPATIENTS PROFILE( 6ayasan Asma Indonesia 7ilayah 8umatera 9tara :;;


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7orld Asthma #arket7orld Asthma #arket

(I#8 2;;;)(I#8 2;;;)

@>

B>

>

1@>

1>

=3>

=>

/2-agonist

Aanthines

*S &ntiinflammatory

Inhaled Steroid&nticholinergics

&ntileukotriene

%ther


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Anti Inflammations isAnti Inflammations is

the mainstay therapythe mainstay therapy


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atural &istory of Asthmaatural &istory of Asthma


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&NORRET TREATMENT&NORRET TREATMENT%9>"%9>"

%&>?I% A8+A%&>?I% A8+A

AI>7A6AI>7A6

>"#?/",,I1>"#?/",,I1

CE(SIS"E*DE %F I*F'&88&"I%*CE(SIS"E*DE %F I*F'&88&"I%*

&I(:&) (E8%6E''I*$&I(:&) (E8%6E''I*$ D#(%*ID &S"#8&D#(%*ID &S"#8&


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AIRWAY REMODELLING IN ASTHMAAIRWAY REMODELLING IN ASTHMA

+es=.amation o% epitheli.m+es=.amation o% epitheli.m

In&rease in airway smooth m.s&leIn&rease in airway smooth m.s&le

8as&.lar proli%eration8as&.lar proli%eration

>ollagen deposition>ollagen depositionhi&$ening o% basement membranehi&$ening o% basement membrane

In&rease in bron&hial glandsIn&rease in bron&hial glands

8as&.lar &ongestion8as&.lar &ongestion

Oedema %ormationOedema %ormation

>ell.lar in%iltration>ell.lar in%iltration


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"pithelial /amage"pithelial /amage

P 'e(e")* in+ Asthma* A,a#emi, P"ess ../



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#$ "%$#$ "%$

Eosinophil

Epithelium

$harma

cokinetic

@


+es=.amation o% epitheli.m+es=.amation o% epitheli.m

hi&$ening o% basement membranehi&$ening o% basement membrane

In&rease in airway smooth m.s&leIn&rease in airway smooth m.s&le


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asement #embrane+hickening


) h l H l i


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)mooth .s&le Hyperplasia



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Fata$ Asthma

Jeery,1994


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"ra of Asthma management"ra of Asthma management

5


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"volving treatment options"volving treatment options

1


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DontrollerDontroller

&nti inflammation&nti inflammation

23#esoni#e4P3$mi,o"tCC5

4In6ami#CC5

2e,$omethasone#i!"o!ionate47e,oti#eCC5

t"iam,ino$onea,etoni#e

so#i3m ,h"omog$i,ate

4Inta$CC5

8etotifen so#i3m ne#o,"omi$

SteroidSteroid*on steroid*on steroid

ild 'sthma has 'irway


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ild 'sthma has 'irway

In%lammation

I>) e#erses In%lammation

Laitinen* ' A$$e"g) $in Imm3no$* ..9

E

BM

Pre and post month treatment !ith B"# $%% &'(d

E

BM


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+ronchodilator+ronchodilator

22 -- agonistagonist

&AanthinAanthin

&&nticholinergic&nticholinergic

Re$ie%e"Re$ie%e"

+(%*D#%6I'&"%(+(%*D#%6I'&"%(


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+(%*D#%6I'&"%(+(%*D#%6I'&"%(

Short &ctingShort &cting 22&$%*IS" ,S&+&&$%*IS" ,S&+&

sal/utamol5al/uterol ,4entolin sal/utamol5al/uterol ,4entolin CC ter/utaline ,+ricasma ter/utaline ,+ricasmaCC procaterol procaterol

fenoterol fenoterol

orciprenaline0 etc orciprenaline0 etc

&*"ID#%'I*E($ID&*"ID#%'I*E($ID

atropine sulfate atropine sulfate

ipratropium /romide0 etc ipratropium /romide0 etc

%"#E( S)8C#&"%8I8E"ID%"#E( S)8C#&"%8I8E"ID

ephedrine ephedrine

adrenaline0 etc adrenaline0 etc

A&*"#I*EA&*"#I*E

theophylline theophylline

'ong &cting'ong &cting 22&$%*IS"&$%*IS"

,'&+&,'&+&

&salmoterolsalmoterol

&formoterolformoterol


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Increased Mem(rane Basic Protein )MBP* positive area ) the redIncreased Mem(rane Basic Protein )MBP* positive area ) the red

and epithelial sheddin' in the s+(ect in clinical remission-and epithelial sheddin' in the s+(ect in clinical remission-

Hea$th) S32


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G.idelines on 'sthma-

,ast and >.rrent rends

LA7A=ISIS

LA7A=IS

GINA ../4a#a!te#5

3""ente%i#en,es

Se%e"e!e"sisten

t

Mo#e"ate!e"sisten

t

Mi$#!e"sisten

t

Inte"mittent

Sho"t-a,ting :-agonists9!"n


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+he rationale behind fixed

combination therapy'o increase a!herence to controller

therapy'o gain better control ith less inhale!

steroi!


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>?@ sai# the)


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%ombination therapy%ombination therapy

8ymbicort8ymbicortCC

udesonide 'ormoteroludesonide 'ormoterol

8eretide8eretideCC

'luticasone 8almoterol'luticasone 8almoterol


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+he eginning of+he eginning of+reatment+reatment


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"xacerbation"xacerbation

+he beginning of treatment+he beginning of treatment @

8table condition8table condition


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Ceak flo! meterCeak flo! meter

@33-B33

;

:;;

, normal ObjectiveObjectivevaluevalue


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"#E $%&'S F%( S;DDESSF;'"#E $%&'S F%( S;DDESSF;'8&*&$E8E*" %F &S"#8&8&*&$E8E*" %F &S"#8&

( NHLBI / WHO, !!"#( NHLBI / WHO, !!"#

&Crevent asthma exacer/ationsCrevent asthma exacer/ations

&&chieve and maintain control of symptoms&chieve and maintain control of symptoms

&Crevent asthma mortalityCrevent asthma mortality

&Crevent development of irreversi/le airflo! limitationCrevent development of irreversi/le airflo! limitation

&&void adverse effect for asthma medications&void adverse effect for asthma medications

&8aintain normal activity levels0 including exercise8aintain normal activity levels0 including exercise

&8aintain pulmonary function as close to normal8aintain pulmonary function as close to normal

levels as posi/lelevels as posi/le


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A+I I',A##A+I? FI$%& LIN''$L)

#AA1"#"+#AA1"#"+

+>I11"> 'A%+?>8+>I11"> 'A%+?>8 AVOID

>"&AI,I+A+I?>"&AI,I+A+I?*O*O

+"%&ID9" +$O+'$L)

+I#"+I#"+$O+'$L)+$O+'$L)

#"/I%I" #"/I%I" %'L'&I-'%'L'&I-'

>?%&?/I,A+?> OB'&I-' -L'


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+&A4 6?9

Ai R # $$i iAi R # $$i i


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Ai"a) Remo#e$$ing inAi"a) Remo#e$$ing in

AsthmaAsthma%

2

%

12

1%

2

%

0orrelation (et!een s+(epithelial layer thic3ness and asthma severity scorein 4 asthmatic patients-

.sthma severity score

% 1$4 1%

rs = 0.581p 0.001S

+(epithe

liallayerthic3ness

)&m*

0hetta 05ES6 19978 111$:$7

GINA 9BB9


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S)stemi, G$3,o,o"ti,oste"oi# 4Pa"ente"a$5

Systemic 'l+cocorticosteroid speed resol+tion o; e SE0ERE PERSISTENT


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TREATMENTTREATMENT

A%oi# o" ,ont"o$ t"igge"sA%oi# o" ,ont"o$ t"igge"s

STEP + INTERMITTENTSTEP + INTERMITTENT


STEP 9+ MILD PERSISTENTSTEP 9+ MILD PERSISTENT


STEP C+ MODERATE PERSISTENTSTEP C+ MODERATE PERSISTENTA%oi# o" ,ont"o$ t"igge"sA%oi# o" ,ont"o$ t"igge"s

STEP >+ SE0ERE PERSISTENTSTEP >+ SE0ERE PERSISTENT

ONTROLLER+#ai$) me#i,ations Inha$e# ste"oi# O" !ossi2$) ,"omone* o"a$

theo!h)$$ine o" anti-$e38ot"iene

RELIE0ERInha$e# :9-

agonist!"n

ONTROLLER+#ai$) me#i,ationsInha$e# ste"oi# an#$ong-a,ting2"on,ho#i$ato"

onsi#e" anti-

$e38ot"iene

RELIE0ERInha$e# :9-

agonist!"n

RELIE0ERInha$e# :9-

agonist!"n

RELIE0ERInha$e# :9-

agonist!"n

ONTROLLER+#ai$) m3$ti!$eme#i,ations

Inha$e# ste"oi#Long-a,ting

2"on,ho#i$ato"O"a$ ste"oi#

ONTROLLER+none

Ste!#onhen

,ont"o$$e#

Ste!#onhen

,ont"o$$e#

Ste! 3!if not ,ont"o$$e#4afte" ,he,8 on

inha$e" te,hni3ean# ,om!$ian,e5

Ste! 3!if not ,ont"o$$e#4afte" ,he,8 on

inha$e" te,hni3ean# ,om!$ian,e5

Patient e#3,ationessentia$ at e%e")

ste!

Re#3,e the"a!)if ,ont"o$$e# fo" at

$east C months

ontin3emonito"ing

asthma long term treatment

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