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Dr Michael Ho

Consultant Respiratory & Sleep PhysicianDandenong Respiratory Group

Director of South Eastern Private Sleep Centre

• Disclosures – Honorariums from Boehringer Ingelheim and GSK

•AGENDA

• Generalised asthma management: Stepwise approach Part 1

• Inhaler workshop Part 2

Summary

Overall asthma control

Symptoms

Activity

Reliever use

Lung function

Current control

Achieve

Defined by

Instability/

worsening

Loss of lung

function

Exacerbations

Adverse effects

of medication

Future risk

Reduce

Defined by

The goal of asthma management –To achieve overall asthma control

Adapted from Bateman ED et al. J Allergy Clin Immunol 2010; 125: 600–608.

Asthma control requires treating underlying pathophysiology

Schematic representation of underlying inflammation and AHR resulting in symptoms and exacerbations of asthma, with the latter representing the ‘tip of the

iceberg’.

Adapted from Currie et al 2004

Symptoms and exacerbations represent only the ‘tip of the iceberg’

COPD

Neutrophilic inflammation

largely

unresponsive

to corticosteroids

Asthma

Eosinophilic inflammation

responsive

to corticosteroids

Why is it important to differentiate COPD and asthma?

Inflammation is different in COPD and asthma so requires a different treatment approach:1,2

References: 1. Barnes PJ. Am J Respir Crit Care Med 2000;161:342–4. 2. Price D et al. Prim Care Respir J 2013;22:92–100.

Asthma vs COPD

Different approaches

ICS is the corner –stone treatment in asthma

for airway inflammation, remodelling and

hyperresponsiveness

LAMA + LABA is the corner-stone treatment

in COPD

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DIFFERENCE IN MANAGEMENT PARADIGM BETWEEN ASTHMA VS COPD

1. Lung Foundation. Stepwise Management of Stable COPD. Available from lungfoundation.com.au. Accessed June 2017. 2. National Asthma Council Australia. Australian Asthma Handbook,

Version 1.2. National Asthma Council Australia, Melbourne, 2016. Website. Available from: http://www.asthmahandbook.org.au. Accessed June 20, 2017. 3. Gosens R et al. Respir Res 2006; 7:

73. 4. SPIRIVA Respimat Approved Product Information, 13 September 2016.

COPD2

• Inflammation:

mainly neutrophils and macrophages1

• Pathway: LAMA or LABA → LABA/LAMA

→ For some: ICS/LABA (+ LAMA)

• Role of SPIRIVA Respimat in COPD:

➢ Initial maintenance therapy for COPD

patients across all severity stages

ASTHMA3

• Inflammation:

mainly eosinophils, mast cells and TH2 cells1

• Pathway: ICS → ICS/LABA

→ For some: ICS/LABA + SPIRIVA Respimat

• Role of SPIRIVA Respimat in asthma4

➢ Add-on treatment for asthma patients who

remain symptomatic on ICS/LABA

Different type of airway inflammation1

Exacerbation prevention

When FEV1

3

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INHALER CHOICE

Choosing appropriate treatment/ device was a challenge for 60% of GPs surveyed1

Reference: 1. Australian Doctor Group. How do you distinguish between COPD and asthma? Survey. August 2018.

Evolution of inhaler devices1

Ellipta® is a registered trademark of GlaxoSmithKline group of companies; Breezhaler® is a registered trademark of Novartis Pharmaceuticals AG; Genuair® is a registered trademark of Almirall, S.A.

Reference: 1. Stein SW, Thiel CG. J Aerosol Med Pulm Drug Deliv 2017; 30: 20–41.

Pressurised metered-

dose inhalers (pMDIs)

Dry powder

inhalers (DPIs) Soft mist inhalers

e.g.

Accuhaler,TH,Handihaler;Breezhaler;Genuair,Elliptae.g. Respimat®

Up to 9/10 patients do not use their inhaler correctly1

• 1. National Asthma Council Australia. Inhaler Technique for people with asthma or COPD. 2016.

~ 1/10 patients use it correctly

• Patients may say they are

using their inhaler correctly

when they are actually not.1

• Even after learning how to use

it correctly, they can lose their

skills within 2-3 months.1

ARE THERE DIFFERENCES BETWEEN INHALER CLASSES?

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• References: 1. Laube B et al. Eur Respir J 2011; 37: 1308–1331. 2. Newman S. Eur Respir Rev 2005; 14: 96, 102–108. 3. Newman S and Busse W. Resp Med 2002; 96: 293–304. 4. Dalby R et al. Int J Pharm 2004; 283: 1–9. 5. Hochrainer D et al. J Aerosol Med 2005; 18: 273–282. 6. Hodder R et al. Int J Chron Obstruct Pulmon Dis 2009; 4: 225–232.

Soft MistTM InhalerpMDIs

• Active device1

• Aerosol cloud of high

velocity and short duration2

• Requires significant

coordination2

DPIs

• Breath-actuated (passive) devices2

• Delivered dose and

particle size dependent on inspiratory flow2,3

• Requires a forceful

inhalation2,3

• Minimum coordination

required2

• Active device4

• Slow-moving aerosol cloud vs pMDIs5

• Requires a slow

inhalation2

• Improved coordination vs

pMDIs4-6

•No propellants

Patient factors which may affect inhaler technique and adherence:3

• Age

• Dexterity

• Inspiratory capacity (ease of inhalation)

• Cognitive ability

• Health literacy

• Ease of use

• Patient preferences

• Patient perceptions

Factors to guide inhaler choice

Up to 90% of patients don’t use their device correctly1

References: 1. National Asthma Council Australia. Inhaler technique for people with asthma or COPD. Information paper for health professionals 2018. Available from www.nationalasthma.org.au. Accessed July 2018. 2. Price D et al. World Allergy Org J 2015;8:26. 3. Hodder R, Price R. Int J COPD 2009;4:381-90.

It’s important that prescribers match inhaler

devices to individual patient needs1-3

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WHAT ARE THE ATTRIBUTES

OF AN IDEAL INHALER?

Accurate and

consistent

dose delivery

Robust

Multiple

doses

SELECTED

ATTRIBUTES OF

AN IDEAL

INHALER1,2

Efficient

delivery of

medication

to the lungs

Liked by

patients

Easy to use

REFERENCES: 1. Rau JL. Respir Care 2005; 50: 367–382. 2. Moroni-Zentgraf P. RDD Europe 2013; 1: 141–152.

THE EFFICACY OF

INHALED THERAPIES

IS DEPENDENT ON

EFFICIENT

DRUG DELIVERY TO THE LUNGS1,2

REFERENCES: 1. Newman SP. Eur Respir Rev 2005; 14: 102–108. 2. Vincken W et al. Prim Care Respir J 2010; 19:1 0–20.

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Key factors affecting lung deposition include:3-5

• References: 1. Newman SP. Eur Respir Rev 2005; 14: 102–108. 2. Vincken W et al. Prim Care Respir J 2010; 19:1 0–20. 3. Hochrainer D, et al. J Aerosol Med 2005;18:273–82. 4. Scichilone N et al. Pulm Pharmacol Ther 2015; 31: 63–67. 5. Ganderton D. J Aerosol Med 1999; 12(suppl 1): S3–S8. 6. Dalby RN et al. Med Devices (Auckl) 2011; 4: 145–155.

The EFFICACY of INHALED therapies is DEPENDENT on the EFFICIENT drug DELIVERY to the LUNGS 1,2

A low aerosol

velocity– to reduce

oropharyngeal

deposition5,6

Long aerosol

cloud duration – may facilitate

coordination of actuation

with inhalation5,6

A high fine

particle fraction – particles ≤5.8 µm in

diameter are ideal to

travel into the lungs6

Patient

factors– can the patient

use the device

correctly?1

DRUG DELIVERY TO THE LUNGS

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Lung deposition scintigraphy study in asthma patients comparing Respimat®, Turbuhaler® and CFC-pMDI1,2

• Adapted from Pitcairn et al. 2005 and Anderson 2006.1,2 *vs Respimat®.†Lung deposition (% of metered dose ex-valve, mean) measured by gamma scintigraphy. Test drug budesonide (Respimat® and Turbuhaler®) or beclomethasone (pMDI). Asthma patients (n=14). CFC, chlorofluorocarbon; pMDI, pressurised metered-dose inhaler; DPI, dry powder inhaler.

• References: 1. Anderson P. Int J COPD 2006; 1: 251–259. 2. Pitcairn G et al. J Aerosol Med 2005; 18: 264–272.

RESPIMAT®

Soft Mist Inhaler

51.6%Lung deposition†

CFC-pMDI

8.9%lung deposition† (p

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SELECTING A SUITABLE INHALER DEVICE FOR

YOUR PATIENTS

GOOD COORDINATION OF ACTUATION WITH INSPIRATION

POOR COORDINATION OF ACTUATION WITH INSPIRATION

Inspiratory flow >30 L/min Inspiratory flow 30 L/min Inspiratory flow

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Autohaler Metered Dose Inhaler

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For DPIs, a rapid and forceful inhalation is needed1,2

Some patients may not be able to inhale forcefully through DPIs1-4

References: 1. National Asthma Council Australia. Inhaler technique for people with asthma or COPD. Information paper for health professionals 2018. Available from www.nationalasthma.org.au. Accessed June 2018. 2. Laube et al. Eur Respir J 2011;37:1308-31. 3. Price D et al. J Allerg Clin Immunol 2017;5:1071-1081. 4. Usmani OS et al. Respir Res 2018; 19: 10. 5. Haidl P et al. Respir Med 2016; 118: 65–75. 6. Dalby RN et al. Med Devices (Auck) 2011:4:145–55. 7. Wachtel H et al. Pulm Ther 2017;3:19-30.

Sub-optimal flow through a DPI can result in drug not dispersing throughout the lungs5-7

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Accuhaler dry powder inhaler

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BREO® Ellipta® dry powder inhaler1

Two 30 dose foil blister strips for combination products

1. Breo Ellipta Approved Product Information.

BREO ELLIPTA dry powder inhaler

1. Click to open

2. Breathe 3. Close

Sequence of Numbers and Flags in Viewing Window (30 dose):

3 main steps:

1. Breo Ellipta Approved Product Information (Version 3.0).

For full device instructions, refer to Breo Ellipta Product Information

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Spiromax dry powder inhaler (Duoresp)- Three steps Activate + Breathe + Close

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Handihaler dry powder inhaler

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Breezhaler dry powder inhaler

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Genuair dry powder inhaler

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Foradile Aerolizer dry powder inhaler

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RESPIMAT® SOFT MIST™ INHALER –

A NEW GENERATION INHALER

How Respimat® Soft Mist™ Inhaler works

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RESPIMAT® SOFT MIST™ INHALER –

THREE STEPS FOR DAILY USE (T.O.P.)1

REFERENCE: 1. Placebo Respimat® inhaler package leaflet; instructions for demonstration. Boehringer Ingelheim International. September 2010.

Thunderstorm ASTHMA

Melbourne is the global capital

WHAT ? - Rare potentially catastrophic allergic event whereby aeroallergens (rye and fungal spores) with thunderstorm activity cause acute bronchospasm in susceptible people

WHY ? - Wet spring allowed lush rye grass growth around northern Melbourne. Thunderstorm lift pollens into charged storm clouds, where the grains absorb moisture and rupture to disperse over 700 particles per grain; strong winds to funnel the pollens into Melbourne dome → PERFECT STORM

WHEN ? - November 1984/ 1987/ 1989/ 2003/ 2010/ 2011/ 2016 in Melbourne. Also documented in UK, USA, Canada, Iran. On 21-11-2016 : 2000 calls in 5hrs (201 bet 7pm-7.15pm or 1 call every 4.5 seconds), 8500 ED visits and sadly TEN deaths.

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Thunderstorm ASTHMA

Plan and Prepare

WHO ? - Mean age 36. Mostly male, 90% hayfever + pollen allergy, >50% undiagnosed asthma, >50% overseas-born. Among asthmatics: 1/3 on ICS, >50% without action plan Tended to be allergic to rye grass (serum RAST or skin prick test)

HOW ? - Critical period between October and December*New State Health Emergency Response that sets out responsibilities of various health & emergency services. *Real- Time Emergency Dept Info Trending System (REDIT) for early recognition of emergency surges in ED, communicating & directing ambulance and health services. *Local hospitals have disaster planning with adequate medical supplies, as well as ensure staff is aware how to manage their asthma. *Medical clinics need to have a disaster plan with local pharmacies to have reasonable stock of bronchodilators, steroids and adrenaline. *Potential patients reminded to be compliant on Preventive Inhalers or Anti-Histamines; ALWAYS carry Reliever Inhalers; stay indoors on very high to extreme pollen count days; aware of daily forecast pollen counts available (www.melbournepollen.com.au/index); remember rule of 4 in emergency (1 puff in spacer + 4 breaths, every 4 mins till help arrives); review asthma action plan.

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SUMMARY

Summary

• Uncontrolled asthma remains a problem in the community

• Asthma control can be achieved with stepwise approach,

with ICS as corner-stone of treatment (whilst LAMA + LABA is the

corner-stone of treatment for COPD)

• Personalise the choice of inhaler and provide education about the

correct way of use : WATCH + SHOW + REPEAT

• Well controlled asthma can be achieved if appropriately managed

1. Bleecker ER et al. J Allergy Clin Immunol Prac 2014: 5:553–561. 2. Breo Ellipta Product Information

Key considerations in asthma control• Each patient is different

• Each patient’s asthma is different

• Choice of appropriate Drug and Dose is dependent on Doctor

• Choice of Inhaler device is largely dependent on Patient

http://www.melbournepollen.com.au/index

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ASSESSING INHALER TECHNIQUE1

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Up to 90% of asthma and COPD patients incorrectly use their inhaler device2,3

– check adherence and inhaler technique ideally at each visit4

• References: 1. National Asthma Council. Australian Asthma Handbook, 2016. 2. Lavorini F et al. Respir Med 2008; 102: 593–604. 3. Melani AS et al. Respir Med 2011; 105: 930–938. 4. Abramson M et al. COPD-X concise guide for primary care. Brisbane: Lung Foundation Australia, 2016.

1Patient demonstrates inhaler technique

2Demonstrate correct technique –highlighting steps that need correction

3Patient re-demonstrates inhaler technique – repeat until all steps performed correctly

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Diagnosis is not the end, but the beginning

of medical practice

~ Dr Martin H. Fischer (1879–1962)

THANK YOU

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