Severe asthma Definition, epidemiology and risk factors. Mina Gaga Athens Chest Hospital

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1 Severe asthma Definition, epidemiology and risk factors Mina Gaga Athens Chest Hospital

2 Difficult asthma Defined as asthma, poorly controlled in terms of chronic symptoms, with episodic exacerbations, persistent and variable airway obstruction and continued requirement for short-acting beta-2-agonists and a reasonable dose of inhaled corticosteroids ERS definition-eur Respir J 1999; 13:

3 Refractory asthma Major criteria Treatment with oral corticosteroids > 50% of the time High doses inhaled corticosteroids (>1200 µg beclomethasone equivalent) Minor criteria requirement for daily treatment with long-acting beta-agonists, theophylline or leukotriene antagonists daily asthma symptoms requiring rescue medication persistent airway obstruction (FEV1 < 80% predicted); diurnal PEF variability > 20% 1 or more urgent care visits for asthma per year 3 or more oral steroid bursts per year prompt deterioration with < 25% reduction in oral or inhaled corticosteroid dose near fatal asthma event in the past ATS Definition- Am J Respir Crit Care Med 2000; 162:

4 Severe asthma The term, severe asthma applies to patients who have refractory asthma who remain difficult to control despite an extensive re-evaluation of diagnosis, management, and following an observational period of at least 6 months by an asthma specialist. Chanez et al, JACI 2007 Workshop Severe Asthma Paris 2006

5 Severe asthma The term, severe refractory asthma should apply to patients who remain difficult to control despite an extensive re-evaluation of diagnosis, avoidance or treatment of exacerbating factors and following a period of at least 6 months of close follow up and tailored and rigorous management by an asthma specialist. Gaga et al, Eur Respir Rev in press

6 Severe and difficult to treat asthma 2-12% of asthmatic patients 50% of asthma costs Severe impact on health and QoL Godard et al, ERJ 2002

7 Estimated total cost of treatment per person ( ) Poor asthma control contributes to substantial healthcare and societal costs Average total cost of treatment by BTS treatment step and occurrence of asthma attack in the previous 12 months 1,200 1,000 Had experienced an asthma attack Had not experienced an asthma attack 1, n = , , , ,853 9, BTS treatment step 4 5 Overall % of asthma costs relate to poor asthma control 2 BTS = British Thoracic Society 1. Asthma UK Asthma Audit, 1999; 2. Barnes PJ, et al. Eur Respir J 1996;9:

8 Costs for uncontrolled patients were more than double those of controlled patients 14,212 vs 6,452 US Dollars; P < Few severe or difficult-to-treat asthma patients achieved control over a 2-year period and the economic consequence of uncontrolled disease is substantial. Sullivan et al, Allergy2007

9 Prevlanece (%) Risk Profile of Patients with Frequent Asthma Exacerbations 100 p=0.10 p<0.05 p<0.05 p<0.05 p< sleep apnoea psychopathology sinus disease gastric reflux recurrent infections ten Brinke et al, ERJ 2005

10 Epidemiology-Genetics Genes and genetic-environmental interactions are associated with severity ADAM33 TGF-ß1 IL-4 IL-4Rα BHR, decline in lung function lower FEV1 lower FEV1, severe exacerbations lower FEV1, severe exacerbations Jongepier et al, Clin Exp Allergy 2004 Pulleyn et al, Hum Genet 2001 Sandford et al, JACI 2000 Lee et al Am J Respir Crit Care Med 2006

11 Genes and genetic-environmental interactions are associated with disease severity and poor response to treatment Studies focusing on severe asthma are needed

12 Epidemiology- Infections Respiratory viruses (and some bacteria) contribute to severe exacerbations of asthma Viruses can persist in the airways for long periods after the exacerbation their role in the development of severe persistent asthma remains poorly understood. Everard, Curr Opin Allergy Clin Immunol 2006

13 Epidemiology Severe asthma is associated with an increased risk of hospitalization and death. Severe asthma in children, but not adults, is associated with elevated IgE (Europe vs USA). Female gender, obesity and smoking are associated with more severe asthma and a poor response to therapy.

14 Prediction TENOR study, risk score Age 3 Gender 1 Race 2 BMI 1 Lung Function 2 Previous history of pneumonia 1 Diabetes 1 Cataracts 1 Previous intubation 1 Steroid bursts 3 Nebuliser ipratropium bromide 1 Systemic corticosteroids 1 Total score 0-18 High risk score>8 Miller et al, ERJ 2006

15 % of patients Trigger factors for asthma attacks Men control severe OR 2.5 ( ) OR 6.8 ( ) OR 0.3 ( ) OR 4.3 ( ) 20 0 Aspirin Stress Exercise Allergens OR=Odds ratios for severe asthma Each OR is adjusted by all the other trigger factors and age ENFUMOSA, ERJ 2003

16 % of patients Trigger factors for asthma attacks Women 100 control severe OR 2.4 ( ) 80 OR 2.1 ( ) OR 3.1 ( ) OR 5.1 ( ) OR 3.9 ( ) 20 0 Premenstrual exacerbation Aspirin Sinusitis Forgetting medication Exercise OR=Odds ratios for severe asthma Each OR is adjusted by all the other trigger factors and age ENFUMOSA, ERJ 2003

17 Risk factors In children and adolescents, increased body weight was found to be associated with asthma severity in girls Sullivan et al, Allergy 2007

18 ATAQ a validated questionnaire may help clinicians identify patients requiring intervention to prevent future severe asthma-related events Chipps et al, JACI, 2007

19 Studies focused in severe asthma are urgently needed Καλό τριημέρο!

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