Lessons Learned from the Severe Asthma Program

Transcription

1 Lessons Learned from the Severe Asthma Program March 20, 2015 Jonathan Gaffin, MD, MMSc Division of Respiratory Diseases Boston Children s Hospital Sachin Baxi, MD Division of Allergy & Immunology Boston Children s Hospital

2 Disclosures No financial disclosures or conflicts of interest related to this presentation Dr. Gaffin s Funding Sources: NIH/NIAID K23AI106945, Boston Children s Hospital Pipeline Indoor air pollution and asthma morbidity in inner city school children

3 Roadmap Asthma basics Definition of severe asthma Proposed investigative pathways Case studies from The Boston Children s Hospital Severe Asthma Program

4 Airway Pathology in Asthma Reversible airways obstruction due to: Smooth muscle contraction Inflammation and edema of airway walls Excess lumenal secretions

5 Asthma Diagnosis Episodic symptoms of airflow obstruction or airway hyper-responsiveness Detailed medical history Airway obstruction at least partially reversible Physical exam Spirometry Alternative diagnoses are excluded Additional studies as needed

6 Severe Asthma Definition Severe asthma is defined as asthma that requires treatment with high dose inhaled corticosteroids plus a second controller and/or systemic corticosteroids to prevent it from becoming uncontrolled or that remains uncontrolled despite this therapy ERS/ATS 2014

7 When to Refer to Subspecialty Evaluation for Severe Asthma Intermittent Asthma Persistent Asthma: Daily Medication Consult asthma specialist if step 4 care or higher is required. Consider consultation at step 3 Step 1 Preferred: SABA PRN Step 2 Preferred: Low dose ICS Alternative: Cromolyn, LTRA, Nedocromil or Theophylline Step 3 Preferred: Low-dose ICS + LABA OR Medium dose ICS Alternative: Low-dose ICS + either LTRA, Theophylline, or Zileuton Step 4 Preferred: Medium Dose ICS + LABA Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton Step 5 Preferred High Dose ICS + LABA AND Consider Omalizumab for patients who have allergies Step 6 Preferred High dose ICS + LABA + oral corticosteroid AND Consider Omalizumab for patients who have allergies Each Step: Patient Education and Environmental Control and management of comorbidities Steps 2 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma Quick-relief medication for ALL patients -SABA as needed for symptoms: up to 3 20 minute intervals prn. Short course of o systemic corticosteroids may be needed. Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control & the need to step up treatment. Step up if needed (first check adherence, environmental control & comorbid conditions) Assess control Step down if possible (and asthma is well controlled at least 3 months)

8 Our Approach to the Severe Asthma Patient

9 Boston Children s Hospital Severe Asthma Clinic Jonathan Gaffin, MD, MMSc Co-Director Pulmonary Sachin Baxi, MD Co-Director Allergy/Immunology Eitan Rubinstein, MD Gastroenterology Nora Davis, RN Nurse-Educator Community Asthma Initiative Roger Nuss, MD Otorhinolaryngology

10 Initial Evaluation History Examination Pulmonary Functions Lab Evaluation for allergies / atopy Adherence review Technique Pharmacy refill data Co-morbidities (selected) VCD, GE Reflux, EoE/food allergy, Chronic Sinusitis Home assessment Clinical Trials

11 12-30% of severe asthma referrals are misdiagnosed Is it asthma? Masqueraders (Children) ERS/ATS 2014

12 Are there comorbid factors? Allergic rhinosinusitis Chronic sinusitis Anxiety/depression Obesity Symptomatic GERD Food allergy/eoe Vocal cord dysfunction

13 Is it Merely Difficult-to-Treat? Medication adherence is insufficient Drug delivery technique is inappropriate Exposure to Tobacco smoke Exposure to known allergens Psychosocial factors complicating care Up to 40% of tertiary referrals Bracken, 2009

14 Difficult-to-Treat Adherence <1/2 picked up 80% prescriptions 1/3 picked up <50% prescriptions Bracken, 2009 Supervision is poor 20% of 7 year olds, 50% of 11 year olds Orell-Valente, 2008 Technique is frequently poor Non-sustainable, continued review is necessary

15 Invasive Assessments Goal to determine asthma phenotype and non-asthma pathology Induced Sputum/Bronchoscopy-BAL+/- Biopsy Determine inflammatory phenotype Inform targeted treatment plan CT scan Not recommended unless atypical features Sinus CT considered for chronic sinusitis

16 Therapy Induced Co-morbidities Growth failure/retardation Obesity Osteoporosis/AVN Cataract/glaucoma Psychiatric illness/behavioral problems GER Hypertension Myopathy Pneumonia Fungal infection

17 Treatment Severe therapy resistant asthma Anti-inflammatory Antineutrophilic Antifungal agents (SAFS) Bronchodilator

18 Case Studies