WAO Dubai To reduce exacerbations and emergency visits! Professor Tari Haahtela Skin and Allergy Hospital Helsinki University Hospital

Transcription

1 2009 WAO Dubai To reduce exacerbations and emergency visits! Professor Tari Haahtela Skin and Allergy Hospital Helsinki University Hospital

2 Cumulative asthma risk in Ontario, (%) Asthma Diabetes All Cancer Canada Age (Years) To T. AJRCCM 2010; 181:

3 GINA = Global Initiative for Asthma) Asthma Control Challenge Cut hospitalizations 50% by 2015! GINA challenges governments, health departments, and health care workers worldwide to cut asthma-related hospitalizations in half over the next 5 years. How? By improving asthma control!

4 Stepwise Approach To Asthma Therapy in Adults 3 Outcome: Asthma Control Outcome: Best Possible Results 2 Controller: None Controller: Daily inhaled corticosteroid Controller: Daily inhaled corticosteroid Daily long- acting inhaled β 2 -agonist Controller: Daily inhaled corticosteroid Daily long acting inhaled β 2 -agonist plus (if needed) -Theophylline-SR -Leukotriene Modifier -Long-acting oral β 2 - agonist -Oral corticosteroid When asthma is controlled, reduce therapy Monitor 1 Reliever: STEP 1: Intermittent Rapid-acting acting inhaled β 2 -agonist prn STEP 2: STEP 3: STEP 4: Mild Persistent Moderate Severe Persistent Persistent STEP Down Alternative controller and reliever medications may be considered. d. GINA 2004

5 GINA Asthma Guidelines November 2006 Control Level Controlled Reduce Treatment Action Maintain and find lowest controlling step Partly controlled Uncontrolled Exacerbation Increase Consider stepping up to gain control Step up until controlled Treat as exacerbation

6 Healthy

7 Finnish Asthma Programme New patients, disability pensions and rehabilitation Number of asthmatics still slightly growing 120 Value of the index Share of asthmatics Absolute decrease in disability 76% 40 Disability pensions 20 0 Patients attending rehabilitation courses : -40% Haahtela T, et al. Thorax 2006, Haahtela T, et al. Allergy 2008, von Hertzen L, et al. Allergy 2009

8 Zero tolerance to asthma deaths! Asthma mortality has almost disappeared in Finland (population 5,3 million) 6 deaths < 65 years, all men women asthma deaths < 75 years, 2007

9 In Finland, hospital days caused by asthma in 2008 asthma as the main diagnosis Puhdas astma, käyttö Sairaalahoitopäiv young boys and old ladies! Miehet Naiset Yhteensä v 6-15-v v v v v v v >=7 6-v Ikäryhmät Kauppi P, Linna M, Haahtela T, in preparation

10 Rapid reduction in asthma hospitalizations in Salvador da Bahia, Brazil (2.7 million inhabitants) Franco R, et al. Allergy 2009 Family costs of severe asthma consumed over one-fourth of the family income of the underprivileged population in a middle-income country. Adequate management brings major economic benefit to individuals and families. ProAR Souza-Machado C, et al. ERJ 2010

11 Four cornerstones to achieve and keep control Hit early and hit hard, win the patient s confidence and improve outcome Treat accoding to severity, follow the patient Tackle exacerbations proactively Educate the patient give a written selfmanagement plan

12 52- year old lady, asthma for 20 years, non-allergic, exacerbations with resp.infections

13 Hit early and hit hard! Early intervention with anti-inflammatory treatment to stop exacerbations Symptoms and decrease of lung function Early detection and intervention with antiinflammatory therapy Usual time point for intervention Severe exacerbation Mild exacerbation Asthma in control Asthma in control Time Haahtela T, et al. NEJM 1991,1994, JACI 2009

14 Lahdensuo A, et al. Guided self-management in asthma BMJ 1996,1998; GINA 2009, modified, Haahtela T, et al. Finnish Allergy Programme Allergy 2008 Adult asthma Control Card/Stamp + Net/Mobile-version 1. Doctor Nurse (Pharmacist) Ask patient is he/she doing OK? 1. Reliever max 2 dose/wk 2. Symptoms max 2 day/wk 3. Symptoms max 1 night/wk 4. No activity restrictions 5. PEF-var. max 50 l/min/wk Ask yourself - is the treatment OK? 1. Reliever need minimal 2. Controller dose adequate 3. Adherent to treatment 4. Correct inhalation 5. Exacerbation plan exists Good morning PEF 2. Patient - guided self-management Notice symptom increase YES 1. Needing more reliever? 2. Feeling cold, flu? 3. Coughing Wheezing 4. Exercise tolerance 5. Morning-PEF PEF-decreases from to Stop exacerbation 1. Increase controller 2-4 fold (2-4 wk), or or start a course of controller (4 wk) 2. Start to use reliever regularily (2-4 wk) 3. If on Combi, double the dose (2 wk) 4. Prednisolon tabl. 20mg/day (1-2 wk) 5. Go to emergency, if no help 6. Later, check controller treatment Doctor/Nurse uses the check-list to assure asthma control, and guide the patient to self-management. Zero tolerance to asthma attacks

15 Keep it simple! ICS ß2-agonisti What do you do, if combi is not working? ICS + ß2-agonisti = fixed Combi ICS Combi ß2-agonisti Increase the dose? Add another drug? Undo the Combi?

16 SMART-strategia? Pavord et al. J Allergy Clin Immunol 2009; Chapman et al. Thorax 2010.

17 44-year old lady, 3 years of long-lasting coughs, now coughing for 2 months

18 27-year old woman, afraid of indoor moulds, hyperventilation, panicing

19 Variable bronchial obstruction (=asthma) is a consequence of long-term mucosal inflammation

20 Inflammation damages the skin and mucosal barrier function and increases permeability INFECTION ALLERGENS INFLAMMATION Normal Inflammation Cork J Allergy Clin Immunol 2006

21 Secondary infections in atopic eczema

22 Hit early and hit hard! -- 1) age, 2) disease outset, 3) exacerbations

23 Improve the barrier function - area of atopic eczema and serum IgE levels (in patients with an affected body area > 60%) after 1 and 10 years of treatment with tacrolimus Affected body surface area Serum total IgE Baseline 1 years 10 years Baseline 1 year 10 years Mandelin J, Remitz A, Virtanen H, et al, J Dermatol Treat (in press)

24 Asthma costs in Finland Scenario (Max) Scenario (Min) Realized costs Use of drugs ,00 % 80,00 % 70,00 % 60,00 % 50,00 % 40,00 % 30,00 % 20,00 % 10,00 % 0,00 % Reissell E, et al. Asthma costs in Finland. A public health model to indicate cost effectiveness during 20 years. Finnish Medical Journal 2010.

25 Welcome to implement global asthma plan to reduce the burden it works!

26 Stop the exacerbation! Add medication proactively for 2 weeks β2-agonisti 1-2 x 2 every time before inhaling ICS ICS 200 µg/dose 1-2 x 1-2 ICS 200 µg/dose 2 x 2-4 ICS 200 µg/dose 1-2 x 1-2 Haahtela T, et al. Finnish Asthma Programme. Thorax 2006; Finnish Allergy Programme. Allergy 2008

27 Ohjattu omahoito on avain!

28 VOS-hoito Avohoito A rapid decrease of hospital days and mortality : - 40% Haahtela T, et al. Thorax 2006