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Primary Care Update 2024 Asthma – making a good diagnosis Steve Holmes th Thur 11 April 2024 Steve Holmes Declaration of Interests (1) • General practitioner, Park Medical Practice, Shepton Mallet • Primary Care Respiratory Society (Service development, Policy and Conference committees) • International Primary Care Respiratory Group (IPCRG) Education Committee • NHS England South West – Regional Clinical Respiratory Lead • RCGP (Clinical Adviser Lead (Clinical Policy) Hon Sec Severn Faculty Board, Taskforce for Lung Health Rep) • NHS Somerset Integrated Care and Respiratory Lead • Health Education England (GP Trainer / Ed Sup in Somerset) • NHS England (National CVD and Respiratory Programme Board) NHS England (Appraiser) • • Recent guideline involvement (Air Travel, Asthma, COPD, Respiratory disease in athletic individuals, Spirometry, Tobacco Dependency) Declarations of Interest (2) Speaker engagements, educational projects, conference attendance, advisory board work (in the last three years) Academic work University College, London; Universities of Birmingham, Cambridge, Edinburgh, Sheffield Other providers Asthma and Lung UK, Best Practice, Education for Health, EQUIP , Guidelines in Practice, MedAll, Mediconf, MIMS, Omniamed, Pulse, RCGP Conferences, Somerset GP Education Trust Pharmaceutical / device companies Astra Zeneca, Boehringer Ingelheim, Chiesi, Pulmonx, Sanofi, Teva, Trudell Medical International, Viatris No tobacco shares. Asthma Management • Treatment options – established and new • A good review (and after an exacerbation) • Severe Asthma and Biologics – who should we be thinking about Hannah – diagnosis made now what? • Diagnosis made on the basis of convincing reversibility spirometry, raised FENO and eosinophil count and the history • What are you going to start her on? Hannah is a fictitious patient whose symptoms and history is typical of many people presenting (but is not modelled on any particular patient)Adapted from BTS/SIGN 158 British Guideline on the Management of Asthma 2019 https://www.brit-thoracic.org.uk/quality-improvement/ guidelines/asthma/ [last accessed 25 Jan 2023];Maintenance And Reliever Therapy (MART) • “Consider the option of combined maintenance and reliever therapy in adult patients who have a history of asthma attacks on medium dose ICS or ICS/LABA.” (Grade A recommendation) British Thoracic Society, Scottish Intercollegiate Guideline Network. SIGN 158 British Guidelines for the Management of Asthma. Guideline. 2019. Why should we stop treating with SABA alone? • Inhaled SABA has been first-line treatment for asthma for 50 years – Asthma was thought to be a disease of bronchoconstriction – Role of SABA reinforced by rapid relief of symptoms and low cost • Regular use of SABA, even for 1–2 weeks, is associated with increased AHR, reduced bronchodilator effect, increased allergic response, increased eosinophils (e.g. Hancox, 2000; Aldridge, 2000) Can lead to a vicious cycle encouraging overuse – – Over-use of SABA associated with  exacerbations and  mortality (e.g. Suissa 1994, Nwaru 2020) • Starting treatment with SABA trains the patient to regard it as their primary asthma treatment • The only previous option was daily ICS even when no symptoms, but adherence is extremely poor • GINA changed its recommendation in 2019 once evidence for a safe and effective alternative was available Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention (2022). 2022 available at www.ginaasthma.org th 1 - EAACI.org EAACI global atlas of asthma 2021 update (accessed 25 Jan 2023) 2- Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention (2022). 2022. Background - the risks of ‘mild’ asthma • Patients with apparently mild asthma are still at risk of serious adverse events had symptoms less than – 30–37% of adults with acute asthma weekly in previous 3 month(Dusser, Allergy 2007; – 16% of patients with near-fatal asthma Bergstrom, 2008) – 15–27% of adults dying of asthma • Exacerbation triggers are unpredictable (viruses, pollens, pollution, poor adherence) • Even 4–5 lifetime OCS courses increase the risk of osteoporosis, diabetes, cataract (Price et al, J Asthma Allergy 2018) Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention (2022). 2022 available at www.ginaasthma.org As-needed low dose ICS-formoterol in mild asthma (n=9,565) (2018) COMPARED WITH AS-NEEDED SABA • The risk of severe exacerbations was reduced by 60–64% (SYGMA 1, Novel START) COMPARED WITH MAINTENANCE LOW DOSE ICS • The risk of severe exacerbations was similar (SYGMA 1 & 2), or lower (Novel START, PRACTICAL) • Small differences in other asthma outcomes, favoring maintenance ICS, but all were less than the minimal clinically important difference – ACQ-5 mean difference 0.15 (MCID 0.5) – FEV 1ean difference ~54 mL – FeNO mean difference ~10ppb (Novel START, PRACTICAL) – No evidence of progressive worsening over 12 months • In Novel START and PRACTICAL, outcomes were independent of baseline features including blood eosinophils, FeNO, lung function, and exacerbation history • Average ICS dose was ~50–100mcg budesonide/day O’Byrne et al, NEJM 2018 1. O'Byrne PM, FitzGerald JM, Bateman ED, Barnes PJ, Zhong N, Keen C, et al. Inhaled Combined Budesonide-Formoterol as Needed *Budesonide-formoterol 200/6 mcg, 1 i in Mild Asthma. N Engl J Med. 2018;378(20):1865-76. Cochrane systematic review of low dose ICS – formoterol in mild asthma • Systematic review of all six studies (five suitable) • “use instead of FABA as required alone reduced exacerbations, hospital admissions or unscheduled healthcare visits and exposure to systemic c corticosteroids” • “FABA/ICS as required is as effective as regular ICS” • “Compared with regular ICS, any changes in asthma control, spirometry, peak flow rates (PFR), or asthma-associated quality of life, though favouring regular ICS, were small and less than the minimal clinically important differences (MCID)” FABA (Fast acting beta agonist) ICS (inhaled corticosteroid) 1. Crossingham I, Turner S, Ramakrishnan S, Fries A, Gowell M, Yasmin F, et al. Combination fixed‐dose beta agonist and steroid inhaler as required for adults or children with mild asthma. Cochrane Database of Systematic Reviews. 2021(5). Adults and Children over 12 years old – Personal Opinion (but not alone) • Use ICS / LABA as required in mild asthma / asthma using only SABA / when initiating therapy after diagnosis appears to be sensible from above (and evidenced) • At the current time only licenced with Symbicort Turbohaler 200/6 (but will change in time) (maximum 8 puffs per day licence) How many don’t comply with ICS (give them both?) • • Likely to reduce exacerbations and probably admissions • Provides treatment for asthma as well as reliever – only explain one inhaler • Good evidence (GINA) and Cochrane – British Guidelines considering Personal Opinion SlideWho to use as required ICS / LABA (Anti Inflammatory Reliever) • Newly diagnosed (one inhaler) People with seasonal asthma (hay fever) • • People using short acting beta agonist alone (for asthma) – remember hyper- responsiveness many using SABA may be making their symptoms worse • If get more symptoms suggest: (always evaluating is the diagnosis right) – Maintenance and Reliever approach or Stable dose ICS / LABA and SABA – Consider addition of LTRA – Consider addition of LAMA – Refer to more specialist colleague Personal Opinion SlideAdapted from BTS/SIGN 158 British Guideline on the Management of Asthma 2019 https://www.brit-thoracic.org.uk/quality-improvement/ guidelines/asthma/ [last accessed 25 Jan 2023]; Hannah – An exacerbation • Started on ICS and within one month much improved (given a personalised action plan, and has emergency blue inhaler started). Only used blue inhaler two or three times a month. • Had exacerbation 6 months later and was asked to come for review after acute treatment. What are you wanting to do? Hannah is a fictitious patient whose symptoms and history is typical of many people presenting (but is not modelled on any particular patient) Exacerbations Asthma and Allergy Blog (Aashwas - India) symptoms/tps://www.aashwas.in/asthma-allergy-blog/asthma-attack- Remember that an exacerbation develops usually over days not minutes Tattersfield AE, Postma DS, Barnes PJ, Svensson K, Bauer CA, O'Byrne PM, et al. Exacerbations of asthma: a descriptive study of 425 severe exacerbations. The FACET International Study Group. Am J Respir Crit Care Med. 1999;160(2):594-9. How common are exacerbations? 222,817 and 211,807 patients with asthma included from the US and UK databases US UK Length between exacerbations (yrs) ≥1 exacerbation during the 12.5% 8.4% 8-11.9 follow-up period ED presentation / 2.3% 1.4% 43.5 – 71.4 hospitalization If admitted – readmission 9.2% 4.7% Not applicable within 30 days Suruki RY, Daugherty JB, Boudiaf N, Albers FC. The frequency of asthma exacerbations and healthcare utilization in patients with asthma from the UK and USA. BMC Pulmonary Medicine. 2017;17(1):74. “The Asthma 4: a new asthma attack care bundle BTS, 2024) • Action 1: Medication Review • Action 2: A Personalised Asthma Action Plan • Action 3: Tobacco dependence advice and support for current smokers • Action 4: Clinical review within 4 weeks British Thoracic Socclinical-resources/asthma/bts-asthma-care-bundles/able at https://www.brit-thoracic.org.uk/quality-improvement/Exacerbation review • “Expertise starts where guidelines finish” • ”Good care starts when templates finished” • What do you think? Post exacerbation • Why did it happen? • What happened outside and in hospital? • Any things patient has had changed or has learnt? • Any triggers? • Check smoking, occupation, inhaler technique, adherence etc • Is medication optimised? • Specialist follow up? Photo kindly provided by IPCRG (2022) Post exacerbation review • “Prior to discharge, follow up should be arranged with the patient’s general practitioner or asthma nurse within two working days and with a hospital specialist asthma nurse or respiratory physician at about one month after admission.” British Thoracic Society, Scottis2019.ercollegiate Guideline Network. SIGN 158 British Guidelines for the Management of Asthma. Guideline. Structured review – many options eg SAILS • Symptoms / control (ACT) • Admissions or exacerbations • Inhaler technique and concordance • Lifestyle (exercise, smoking, work) / Lung function (PFR) • Self management plan (for emergency) Holmes S and Scullion J (2020) (adapted from a variety of recommendations including SIMPLES (Ryan D, Murphy A, Stallberg B, Baxter N, Heaney LG. ‘SIMPLES’: a structured primary care approach to adults with difficult asthma 2013) – Painting is by Alan Furneaux (part of full painting) SIMPLES - Performing a structured review Smoking Ask every patient, every time – don’t assume Inhaler technique Major cause of poor control Monitoring E.g. Royal College of Physicians’ ‘3 questions’, ACT Pharmacotherapy Review current prescriptions; step up or down Lifestyle Exercise, diet, alcohol – vaccines and comorbidities Education Knowledge, medication, self-monitoring, emergency plan Support Social,psychological Ryan D, Murphy A, Stallberg B, Baxter N, Heaney LG. ‘SIMPRyan D, et al. Prim Care Resp J. 2013; 22:365–73. with difficultRespiratory Pharmacist. asthma 2013 [Available from: http://www.thepcrj.org/journ/view_article.php?article_id=1065.Benefits of a personal asthma action plan PEFR Hannah – the review • Symptoms brewed up over several days. • No clear trigger • Attended out of hours service at local hospital – given steroids and a course of antibiotics and told to call again or see practice when better • No PEFR in your discharge letter and not done in out of hours • Has required a week off work in total to recover • In between appeared to have good control? • WHAT ARE YOUR NEXT STEPS? (Increase steroid / LABA – ICS, LAMA add in, theophylline?) Hannah is a fictitious patient whose symptoms and history is typical of many people presenting (but is not modelled on any particular patient) Maintenance And Reliever Therapy (MART) • “Consider the option of combined maintenance and reliever therapy in adult patients who have a history of asthma attacks on medium dose ICS or ICS/LABA.” (Grade A British Thoracic Society, Scottish Intercollegiate Guideline Network. SIGN 158 British Guidelines for the Management of Asthma. Guideline. 2019. Poorly controlled and severe asthma – triggers for referral (PCRS 2022 Update) 1. On regular OCS for their asthma 2. Admitted / ED in last year 3. Two or more courses of OCS in last year 4. 6 SABA inhalers or more in last year 5. Ongoing symptoms despite controller medication Holmes S, Kane B, Pugh A, Whittaker A, McArthur R, Carroll W. Poorly controlled and severe asthma: triggers for referral for adult or paediatric specialist care – a PCRS pragmatic guide. Primary Care Respiratory Update. 2019;Autumn 2019(18):22-7. Severe asthma and the biologics • Biologic treatments used for asthma are also known as monoclonal antibodies or mAbs for short, they are specialist initiated • Use antibodies produced from cells in a laboratory which can target specific cells in the body. • They can treat some types of severe asthma by helping to stop body processes that cause lung inflammation. Adapted Asthma and Lung UK www.asthmaorg.uk (Last accessed in Jan 2023) How do they treat asthma? • Available for certain types of severe asthma which are not well controlled with high doses of steroid inhalers: • Severe allergic asthma  - omalizumab • Eosinophilic asthma  - mepolizumab, reslizumab and benralizumab • Severe asthma with type 2 inflammation driven by both allergies and high levels of eosinophils - dupilumab www.asthmaorg.uk Last accessed Jan 2023 Adapted from Asthma and Lung UK www.asthmaorg.uk (Last accessed in Jan 2023) Current biologics • benralizumab (Fasenra) • dupilumab (Dupixent) • mepolizumab (Nucala) • omalizumab (Xolair) • reslizumab (Cinqaero) (Licence and indications vary) Asthma and Lung UK www.asthmaorg.uk (Last accessed in Jan 2023) Table from PCRU: Holmes S, Carroll W, Mosgrove F, Pugh A, Stone R. Severe Asthma: A pragmatic guide Respiratory Update. 2022;25(Winter):7-15. re Management • Treatment options – established and new • A good review (and after an exacerbation) • Severe Asthma and Biologics – who should we be thinking about Primary Care Update 2024 Management of Asthma •Steve Holmes •Thur 11 April 2024