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AsthmaA Global Healthcare Issue
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AsthmaA GLOBAL HEALTHCARE ISSUE
Asthma is a worldwide problem
Approximately 300 million individuals are affected1
Over the last 40 years there has been a sharp increase in theglobal prevalence, morbidity, mortality, and economic burden
associated with asthma2
Asthma prevalence is expected to increase by 50% every
decade2
Hence, 150 million more people will become asthma sufferers
1. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention. Revised Edition 2007.
2. Braman SS. Chest2006; 130: 4S12S.
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Too many patients still die from theirasthma
There are an estimated 250,000 annual worldwide
deaths from asthma1
Most asthma deaths occur in those >45 years old and
are largely preventable2
1. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention. Revised Edition 2007.
2. Braman SS. Chest2006; 130: 4S12S.
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Asthma prevalence in children
Asthma is the most common
disease among children1,2
Children living in poverty:3
Suffer the largest burdenof childhood asthma
morbidity
Are more likely to receive
inadequate therapy
1. ISAAC Steering Committee. Lancet1998; 351: 12251232. 2. Bibi HS et al. Respir Med2006; 100: 458462.
3. Halterman JS et al.Ambulatory Paed2003; 3: 102105.
PeruNew Zealand
AustraliaUruguay
KuwaitCanada
USAKenyaChile
JapanParaguay
Hong KongSingapore
PhilippinesMalta
France
PakistanSpainMorocco
ArgentinaThailand
South AfricaPortugalMalaysiaAustriaSweden
GermanyItaly
FinlandLebanon
South KoreaPoland
IranIndiaChina
EstoniaTaiwan
IndonesiaUzbekistan
LatviaRussia
Albania
0 5 10 15 20 25 30Prevalence of asthma symptoms (%)3
Country
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Asthma Insights & Reality in Pakistan Survey(AIRIP)1
Presence of patients Asthma symptoms in the last 4 weeks
Moderate
symptoms
Mild to no
symptoms
Severe
symptoms
1. Jones, P.W, et al., Survey of Asthma Insights and Reality In Pakistan (AIRIP), Journal of Respirology, 2006
47%
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Asthma Insights & Reality in Pakistan
Survey(AIRIP)
Frequency of asthma in past 12 months(sudden severe episodes of cough, wheeze tightness, or breathlessness)1
1. Jones, P.W, et al., Survey of Asthma Insights and Reality In Pakistan (AIRIP), Journal of Respirology, 2006
32%
51%
0% 10% 20% 30% 40% 50% 60%
Adults
Children
Adults 51%
Children 32%
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Asthma emergencies in thelast 12 months (AIRIP)1
50% admitted to emergency ward
overnight
Almost 50% saw doctor as an
emergency
1. Jones, P.W, et al., Survey of Asthma Insights and Reality In Pakistan (AIRIP), Journal of Respirology, 2006
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Asthma Insights and Reality in Europe (AIRE)
Majority of patients overestimate their level of
asthma control1
1. Rabe KF et al.Eur Resp J2000; 16: 802807.
SP: severe persistent; MOP: moderate persistent; MP: mild persistent; MI: mild intermittent;
Well/completely controlled Somewhat controlled Poorly/not controlled
100
75
50
25
0
Patient
s%
SP MOP MP MI
Children
SP MOP MP MI
Adults
However, only 5.3% of all patients (5.1% of adults and 5.8% ofchildren) met all the criteria for asthma control
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Parents underestimate the level of theirchildrens asthma1
Not
daily
Daily 2x/wk Freq Not
daily
Daily < 3 3 0 1 Yes No
Daytime asthma
symptoms
Night time asthma
symptoms
Rescue medication
use
Office/
emergency room
visits
Hospitalisations Preventative
medication use
1. Halterman JS et al.Ambulatory Paed2003; 3: 102105.
8078
8284
78
73
64
76
65
70
76
81
0
10
20
30
40
50
60
70
80
90
Parentsreportinggoodcontrol(%)
Parents reporting good control Actual level of asthma control
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Physician assessment of control in thePrimary Practice Audit study1
58%
42%
Controlled
Uncontrolled
1. Chapman KR et al. Eur Respir J. 2008; 31: 320325.
n=10,428
59%
41%
Controlled
Uncontrolled
Physician Guideline
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PhysicianAcceptance of a certain level of
symptoms for their asthmatic patients
As patients do not complain,
assumption that patients are well
enough controlled
PatientAcceptance of asthma symptoms as
part of their usual life: under-report
Trust in their physicians to accurately
assess their condition and give them
the best treatment
Current status of asthma control:a vicious circle
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Patients want to avoid asthmasymptoms1
1. Lloyd A et al. Prim Care Resp J2007; 16: 241248.
35
109
94
0
20
40
60
80
100
120
Avoid a day with
symptoms
Avoid asthma attacks
that required emergency
visits to GP/ER
To achieve total
avoidance
of asthma symptoms
Willingnesstopay
(Eurospermonth)
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What do you think?
According to the AIRIP survey what percentage of
asthmatic patients in Pakistan had ever been
administered a lung function test?1
1. 15%
2. 48%
3. 30%
4. 58%
Asthmaticpatients notadministered lungfunction test
85%
Asthmatic patientsadministered lungfunction test
15%
1. Jones, P.W, et al., Survey of Asthma Insights and Control In Pakistan (AIRIP), Journal of Respirology, 2006
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AsthmaThe Financial Burden of theDisease
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The cost of asthma: a financial burden onthe healthcare system
Asthma Insights & Reality in Latin America survey (AIRLA)1
5255
31
69
6158
0
10
20
30
40
50
60
70
80
Use of emergency care in the
past 12 months
Current use of quick relief
bronchodilators
School/work absence
Patients(%
)
Adults Children
1. Neffen H et al.Pan American J Public Health2005; 17: 191197.
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AsthmaA FINANCIAL BURDEN
Direct and Indirect costs associated with uncontrolled asthma1:
According to a UK study, the total cost per patient is 3.5 times higher inthe uncontrolled (attack) group than in the controlled (non-attack) group1
This highlights the importance of controller medication to prevent attacks /
exacerbations and keep asthma under control, resulting in significant cost
saving and improved quality of life1
Rescuemedication
use
Hospitalization/
Emergencyroom visits
Indirect costs(lost time at
work, school,etc)
Impaired
Quality of Life
RepeatedGP
consultations
1. Hoskins, G., et al., Risk factors and costs associated with an asthma attack, Thorax; 55:19-24 (2000).
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Asthma care can be improved: inhaledsteroids and asthma
Ministry of Social Affairs and Health in Finland National Action Programme1
1. Haahtela T et al.Thorax2001; 56; 806814.
400
350
300
250
200
150
100
50
0
1981 1983 1985 1987 1989 1991 1993 1995 1997 1999
Year
Index(1981=100)
Proportion of asthmatic patients
in the population
Death rate due to asthma
among asthmatic patients
Days in hospital due to asthmaamong asthmatic patients
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Knowledge of Inhaled Corticosteroids(AIRIP)1
86.5 87 87.5 88 88.5
Not at all
familiar
% of respondents
Adults
Children
In Pakistan, over
80% of individuals
(adults andchildren) were not
familiar with
inhaled
corticosteroids
(ICS)
1. Jones, P.W, et al., Survey of Asthma Insights and Control In Pakistan (AIRIP), Journal of Respirology, 2006
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AsthmaA Two-Component Disease
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Asthma symptoms:the tip of the iceberg1
Airway inflammation
Bronchial hyperresponsiveness
ASTHMA SYMPTOMS
Airway obstruction
1. Warner O. Am J Resp Crit Care Med2003; 167: 14651466.
Bronchoconstriction
Bronchial oedema
Mucous hypersecretion
Inflammatory cell recruitment eosinophils
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Any symptoms of asthma are a sign ofinflammation
Inflammation in asthma patients can be present during
symptom-free periods:1
Symptoms resolve quickly. Inflammation, however, as measured byairway hyperresponsiveness, takes far longer1
As chronic inflammation causes an increase in airway
hyperresponsiveness, if the inflammation is notcontrolled, symptoms are likely to reoccur
1. Woolcock AJ. Clin Exp AllergyRev2001; 1: 6264.
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Chronic inflammation is associated withairway hyperresponsiveness
AHR is defined as the ability of the airways to narrow too easily and
by too much in response to provoking stimuli, leading to:1
Recurrent episodes of wheezing2
Breathlessness2
Chest tightness and coughing2
Airway narrowing leads to variable airflow limitation and intermittent
symptoms2
Airway remodelling is even apparent in children with mild,
intermittent asthma3,4
Seretide (SFC) treats the two main components of asthma:
inflammation and bronchoconstriction
1. Downie SR et al.Thorax2007; 62: 684689. 2. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention.Revised Edition 2007. 3. Bibi HS et al.Respir Med2006; 100: 458462. 4. Jeffery P. Pediatric Pulmonol2001; (Suppl. 21): 316.
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Asthma:A two-part problem of
Inflammation and bronchoconstriction1
Normal airway Airway inflammation
and bronchoconstriction
InflammationDamaged airway passage wall
1. Bousquet J et al. Am J Resp Crit Care Med2000; 161: 17201745.
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Symptoms / exacerbations
LABA ICS
Inflammatory cell infiltration/
activation
Mucosal oedema
Cellular proliferation Epithelial damage
Basement-membrane thickening
Bronchoconstriction
Bronchial hyper-reactivity
Hyperplasia Inflammatory-mediator release
Smoothmuscle
dysfunction
Airwayinflammation/remodelling
Asthma is a two component disease:complementary effects of long-acting 2-agonist &
corticosteroid combination therapy1
1. Johnson M. Proc Am Thorac Soc2004; 1: 200206.
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FP and salmeterol have synergistic
properties when used together
The combination of LABA and ICS is now the most effective
treatment for patients with persistent asthma1
Specifically, the combination of FP and salmeterol has been
shown to be an effective treatment for patients with persistent
asthma, previously uncontrolled on either FP or salmeterol alone2
1. Barnes PJ. Eur Respir J2002; 19:182191. 2. Shapiro G et al.Am J Respir Crit Care Med2000; 161:527534.
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Asthma Controlas per Guidelines
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GINA 2006:Assess, Treat and Monitor
This cycle involves:
ASSESSING CURRENT LEVEL OF ASTHMA CONTROLGINA Guidelines help to identify what level of control your patient is currently on
(Controlled / Partly Controlled / Uncontrolled)1
TREATING TO ACHIEVE CONTROLGINA Guidelines highlight that the aim of asthma treatment is to achieve control2.
GOAL (Gaining Optimal Asthma ControL) study proves that this is achieved with
2
MONITORING TO MAINTAIN CONTROLGOAL study shows that daily treatment with Seretide helps maintain control of
asthma symptoms2
The use of the ACT questionnaire to facilitate in monitoring patient progress2
1. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention. Revised Edition 2007.2. Bateman, E D., Can Guideline-defined Asthma Control be Achieved? The Gaining Optimal Asthma ControL Study, Am J Respir Crit Care Med, Vol. 170, pg.
836-844 2004
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Assessing Current Level of Asthma ControlGINA 2006: Levels of asthma control1
CharacteristicControlled
(All of the following)
Partly controlled(Any measure present
in any week)Uncontrolled
Daytime symptomsNone
(Twice or less / week)
More thantwice / week
3 or more
features
of partly
controlled asthmapresent in
any week
Limitations of activities None Any
Nocturnal symptoms /awakening
None Any
Need for reliever / rescuetreatment
None (Twice or less /week)
More thantwice / week
Lung function(PEF or FEV1)*
Normal< 80% predicted or personal
best (if known)
Exacerbations None One or more/ year** One in any week***
*Lung function is not a reliable test for children 5 years and younger
**Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate
***By definition, an exacerbation in any week makes that an uncontrolled asthma week
.
The Aimof AsthmaTreatment
1. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention. Revised Edition 2007.
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Treating to Achieve ControlMedications to treat asthma can be classified as controllers or
relievers1
Controllers Relievers
Are medications taken daily
on a long-term basis to keepasthma under clinical controle.g: long acting inhaled beta-2 agonists in combination with
inhaled glucocorticosteroids
Also known as rescue
medication is used only on anas-needed / SOS basis at thetime of an acute attack. These
act quickly to reversebronchoconstriction & should
not substitute the use of a
controllere.g: rapid-acting inhaled beta-2 agonists (salbutamol)
1. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention. Revised Edition 2007.
Increased use, especially daily use, of reliever medication is a warning ofdeteroriation of asthma control and indicates the need to re-assess
treatment
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Step 1 Step 2 Step 3 Step 4 Step 5Asthma education
Environmental Control
As needed rapid-acting Beta-2 agonist
ControllerOptions
Select one Select one Add one or more Add one or both
Low doseinhaled ICS*
Low-dose ICSplus long actingBeta 2 agonist
Medium or high doseICS plus long actingBeta 2 agonist
Oral
Glucocorticosteroid
(lowest dose)
Leukotriene modifier** Medium or high dose ICS Leukotriene Modifier Anti-IgE treatment
Low dose ICS plusLeukotriene modifier
Sustained release theophylline
Low dose ICS plus sustained
release theophylline
Recommended Treatment Alternative Treatment *ICS = Inhaled Glucocorticosteroids** = Receptor antagonist or synthesis inhibitors
Alternative reliever treatments include inhaled anticholinergics, short acting oral beta 2 agonists, some long acting beta 2 agonists and short acting
theophylline. Regular dosing with short and long acting beta 2 agonist is not advised unless accompanied by regular use of an inhaled
glucocorticosteroid
REDUCE INCREASE
Management Approach To Achieve ControlAsthma control rather than severity1
1. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention. Revised Edition 2007.
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What do you think?
A 26 year old asthmatic, normally controlled onbeclomethasone 400 mcg daily and salbutamol 100mcg prn, presents to your surgery with worseningwheeze for the past 2 months. She is having daily
nocturnal attacks Her peak flow is 150 l/min.How would you describe her asthma control?
1. Totally Controlled OR
Well Controlled2. Partially Controlled
3. Un-controlled
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What do you think?
A 20 year old lady complains of intermittent
shortness of breath and wheeze. This occurs twice aweek at the most. You correctly diagnose asthma.What is the best advice for her?
1). Start oral Ventolin
2). Start anti-histamines
3). Start leukoterine receptor antagonist
4). Take inhaled short acting B2 agonist on an as-
needed basis
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?
Can Guideline defined
Asthma Control beAchieved?
YES NO
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Such stringent and sustained measures of asthma controlhave never previously been assessed in a clinical trial
1
>5001000 mcgbeclomethasone
equivalent(moderate to
high dose ICS)
500 mcgbeclomethason
e equivalent(low dose ICS)
Steroid-nave(no ICS)
FluticasonePropionate 250 b.d.
FluticasonePropionate100 b.d.
3
2
1
Study treatment*Study strata based on previous total daily dose of ICS
4weekrun-in
3416uncontrolled
asthmapatients
1
1. Bateman et al. Am J Respir Crit Care Med2004. 2. Adams et al. The Cochrane Library, 2002. Oxford.
250 b.d.
100 b.d.
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This study demonstrated the advantage of
over inhaled fluticasone inachieving comprehensive sustainedasthma control1
Bringing a new paradigm toAsthma Control
This is the 1st landmark study to-date to assess whether guideline-defined asthma control canbe achieved7
1. Bateman et al. Am J Respir Crit Care Med2004. 2. Adams et al. The Cochrane Library, 2002. Oxford.
41%
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uncontrolled asthmatics were TOTALLY controlledwith
Total Controlmeant that an uncontrolled asthmatic achieved all of the following in each assessment week:
Totally controlled asthmawas achieved if the patient
during the 8 consecutive
assessment weeks recorded
7 totally controlled weeks
and had no exacerbations,
emergency room criteria, or
medication-related adverse
events criteria 4
*Predicted PEF was calculated based on the European Community for Steel and Coal standards (40) for patients 18
years and older and on the Polgar standards (41) for patients 12-17 years old.
**Exacerbations were defined as deterioration in asthma requiring treatment with an oral corticosteroid or an emergency
department visit or hospitalization
Day timeSymptoms
Rescue Beta 2agonist use
Night-timeawakening
Morning PEF
Exacerbations**
Emergencyvisits
Treatment relatedadverse events
None
None
80% predicted * every day
None
None
None
None enforcing change inasthma therapy
41%
1. Bateman et al. Am J Respir Crit Care Med2004. 2. Adams et al. The Cochrane Library, 2002. Oxford.
1
75%
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uncontrolled asthmatics, not controlled on low-dose ICS, were WELL-CONTROLLED with
Well Controlledmeant that an uncontrolled asthmatic experienced
Daytime Symptoms 2 days with symptom score > 1**
Rapid-acting Beta 2agonist use Use on 2 days and 4 occasions/week
Morning PEF 80% predicted *** every day
Night-time awakening None
Exacerbations* None
Emergency visits None
Treatment-related adverse events None enforcing change in asthma therapy
2 or more of the following in each
assessment week
ALL of the following in each assessment week:
*Exacerbations were defined as deterioration in asthma requiring treatment with an oral corticosteroid or an emergency
department visit or hospitalization
**Symtpom score: 1 was defined as symptoms for one short period during the day. Overall scale: 0 (none) 5 (severe)
***Predicted PEF was calculated based on the European Community for Steel and Coal standards (40) for patients 18 years andolder and on the Polgar standards (41) for patients 12-17 years old.
75%
1. Bateman et al. Am J Respir Crit Care Med2004. 2. Adams et al. The Cochrane Library, 2002. Oxford.
1
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7 out of 10 patients can achieve guidelinedefined control of their asthma with
Patientswitha
w
ell-controlledwe
ek(%)
Week of study
80
60
40
20
0-4 0 4 8 12 10 20 24 28 32 36 40 44 48 52
(n=1709)FP (n=1707)
Run-in
Phase I
Phase II
p
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Adding a LABA vs. higher-dose ICS in patientswith uncontrolled asthma on ICS alone1
n=162
n=159
n=208
***
**
***
**
**
n=144
n=142
n=126
n=135
n=136
n=149n=156
n=195
n=137
35
30
25
20
15
10
5
0
Higher-dose ICS
Weeks of treatment
C
hangeinmeanm
orning
PEF(L/min
)
2117139510
1. Greening AP et al. Lancet1994; 344: 219224.
*
*p
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SFC provides similar control of asthmasymptoms with less steroid1
%
patientsachie
ving
TotalContro
l
0
10
20
30
40
FP
500
n=577 n=583
p
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A Cochrane database review has shown that the use of FP leads
to fewer symptoms and less rescue medication use compared with
beclometasone and budesonide, at half the dose
FP given at half the daily dose of beclometasone or budesonidewas also shown to lead to small improvements in measures of
airway calibre
FP produced a significantly greater end of treatment FEV1 (0.04
litres (95% CI: 0.0 to 0.07 litres), end of treatment and change in
morning PEF, but not change in FEV1 or evening PEF compared
with budesonide and beclometasone, at half the dose
FP = Fluticasone Propionate
Adams N et al. Cochrane Database Syst Rev2008;2: CD002310.
FP leads to fewer symptoms and less rescue medication
use when given at half the dose of beclometasone andbudesonide1
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SFCreduces the need for patients totake their rescue inhaler1
Woodcock1
Median use of salbutamol in the SFC group
was significantly lower than in the ICS-only
group (p
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SFC increases the number of symptom-freedays experienced by asthma patients1
SFC = Salmeterol/Fluticasone PropionateFP = Fluticasone Propionate
1. Woodcock AA et al. Primary Care Respir J2007; 16: 155161.
0
10
20
30
40
50
60
70
80
90
Stratum 1(steroid nave)
Stratum 2(low dose ICS)
Stratum 3(moderatedose ICS)
Pooled strata data
SFC
FP
W
eeks152adjusted
meanchange(%
)
81.5
76.6 74.2
51.055.9
29.9
72.5
54.5
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Asthma control is maintained and
sustained with SFC1
With sustained treatment, asthma control stability is maintained over
months and is positively associated with the initial level of asthma
control and SFC use
SFC = Salmeterol/Fluticasone Propionate
1. Bateman ED et al.Am J Respir Crit Care Med2004; 170: 836844.
0
10
20
30
40
50
60
70
8090
100
Total control Well controlled
%
weekscontrolmaintaine
d
81%86%
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SFC compared with LTRAstudy design1
SFC = Salmeterol/Fluticasone Propionate
1. Calhoun WJ et al. Am J Respir Crit Care Med2001; 164: 759763.
SFC 50/100g BID
Montelukast 10mg BID
Screening
period Randomisation
12-weektreatment period
0
Weeks
SFC treatment group
MON treatment group
814
Days
2 4 6 8 10 12
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p
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p
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SFC = Salmeterol/Fluticasone Propionate
1. Ringdal N et al. Respir Med2003; 97: 234241.
SFC 50/100 g
FP 100g BID + montelukast 10 mg QD
Treatment week
MeanmorningPEF
(L/min) 420
400
380
360
0
Run-in 12 34 56 78 910 1112
SFC is more effective than FP +oral montelukast in asthma 1
Endpoint
p
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SFC compared with FP +montelukast: exacerbations 1
0
20
40
60
80
FP 100 g BID
+ MON 10 mg QD
SFC
50/100g BID
Numberofpa
tients
p < 0.05
SFC = Salmeterol/Fluticasone Propionate
1. Gold M et al. Eur Respir J2001; 18 (Suppl 33): 262s.
The number of
patients with at
least one
exacerbation and
the time to the first
exacerbation was
significantly lower in
the Seretide group
Treatment ith
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p
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SFC vs. Montelukast (LTRA)
Higher increase in mean morning FEV11
Greater number of symptom-free days2
Produced better lung function & asthma control; hence moreeffective than montelukast + fluticasone propionate3
Lower rate of exacerbations4
More effective initial management strategy than montelukast1
Treatment with SFC resulted in:
SFC = Salmeterol/Fluticasone Propionate
1. Calhoun WJ et al. Am J Respir Crit Care Med2001; 164: 759763.
2. Data on File, GlaxoSmithKline. SAS40021. 2. Calhoun WJ et al. Am J Respir Crit Care Med2001; 164: 759763.3. Ringdal N et al. Respir Med2003; 97: 234241.4. Gold M et al. Eur Res ir J 2001 18 Su l 33 : 262s.
SFC t l k t ti t
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*Patients responded that they were satisfied or very satisfied with their therapy in each of
these categories
SFC versus montelukast: patientsatisfaction1
SFC = Salmeterol/Fluticasone Propionate1. Data on File. GlaxoSmithKline. SAS40020
p
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Response to the use of LTRA is independent of the use of
ICS
Response to LTRA has been shown to be the same
regardless of ongoing use of ICS
The effect of LTRAs appears to be additive to that of ICSs
There is no evidence of a synergisticeffect when LTRA is added to ICS in
patients with asthma
1
1. Beckeret al. CMAJ2005; 173(6 Suppl): S37S38.
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Asthma Management
Options
P ti t li ith th
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Patient compliance with asthmamedication
Compliance with asthma medicationdecreases over time
In one study, only 40% of asthma patients were compliant with their
medication over 5 weeks1
In another study, compliance with asthma medication decreased
from 51% during the first week to less than 30% after 10 weeks2
1. Chmelik F et al. Ann Allergy1994; 73: 527532. 2. Onyirimba F et al. Ann Allerg Asthma Immunol2003; 90: 411415.
P ti t li ith th
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Patient compliance with asthmamedication1
1. Horne R. Chest2006; 130; 6572
PoorCompliance
Concern about side effects
Patients negative attitude towards
medicines in general
Past experience
Views of others
Cultural influencesPractical difficulties
Patients perceived need
R li M di ti Mi
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Reliever Medication Misuse
In Pakistan, in the indication of Asthma, there is a large use of relievermedication1indicating that patients asthma is uncontrolled and theyexperience frequent attacks.
According to GINA, this is a warning of deterioration of ones asthma
condition2
This highlights misunderstandings of the disease and the low level ofpatient compliance
Aiming for Total Control with results in the virtualelimination of exacerbations and hence, reliever medication use3
1. IMS Data, MIS Qtr 3/2008 & PKPI 1S/2008
2. Global Initiative for Asthma (GINA): Global Strategy for Asthma Management & Prevention, Revised Edition 20073. Bateman et al. Am J Respir Crit Care Med2004. 2. Adams et al. The Cochrane Library, 2002. Oxford.4. Hoskins 2000
According to a UK study, the average total cost of asthma per patient was 2.1times higher in the attack (exacerbation) group than the non-attack (no
exacerbation) group, excluding cost of hospitalization4
I i ti t li
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Improving patient compliance
Simple, regular dosing
Simple dose regimens are generally
easier for patients to follow1
Compliance rates are most highly
correlated with the number of doses
rather than the number of medications or
tablets that must be taken daily1
The core issue for patients is: How
many times a day must I remember totake a dose?1
1. Cramer J.A. Heart2002; 88: 203206.
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Regular, twice-daily SFCgives control of asthma:what does this mean for the patient?
Well controlled asthma control is achieved1
SFC leads to more symptom-free days and
virtual elimination of exacerbations2
The twice-daily dosing may facilitate improvedpatient compliance3
1. Bateman ED et al. Am J Respir Crit Care Med2004; 170: 836844. 2. Woodcock AA et al. Primary Care Respir J2007; 16: 155161. 3. CramerJA. Heart2002; 88: 203206.
SFC = Salmeterol/Fluticasone Propionate
i T t l C t l f
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gives Total Control ofasthma
Patients can experience improvements in quality of life (QoL)to levels where there is little or no impact of asthma onQoL for patients1
The patients perspective of how well their asthma is being treated is
best represented by QoL1 Well controlled asthma can result in little or no impact of asthma symptoms
on QoL for many patients1
At least 7 out of 10 asthma patients are well controlled taking1
SFC = Salmeterol/Fluticasone Propionate
1. Bateman ED et al. Eur Respir J2002; 20: 588595.
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Monitoring Asthma Control inClinical Practice
A th C t l T t (ACT)
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Asthma Control Test (ACT)
ACT is an effective, validated andindependent method of assessingasthma control in clinical practice
Asthma treatment target previously
not defined
Despite the availability of effective
treatments and comprehensive
guidelines, outcomes of asthma
management are frequently sub-optimal
Clear targets are needed to guide treatment andfacilitate assessment of CONTROL
1,2
1
1
1. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention. Revised Edition 2007.
2. ACT: The Asthma Control Test, GSK Data on File
A th C t l T t (ACT)
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Asthma Control Test (ACT)
Clear therapeutic targets exist
for many chronic diseases
Philosophy of treat to targetHypertension BP
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2002, by QualityMetric Incorporated.Asthma Control Test is a trademark of QualityMetric Incorporated.
Whats Yo r Score?
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Whats Your Score?
A score20 indicates that asthma iswell controlled.
A score 19 indicates that asthma
may not be well controlled
With TOTAL CONTROL of asthma now a reality, ACT can beused to raise expectations of asthma management and help
make TOTAL CONTROL the aim for all patients.
Maximum score of 25 indicates
TOTAL asthma control.
Asthma Control Test (ACT)
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Asthma Control Test (ACT)
Is endorsed by severalinternational societies including:
Pakistan -Pakistan Chest SocietyCanada -Canadian Thoracic Society (CTS)Canadian Lung Association (CLA)Australia -Asthma Foundation Australia (AFA)National Asthma Council (NAC)Turkey -
Turkish Thoracic Society (TTS)Korea -Korea Asthma Allergy FoundationAnd many more
Conclusions
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ConclusionsNew Concepts in Asthma Control
TOTAL CONTROLof asthma is achievable
NO Daily Symptoms
NO Rescue salbutamol useNO Days at 80% AM PEF*NO Night-time awakeningNO Exacerbations**NO Adverse Events leading to treatment change
With the right treatment approach, anasthmatic can have a better Quality of Life
1
1. Bateman ED et al.Am J Respir Crit Care Med2004; 170: 836844.
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Full Prescribing Information is available on request
GlaxoSmithKline Pakistan Limited
35 - Dockyard Road, West Wharf, Karachi - 74000
Seretide is a trademark of GlaxoSmithKline group of companies.
GlaxoSmithKline Pakistan Limited is a member of
GlaxoSmithKline group of companies.
GlaxoSmithKline Pakistan Limited
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CASESTUDIES
CASE - A
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CASE A
Patient name: Maryam AhmedAge: 51
Maryam is a 51-year old woman with a history of asthma. She has beenexperiencing a gradual increase in symptoms over the recent years.These include daily symptoms as well as night waking once a weekdespite being treated with inhaled steroids. Her early morningexercise routine is triggering symptoms leading to an over-use of
relief inhalers.As part of the treatment long-acting B2 agonists were added to inhaled
corticosteroids which seemed to bring about relief.However on one occasion, she was exposed to a trigger for an acute
exacerbation which resulted in an attack. Her previous practice oftaking oral corticosteroids was not acted upon due to confusion.When she was presented at a surgery, the receptionist recognized theneed of immediate assessment. When tested, her Peak flow wasmeasured to be 45% and the respiratory rate was 27 breaths/minute.Although Maryam was breathless she was able to speak and explainabout the whole situation to the nurse on duty.
CASE A
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CASE A
Questions
Q1). How will you tackle the problems presented by Maryam?
Q2). What should the doctor do now?
Q3). How should Maryams response be monitored?
Q4). Should Maryam be admitted to the hospital?
?? ?
CASE - B
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CASE B
Name: Maimoona NaseemAge: 40
A 40-year old woman has had increasingly difficult to control asthmasince the birth of her third child at the age of 30 years. She has beenunder the care of another physician, but requests a second opinion.
You confirm that she has been on beclomethasone 1000g twice dailyfrom a pMDI with a spacer device, and that her inhaler technique is
good. In spite of this she has night waking at least 4 times per week,has difficulty completing household chores like sweeping andwashing clothes, and seldom goes out, fearing that she will have anasthma attack.
She has required emergency treatment at your rooms on 4 occasions inthe last year, and on each occasion has required a burst of oralprednisone 40mg daily for 7 days. She has gained weight to 85 kgover the last 2 or 3 years. Previous treatment with theophylline syrup
has provided temporary relief. On examination she has a prominentwheeze, and her FEV1 is 65% of predicted at best. Values as low as28% of predicted have been recorded at emergency visits to the clinic.
CASE B
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CASE B
Questions
Q1) How would you define this patients asthma?
Q2) What should the management/treatment goals be for thiscase?
Q3) For how long should the treatment be continued? When
would you consider stopping treatment?
Q4) What is/ are the most practical method/s for establishingwhether a patients asthma is controlled?
Q5) Which patients should be targeted for use of an AsthmaControl Test?
??
?
CASE - C
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CASE C
Patient name:Uzma KhanAge: 18
Uzma is a 18-year-old female who was referred by her family physician to anallergist, Dr.Raffay. She has moderate persistent asthma and chronicallyuses inhaled corticosteroids. Her chief complaint is of frequent asthmaexacerbations, which have had a significant impact on her quality of lifeand have taken significant time from her studies and other social activities.
These exacerbations often require urgent care visits and treatment withsystemic corticosteroids but is not fully compliant to her medication. Shealso suffers from atopic dermatitis, is allergic to nuts, and is on animmunotherapy regimen.
Uzmas parents are also concerned that shes of marriageable age and howthis problem is going to affect her marriage prospects. Thus they tend toconceal this problem rather than actively seeking out treatment.
Expert Commentaries: Dr. Usman Rafi:The take home message with this patient is that youre dealing with a 18-year-old teenager who will now most likely have life-long asthma andwhose asthma is interfering significantly with her life and the life of herfamily.
CASE C
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CASE C
Questions
Q). Identify key areas where the patient isexperiencing problems in life and explain
how you would help this patient managethe challenges of having asthma.
?
?
?
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TOTAL ASTHMA CONTROL
WHEN?For all uncontrolled asthmatics (4 years & above)
HOW?Daily use of 2 puffs, twice daily
WHY?
Seretideprovides TOTAL ASTHMA CONTROLallowing patients to live life to the fullest
1
1
2
1. Bateman ED et al.Am J Respir Crit Care Med2004; 170: 8368442. Seretide Evohaler Data sheet. Version No. GDS24/IPI12. Date of issue: 31st Jan 2008.
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Live life to the fullest 1