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Transcript of VERSO UN TRATTAMENTO PERSONALIZZATO DELL’ASMA. Valore del farmaco nell’ASMA Controllo della...
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VERSO UN TRATTAMENTO PERSONALIZZATO
DELL’ASMA
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Valore del farmaco nell’ASMA
Controllo della malattia
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panel afirst four days of treatment
panel bfour days of the following week
panel cthe last four daysbefore the fatal attack
mucous plug
thickening of thebasement membrane
Saetta M et al. ERJ 1989;2:1008-1012
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Dissociation between Airway Inflammation and Airway hyperresponsiveness in Allergic Asthma
Crimi E et al. Am J Respir Crit Care Med 1998; 157:4-9
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0
2
4
6
Pre-BD 6 wk
Effects of Inhaled Corticosteroids
Bronchial Function Bronchial SubmucosaAsthmaticsymptoms
Severi
ty
0,01
0,1
1
10
100
Pre-BD 6 wk
PC20 methacholine
(mg/ml)m
g/m
l
nu
mb
er
of
cells
/mm
2 o
f su
bm
uco
sa
eosinophilsT lymphocytesmast cells
0
40
80
120
160
200
240
720
760
Pre-BD6 wk Pre-BD6 wk Pre-BD6 wk
Djukanovic et al, Am Rev Respir Dis 1992;145:669-74
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Added salmeterol versus higher-dose corticosteroid in asthma patients with symptoms on existing inhaled corticosteroidsAP Greening, PW Ind, M Northfield, G Shaw
Lancet 1994; 344:219-224
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A substantial body of evidence from randomized controlled trials indicates that addition of a LABA to existing ICS therapy is clinically more effective than increasing the dose of ICS monotherapy
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L’obiettivo principale del trattamento è ottenere il “buon controllo” dell’asma
Tale indice composito include tutte le principali misure cliniche e funzionali, ed è realisticamente raggiungibile in una alta percentuale di pazienti
Il solo controllo delle riacutizzazioni, senza tener conto dei sintomi quotidiani e del livello di funzione polmonare, non è sufficiente
La rivalutazione periodica dell’ottenuto controllo permette di adeguare la terapia sia in step-up che in step-down
Controllo dell’Asma
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Sintomi diurni nessuno
Uso farmaci al bisogno nessuno
PEF del mattino > 80% predetto
Risvegli notturni nessuno
Riacutizzazione di qualsiasi gravità nessuna
Visite di emergenza nessuna
Eventi avversi dovuti al trattamento nessuno
Definizioni di “controllo”Controllo Totale dell’asma
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Il CONTROLLO TOTALE dell’asma migliora con il trattamento prolungato
Il CONTROLLO TOTALE dell’asma migliora con il trattamento prolungato
100
20
80
0
60
40
Settimane
Salm/FP
Fluticasone
-4 0 4 40 44 4812 16 24 28 32 36 528 20
% d
i pa
zie
nti
con
tro
llati
og
ni s
ett
ima
na
=
To
tal C
on
tro
l Ast
hm
a W
ee
ks
Bateman et al , GOAL study, ARJCCM 2004
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Controllo dell’asma
Nonostante la larga diffusione delle Linee Guida, il controllo dell’asma è ancora insoddisfacente
La gestione del paziente asmatico
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Adherence
Different Phenotypes
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A major reason of the poor control of asthma is that patients fail to adhere to their treatment.
The aim of this study was to identify factors affecting changes in asthma treatment adherence in an
international court
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Among the 428 non-adherent subjects in ECRHS-I, the only predictors of increased adherence among the variables considered were having regular appointments for asthma or not thinking that it is bad to take medicine all the time.
Gender, age at baseline, duration of the disease, smoking habit, educational level, having written instruction from a doctor, having a personal PEF meter and having had spirometry during the previous 12 months were not significant determinants for the improvement or the persistence of adherence to antiasthmatic treatment.
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Adherence
Different Phenotypes
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Nonatopic/Intrinsic
Traditionally asthma has been categorized as…
Atopic/Extrinsic
Allergen exposures,
Progressive allergic inflammation,
Hyperresponsiveness and symptoms in the airways
• Adult onset form of the disease• Absence of family history.• More severe symptoms and nasal
polyps, and persistent airflow limitation in men.
• Atopic asthma often starts in childhood,• Family history• Response to treatment against anti T-
helper cell type 2 (anti-Th2) inflammation
Hyperresponsiveness and symptoms in the airways
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Complexity of asthma
mechanisms
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Clinical or physiological phenotypesSeverity- defined
Exacerbation-prone
Defined by chronic restriction
Treatment-resistant
Defined by age at onset
Phenotypes related to the following triggersAspirin or on-steroidal anti-inflammatory drugs
Enviromental allergens
Occupational allergens or irritants
Menses
Exercise
Inflammatory phenotypesEosinophilic
Neutrophilic
Pauci-granulocytic
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Volume 132, Issue 2 , Pages 336-341
The majority of patients with severe adult-onset asthma are nonatopic and have persistent eosinophilic airway inflammation.
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Wenzel S, Lancet 2006;386:804-813
Eosinophilicsteroid-responsive
Exacerbationprone
Severe
Fixedobstruction
Allergic
Exercise-induced
Early/childhood onset phenotypesEarly/childhood onset phenotypes
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Wenzel SE. Lancet 2006; 368: 804–13Wenzel SE. Lancet 2006; 368: 804–13
Allergic
Severe
OccupationalNon-Allergic
Aspirin-sensitive
Eosinophilic corticosteroid responsive
PMA
Late/adult onsetLate/adult onset
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Clinical or physiological phenotypesSeverity- defined
Exacerbation-prone
Defined by chronic restriction
Treatment-resistant
Defined by age at onset
Phenotypes related to the following triggersAspirin or on-steroidal anti-inflammatory drugs
Enviromental allergens
Occupational allergens or irritants
Menses
Exercise
Inflammatory phenotypesEosinophilic
Neutrophilic
Pauci-granulocytic
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Eosinophilic asthmaNeutrophilic asthma
Paucigranulocytic asthma
EG2 +
Neutrophil elastase +
Haldar e Pavord JACI 2007
Inflammatory Phenotypes
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Eosinophilic asthma
EG2 +Haldar e Pavord JACI 2007
Inflammatory Phenotypes
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Comparison of two methods of processing induced sputum: selected versus entire sputum
A Spanevello et al. AJRCCM 1998; 157: 665-668
30
25
20
15
10
5
0
Selected Sputum Entire Sputum
Eos
inop
hils
(%
) asthmatics
normals
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1
10
100
1000
10000
Eosinophils
(X 1
03 /g)
p<0.05
p<0.001
p<0.01
Control
group
Intermittent
asthma
Mild to moderate
asthma
Severe
asthma
p<0.001
Sputum eosinophils are higher in asthmatics than in controls and their amount in sputum increases with the severity of the disease
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Sputum eosinophil count predicts response to corticosteroids
Meijer et al Clin Exp Med 2002;32:1096-1103
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Asthma exacerbations and sputum eosinophil counts: a randomised controlled trial
Ruth H Green, Christopher E Brightling, Susan McKenna, Beverley Hargadon, Debbie Parker,
Peter Bradding, Andrew J Wardlaw, lan D Pavord
Lancet 2002;360: 1715-21
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Effects of Anti-IgE Omalizumab on Inflammation in Asthma
Djukanovic et al Am J Respir Crit Care Med 2004:170 p583-593
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Targeted therapy with anti IL-5 in asthmaPatients with sputum eosinophils > 3% despite steroid treatment
Haldar et al. NEJM 2009;360:973-984
placebo
250 mg
75 mg
750 mg
Eosinophilic asthma
placebo
75 mg
250 mg
750 mg
exacerbationsexacerbations
Sputum eos Sputum eos
Pavord et al. 2012
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Benralizumab targets eosinophils by binding IL-5 receptor α, inducing apoptosis through antibody-dependent cell-mediated cytotoxicity.
Single-dose intravenous and multiple-dose subcutaneous benralizumab reduced eosinophil counts in airway
mucosa/submucosa and sputum and suppressed eosinophil counts in bone marrow and peripheral blood.
Laviolette M., et al.
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Wenzel S., et al
Patients with persistent, moderate-to-severe asthma and elevated eosinophil levels
human monoclonal antibody to the alpha subunit of the interleukin-4 receptor
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Neutrophilic asthma
Neutrophil elastase +
Haldar e Pavord JACI 2007
Inflammatory Phenotypes
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Neutrophilic Inflammation in severe persistent asthma. A Jatakanon et al. AJRCCM 1999; 160: 1532-1539
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Paucigranulocytic asthma
Haldar e Pavord JACI 2007
Inflammatory Phenotypes
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PhenotypesPhenotypes
Clinical sputum database from January 2005388 samples
297 patients
• AO + AHR + Eosinophils
• AO + AHR + Neutrophils (infective)
• AO + AHR + Neutrophils (non-infective)
• AO + AHR + Eosinophils + Neutrophils
• no AO + AHR + eosinophils
• no AO + AHR, no cellular inflammation
• no AO + no AHR + eosinophils
Data submitted
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Paucigranulocytic asthma
Severe asthma
No inflammatory cells
No biological markers identified
Steroid-resistant
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Assessment of Airway Inflammation
Indirect Indices
Blood inflammatory cells
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The inflammatory marker serum eosinophil cationic protein (ECP) compared with PEF as a tool to decide inhaled corticosteroid dose in asthmatic patientsLowhagen O et al.
Respir Med 2002; 96:95-101
The objective of this study was to compare the inflammatory marker eosinophil cationic protein (ECP) with peak expiratory flow (PEF) in
determining the therapeutic needs of inhaled corticosteroids in asthma patients assessed as asthma symptoms
None of the used algorithms for ECP and PEF led to improvement in symptom scores, in spite of increased doses of inhaled corticosteroids. In
the respect, both methods were equivalent and insufficient
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AJRCC 2009
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AJRCC 2009
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AJRCC 2009
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Lebrikizumab IgG4 humanized monoclonal antibody that binds to IL-13
Stratifying patients into a high Th2 phenotype using serum periostin, which is upregulated in lung epithelial cells by IL-13, may identify individuals responsive to blockade of IL-13.
Corren J et al.
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TAKE HOME MESSAGES
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Where are we now? Asthma is treated empirically
Cont. Uncont.
Step 1SABA PRN
Step 2Low-dose ICS
Step 3Low-dose ICS + LABA,
or Medium-dose ICS
Step 4Medium-dose ICS
+ LABA
Step 5High-dose ICS
+ LABA
Step 6High-dose ICS
+ LABA + oral corticosteroid
High-Need (severe)
NHLBI Guidelines for the Diagnosis and Management of Asthma, Oct 2007
• Standard of care guidelines:
asthma is treated empirically according to clinical severity and response to treatment,
not according to underlying biology
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Treatment A
Treatment B
Treatment C
Treatment D
Asthma TreatmentWhere do we need to go?
Personalized Medicine
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Personalized Medicine for AsthmaGetting there
Improved understanding of the molecular mechanism of different clinical phenotypes of
asthma.
Non-invasive (preferably blood-based) biomarkers that identify molecular phenotypes to guide
treatment.
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Cont. Uncont.
Step 1SABA PRN
Step 2Low-dose ICS
Step 3Low-dose ICS + LABA,
or Medium-dose ICS
Step 4Medium-dose ICS
+ LABA
Step 5High-dose ICS
+ LABA
Step 6High-dose ICS
+ LABA + oral corticosteroid
High-Need (severe)
NHLBI Guidelines for the Diagnosis and Management of Asthma, Oct 2007
OK!!!!
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