Dr Terry O'Connor, Consultant in Respiratory Medicine, Mercy ...

Dr Terry O’Connor, Consultant in Respiratory Medicine, Mercy University Hospital, Cork

Asthma - Treatment
Dr Terry O’Connor,
Consultant Respiratory Physician,
Mercy University Hospital, Cork

Diagnosis of Asthma
• Episodic symptoms of airflow obstruction are present.
• Airflow obstruction is at least partially reversible
– Spirometry is performed when the patient has avoided
inhaled β2-agonists for 12 hours and repeated 15-30
minutes after β2-agonist inhalation. A rise of 12% or more
and 200 mls in the FEV 1 constitutes significant reversibility
• Alternative diagnoses are excluded

Goals for Asthma Control
• Achieve and maintain control of symptoms
• Prevent asthma episodes or attacks
• Minimal use of reliever medication
• No emergency visits to doctors or hospitals
• Maintain normal activity levels, including exercise
• Maintain pulmonary function as close to normal as possible

Patients achieving control
Only 8% of patients
achieve asthma
control
Manning P, et al. AIRI Study Irish Medical Journal 2005

Risk Factors that Lead to Asthma
Predisposing Factors
• Atopy
• Genetic profile
Causal Factors
• Indoor Allergens
– Domestic mites
– Animal Allergens
– Cockroach Allergens
– Fungi
• Outdoor Allergens
– Pollens
– Fungi
• Occupational Sensitizers
Contributing Factors
• Respiratory infections
• Small size at birth
• Diet
• Air pollution
– Outdoor pollutants
– Indoor pollutants
• Smoking
– Passive Smoking
– Active Smoking

Asthma candidate genes
Potential genes involved in asthma pathogenesis
• ADAM33 a disintegrin and metalloproteinase-33 gene
• PHF 11 possibly regulates lymphocyte activation, B cells
& immunoglobulin synthesis
• DPP10 may regulate chemokines and cytokines
• GPRA a G protein-coupled receptor
Potential genes involved in response to therapy
• Polymorphisms in β 2-adrenoceptor gene
• Polymorphisms in leukotriene C4 synthase gene
Treatments of asthma in the future could conceivably be tailored
to a patient’s specific genotype – DNA microarray chip

Allergy assessment and treatment

RAST versus Skin tests
IgE 324 kU/L (

RAST
HDM
6
5
4
3
2
1
0
0 10 20 30 40 50 60 70
Age (Years)
r = -0.7057
p < 0.0001
Sheikh S, O’Connor TM. European Respir J 2006; 677s.

Asthma treatment

Classification of Asthma Medication
Relief
• Short-acting β2-agonists – Salbutamol
– Terbutaline
• Anticholinergics
– Ipratropium Bromide
• Short-acting theophylline
– Aminophylline
• Adrenaline injections
Control
• Corticosteroids
– Beclomethasone
– Budesonide
– Fluticasone
• Sodium Cromoglycate
• Long-acting β 2 -agonists
– Salmeterol, Formoterol
• Long-acting theophylline
• Leukotriene receptor antagonists
– Zafirlukast, Montelukast

GINA 2007

• Relievers
• Inhaled
bronchodilators
– Ventolin ®
– Bricanyl ®
• Injectable agents
– Xolair ®
Types of Treatment
• LTRAs
– Singulair ®
• Theophyllines
– Uniphyllin ®
• Controllers
• Inhaled corticosteroids
– Becotide ®
– Beclazone ®
– Pulmicort ®
– Alvesco ®
• Inhaled corticosteroids
plus bronchodilators
– Symbicort ®
– Seretide ®

How MDI Technology Works

How DPI Technology Works

Controllers
Inhaled Corticosteroids
• Reduces airway swelling over time, decreases airway hyperresponsiveness
• Must be taken daily, even if no symptoms
• Will not relieve acute asthma symptoms

Time courses of improvement with
ICS therapy
% improvement 100
0
No night
symptoms
Days
FEV 1
Weeks
am PEF
Months
No SABA use
AHR
Years
Woolcock AJ. Clin Exp Allergy Rev 2001; 1:62

Side-Effects of Inhaled Steroids

Local
Inhaled Steroids Side Effects
• Hoarseness (5%)
• Candidiasis - oropharyngeal and
oesophageal (2%)
• Local irritation - cough,
bronchoconstriction (1%)
Systemic
• Hypothalamic - pituitary -
adrenal axis
• Osteopenia
• Growth impairment
• Skin thin/bruising
• Postcapsular cataract

Steroid Phobia: Unfounded!
• Inhaled steroids in doses most often prescribed are very safe
• Inhaled meds delivered directly to lungs where they are needed
• Little systemic absorption if proper technique used

Xolair (Omalizumab)
IgE Blocker Therapy
• Dosing based on IgE levels and weight
• Only for ages over 12 years old
• Must have evidence of specific allergy sensitivity
• Used for those with poorly controlled asthma and noncompliant
with standard recommended therapy
• Delivered by Subcutaneous injection

Asthma prevention
• In all infants breastfeeding should be encouraged for at least 4-6
months, and exposure to tobacco smoke should be avoided
during pregnancy and early childhood.
• With high risk of allergy, the optimal age for the introduction of
selected supplemental foods should be 6 months, dairy products
12 months, hen's egg 24 months, and peanut, tree nuts, fish,
and seafood at least 36 months.
• In homes of HR-infants, evidence supports measures to reduce
the levels of indoor allergens.

Alternative Therapies
• The reported level of use for adults ranges from 4% to 79%, and
for children from 33% to 89%.
• Four common treatments:
– Breathing techniques (including Buteyko)
– Herbal products
– Homeopathy
– Acupuncture
• There is no strong evidence for effectiveness for any of these
modalities.
• Futher research needed before any of these treatments can be
recommended
Holloway E, et al. Breathing exercises for asthma. Cochrane Database Syst Rev. 2004;:CD001277. Review.
McCarney RW, et al. Homeopathy for chronic asthma. Cochrane Database Syst Rev. 2004;:CD000353. Review.
McCarney RW, et al. Acupuncture for chronic asthma. Cochrane Database Syst Rev. 2004;:CD000008. Review.

• Asthma is a chronic disease
Conclusions
• Control is the ideal, not lots of puffs of Ventolin
• The only way to achieve control is to take controllers regularly
• Complementary therapies unproven
• Total control is achievable for most patients

Denis Hickie
Asthma without Limits
Paul Scholes
Ronan O’Gara
Paula Radcliffe
Mark Spitz