ASTHMA

MANAGEMENT

LONG-TERM THERAPY

Pathogenesis of asthma

Pathogenesis of
asthma
(NHLBI/WHO 1995)

Environmental risk factor

Inflammation

Symptoms
Airway
hyperresponsiveness

Airflow limitation

Triggers

Asthma is an inflammatory
disease

Triggers

Inflammation
()
(+)

Normal
Bronchial hyperreactivity (-)

Symptoms (-)

Asthma
Bronchial hyperreactivity
Symptoms (+)

Ca++ Histamin

Ag

Ig E

YY

Phospholipid

Methyl
transferase

Phosphatidyl
ethanolamine

Phosphatidyl
choline

Phospho Ca++
Arachidonic acid lipase A2
lypoxygenase
cyclooxygenase
5-HETE

Leucotrienes
LTB4
LTC4
LTD4
LTE4

Mediator release in
asthma reactions

Histamin
ECF, NCF

Thromboxanes Prostaglandins
TXA2
PGD
PGF2

ASTHMA PROFILE

ASTHMA PROFILE IN THE WORLD

Globally, over 150 million people diagnosed with asthma

Globally, over 180,000 people die from asthma each year
Globally, the economic burden of asthma are estimated
to be greater than TB and HIV/AIDS or combined
Major factors contributing to asthma morbidity and mortality
are underdiagnosis and inappropriate treatment

PATIENTS
( Yayasan Asma
Indonesia Wilayah Sumatera Utara , 200, 93-95)
PROFILE
More than one year

93 %

Used anti inflammation

25 %

Used objective values

9%

Inhaller tehnique (poor )

92 %

Compliance

19 %

Dose interval

17 %

PATIENTS PROFILE

( Yayasan Asma Indonesia Wilayah Sumatera Utara, 300, 96-99)

More than one year

96 %

Used anti inflammation

32 %

Used objective values

7%

Inhaller tehnique (poor )

89 %

Compliance

23 %

Dose interval

21 %

Reflected in Indonesian Asthma Market

(IPMG Nov 2001)

World Asthma Market

(IMS 2000)
1%
16%

30%
5%

6%

7%

35%

b2-agonist
Xanthines
NS Antiinflammatory
Inhaled Steroid
Anticholinergics
Antileukotriene
Other

Change paradigm
of asthma
To/

To/

Symptoms

Diseases

control

control

Anti Inflammations is
the mainstay therapy

Inflammation

Controller

Bronchial hyperreactivity
Reliever

Symptoms
Pathogenesis of asthma

AIRWAY REMODELLING IN ASTHMA

Desquamation of epithelium
Increase in airway smooth muscle
Vascular proliferation
Collagen deposition
Thickening of basement membrane
Increase in bronchial glands
Vascular congestion
Oedema formation
Cellular infiltration

Natural History of Asthma

CURE

UNCORRECT TREATMENT

CHRONIC ASTHMA
AIRWAY
REMODELLING

PERSISTENCE OF INFLAMMATION
AIRWAY REMODELLING

CHRONIC ASTHMA

AIRWAY REMODELLING IN ASTHMA

Pha

?
c
i
t
e
n
i
k
o
rm ac

Eosinophil

Desquamation of epithelium

MBP, ECP
Epithelium

Thickening of basement membrane

Increase in airway smooth muscle

Epithelial Damage

P Jeffery, in: Asthma, Academic Press 1998

FE
V

Symptom
Exacerbatio
n
Symptom

e lli
d
o
Rem
g

Time

Era of Asthma management

1930th

: Xanthin

1960th

: Beta2-agonist

1970th

: Steroid inhallation

2000th

: Combination

2003th

: Single inhaler combination

Steroid depo ?

Evolving treatment options

Large use of
short-acting
2-agonists
1975

ICS treatment
introduced
1972

Adding
LAA to ICS therapy

Kips et al, AJRCCM 2000

Pauwels et al, NEJM 1997
Greening et al, Lancet 1992 Single

inhaler therapy
(Symbicort)
Fear of
short-acting
2-agonists

1980

1985
1990
Bronchospasm

1995
Inflammation

Remodelling

2000

Controller:
Anti inflammation
Non steroid

Steroid

sodium chromoglicate
budesonide
(Pulmicort)
(Intal)
(Inflamid)
ketotifen

beclomethasone
dipropionate
sodium nedocromil
(Becotide)
triamcinolone
acetonide

Reliever
Bronchodilator
2 - agonist
Xanthin
Anticholinergic

BRONCHODILATOR
Short Acting 2 AGONIST (SABA):

Long Acting 2 AGONIST:

* salbutamol/albuterol (Ventolin )

(LABA)

* terbutaline (Bricasma)
* procaterol
* fenoterol
* orciprenaline, etc

salmoterol
formoterol

ANTICHOLINERGIC:

XANTHINE:

* atropine sulfate

* theophylline

* ipratropium bromide, etc

OTHER SYMPHATOMIMETIC:

* ephedrine
* adrenaline, etc

ADULT PATIENTS & CAREGIVERS OF CHILDREN WITH ASTHMA

WERE ASKED WHY THEY DID NOT TAKE THEIR INHALED
CORTICOSTEROID AS PRESCRIBED?

45% said they just forgot

42% said that they felt
well

Stahl AJRCCM, 2002

Combination therapy
Symbicort
Budesonide + Formoterol

Seretide
Fluticasone + Salmoterol

The Beginning of
Treatment

Exacerbation

The beginning of treatment

Stable condition

Peak flow meter

Objective
value

600-700 (

300

normal )

PEFR Monitoring:
A Major Tool in Asthma Self-Management
Chronic Diseases

Monitor

Hypertension

Blood pressure

Diabetes

Serum glucose

Asthma

PEFR

THE GOALS FOR SUCCESSFUL

MANAGEMENT
OF1995)
ASTHMA
( NHLBI / WHO,
Achieve and maintain control of symptoms
Prevent asthma exacerbations
Maintain pulmonary function as close to normal
levels as posible
Maintain normal activity levels, including exercise
Avoid adverse effect for asthma medications
Prevent development of irreversible airflow limitation
Prevent asthma mortality

MANAGEMENT
ANTI INFLAMMATION, FIRST LINE, EARLY
BRONCHODILATOR, OBJECTIVE VALUE
MEDICINE , SELECTIVE
TIME, PROPERLY
TECHNIQUE, PROPERLY
REHABILITATION, DO
TRIGGER FACTORS, AVOID

THANK YOU