asthma long term treatment
TRANSCRIPT
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ASTHMAASTHMAMANAGEMENTMANAGEMENT
LONG-TERM THERAPY
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Inhalation therapy isInhalation therapy is
the mainstay therapythe mainstay therapy
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Gaps between treatment goal and the
reality
no chronic symptoms
no asthma attacks
no emergency visits
no need for quick relief (asneeded) 2-agonist
normal physical activity
including exercise
lung function as close tonormal as possible
no adverse effects from
medicine
Frequent chronic symptoms
Some asthma attacks
Some emergency visits
Excessive use of 2-agonist
as reliever
Impaired physical activity
including exercise
Some ups and do!ns in
lung function
Frequent adverse effects from
medicine
"#E $%&'"#E $%&' "#E (E&'I")"#E (E&'I")
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Pathogenesis of asthmaPathogenesis of asthma
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Pathogenesis ofPathogenesis of
asthmaasthma
(NHLBI/WHO 199!(NHLBI/WHO 199!
InflammationInflammation
"n#ironmental ris$ %a&tor"n#ironmental ris$ %a&tor
'irway'irwayhyperresponsi#enesshyperresponsi#eness
riggersriggers
'ir%low limitation'ir%low limitation
)ymptoms)ymptoms
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Asthma is an inflammatoryAsthma is an inflammatory
diseasedisease
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*ormal &sthma
Inflammation()(!)
+ronchial hyperreactivity+ronchial hyperreactivity ,-
Symptoms ,.Symptoms ,-
"r
iggers
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Ig "Ig "
AgAg
**
#ethyl#ethyl
transferasetransferase$hospholipid$hospholipid $hosphatidyl$hosphatidyl
ethanolamineethanolamine
$hosphatidyl$hosphatidyl
cholinecholine
$hospho$hospholipase Alipase A22
%a%a &istamin&istamin
%a%a &istamin&istamin
"%' %'"%' %'Arachidonic acidArachidonic acid
lypoxygenaselypoxygenase cyclooxygenasecyclooxygenase
*-&"+"*-&"+",eucotrienes,eucotrienes
,+,+..,+%,+%..,+/,+/..,+",+"..
+hromboxanes+hromboxanes
+0A+0A22
$rostaglandins$rostaglandins
$1/$1/$1'$1'22
#ediator release inasthma reactions
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+iagnosis
+ata
'nalisis
,lanning
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+iagnosis+ata-
'nalisis
,lanning
'sma
Bat.$
)esa$engi
0el.arga asma
Obat asma
,em2isi$
)pirometri
',"
es ,ro#o$asi
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'% 3 4$
the total volume forcibly exhaled
'"5 3 "$5
the amount exhaled in the first second
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3
4
5
6
1
7
'"5 '%
1 6 5 4 3
ime (se&!
8
ol.me(liters!
Fig 2. Normal forced expiration curve
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,ea$ 2low eter /,"2/',"
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ASTHMA PROFILEASTHMA PROFILE
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ASTHMA PROFILE IN THE WORLDASTHMA PROFILE IN THE WORLD
$lo/ally0 over$lo/ally0 over 13 million13 millionpeople diagnosed !ith asthmapeople diagnosed !ith asthma
$lo/ally0 the economic /urden of asthma are estimated$lo/ally0 the economic /urden of asthma are estimated
to /e greaterto /e greaterthan "+ and #I45&I6S or com/inedthan "+ and #I45&I6S or com/ined
$lo/ally0 over$lo/ally0 over 1730333 people1730333 peoplediedie from asthma each yearfrom asthma each year
8a9or factors contri/uting to asthma mor/idity and mortalityare underdiagnosisand inappropriate treatment
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PATIENTSPATIENTS
PROFILEPROFILE, )ayasan &sma Indonesia :ilayah Sumatera;tara 0 2330
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PATIENTS PROFILEPATIENTS PROFILE( 6ayasan Asma Indonesia 7ilayah 8umatera 9tara :;;
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7orld Asthma #arket7orld Asthma #arket
(I#8 2;;;)(I#8 2;;;)
@>
B>
>
1@>
1>
=3>
=>
/2-agonist
Aanthines
*S &ntiinflammatory
Inhaled Steroid&nticholinergics
&ntileukotriene
%ther
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Anti Inflammations isAnti Inflammations is
the mainstay therapythe mainstay therapy
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atural &istory of Asthmaatural &istory of Asthma
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&NORRET TREATMENT&NORRET TREATMENT%9>"%9>"
%&>?I% A8+A%&>?I% A8+A
AI>7A6AI>7A6
>"#?/",,I1>"#?/",,I1
CE(SIS"E*DE %F I*F'&88&"I%*CE(SIS"E*DE %F I*F'&88&"I%*
&I(:&) (E8%6E''I*$&I(:&) (E8%6E''I*$ D#(%*ID &S"#8&D#(%*ID &S"#8&
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AIRWAY REMODELLING IN ASTHMAAIRWAY REMODELLING IN ASTHMA
+es=.amation o% epitheli.m+es=.amation o% epitheli.m
In&rease in airway smooth m.s&leIn&rease in airway smooth m.s&le
8as&.lar proli%eration8as&.lar proli%eration
>ollagen deposition>ollagen depositionhi&$ening o% basement membranehi&$ening o% basement membrane
In&rease in bron&hial glandsIn&rease in bron&hial glands
8as&.lar &ongestion8as&.lar &ongestion
Oedema %ormationOedema %ormation
>ell.lar in%iltration>ell.lar in%iltration
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"pithelial /amage"pithelial /amage
P 'e(e")* in+ Asthma* A,a#emi, P"ess ../
AIRWAY REMODELLING IN ASTHMAAIRWAY REMODELLING IN ASTHMA
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#$ "%$#$ "%$
Eosinophil
Epithelium
$harma
cokinetic
@
AIRWAY REMODELLING IN ASTHMAAIRWAY REMODELLING IN ASTHMA
+es=.amation o% epitheli.m+es=.amation o% epitheli.m
hi&$ening o% basement membranehi&$ening o% basement membrane
In&rease in airway smooth m.s&leIn&rease in airway smooth m.s&le
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asement #embrane+hickening
P 'e(e")* in+ Asthma* A,a#emi, P"ess ../
) h l H l i
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)mooth .s&le Hyperplasia
P 'e(e")* in+ Asthma* A,a#emi, P"ess ../
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Fata$ Asthma
Jeery,1994
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"ra of Asthma management"ra of Asthma management
5
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"volving treatment options"volving treatment options
1
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DontrollerDontroller
&nti inflammation&nti inflammation
23#esoni#e4P3$mi,o"tCC5
4In6ami#CC5
2e,$omethasone#i!"o!ionate47e,oti#eCC5
t"iam,ino$onea,etoni#e
so#i3m ,h"omog$i,ate
4Inta$CC5
8etotifen so#i3m ne#o,"omi$
SteroidSteroid*on steroid*on steroid
ild 'sthma has 'irway
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ild 'sthma has 'irway
In%lammation
I>) e#erses In%lammation
Laitinen* ' A$$e"g) $in Imm3no$* ..9
E
BM
Pre and post month treatment !ith B"# $%% &'(d
E
BM
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+ronchodilator+ronchodilator
22 -- agonistagonist
&AanthinAanthin
&&nticholinergic&nticholinergic
Re$ie%e"Re$ie%e"
+(%*D#%6I'&"%(+(%*D#%6I'&"%(
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+(%*D#%6I'&"%(+(%*D#%6I'&"%(
Short &ctingShort &cting 22&$%*IS" ,S&+&&$%*IS" ,S&+&
sal/utamol5al/uterol ,4entolin sal/utamol5al/uterol ,4entolin CC ter/utaline ,+ricasma ter/utaline ,+ricasmaCC procaterol procaterol
fenoterol fenoterol
orciprenaline0 etc orciprenaline0 etc
&*"ID#%'I*E($ID&*"ID#%'I*E($ID
atropine sulfate atropine sulfate
ipratropium /romide0 etc ipratropium /romide0 etc
%"#E( S)8C#&"%8I8E"ID%"#E( S)8C#&"%8I8E"ID
ephedrine ephedrine
adrenaline0 etc adrenaline0 etc
A&*"#I*EA&*"#I*E
theophylline theophylline
'ong &cting'ong &cting 22&$%*IS"&$%*IS"
,'&+&,'&+&
&salmoterolsalmoterol
&formoterolformoterol
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Increased Mem(rane Basic Protein )MBP* positive area ) the redIncreased Mem(rane Basic Protein )MBP* positive area ) the red
and epithelial sheddin' in the s+(ect in clinical remission-and epithelial sheddin' in the s+(ect in clinical remission-
Hea$th) S32
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G.idelines on 'sthma-
,ast and >.rrent rends
LA7A=ISIS
LA7A=IS
GINA ../4a#a!te#5
3""ente%i#en,es
Se%e"e!e"sisten
t
Mo#e"ate!e"sisten
t
Mi$#!e"sisten
t
Inte"mittent
Sho"t-a,ting :-agonists9!"n
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+he rationale behind fixed
combination therapy'o increase a!herence to controller
therapy'o gain better control ith less inhale!
steroi!
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>?@ sai# the)
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%ombination therapy%ombination therapy
8ymbicort8ymbicortCC
udesonide 'ormoteroludesonide 'ormoterol
8eretide8eretideCC
'luticasone 8almoterol'luticasone 8almoterol
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+he eginning of+he eginning of+reatment+reatment
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"xacerbation"xacerbation
+he beginning of treatment+he beginning of treatment @
8table condition8table condition
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Ceak flo! meterCeak flo! meter
@33-B33
;
:;;
, normal ObjectiveObjectivevaluevalue
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"#E $%&'S F%( S;DDESSF;'"#E $%&'S F%( S;DDESSF;'8&*&$E8E*" %F &S"#8&8&*&$E8E*" %F &S"#8&
( NHLBI / WHO, !!"#( NHLBI / WHO, !!"#
&Crevent asthma exacer/ationsCrevent asthma exacer/ations
&&chieve and maintain control of symptoms&chieve and maintain control of symptoms
&Crevent asthma mortalityCrevent asthma mortality
&Crevent development of irreversi/le airflo! limitationCrevent development of irreversi/le airflo! limitation
&&void adverse effect for asthma medications&void adverse effect for asthma medications
&8aintain normal activity levels0 including exercise8aintain normal activity levels0 including exercise
&8aintain pulmonary function as close to normal8aintain pulmonary function as close to normal
levels as posi/lelevels as posi/le
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A+I I',A##A+I? FI$%& LIN''$L)
#AA1"#"+#AA1"#"+
+>I11"> 'A%+?>8+>I11"> 'A%+?>8 AVOID
>"&AI,I+A+I?>"&AI,I+A+I?*O*O
+"%&ID9" +$O+'$L)
+I#"+I#"+$O+'$L)+$O+'$L)
#"/I%I" #"/I%I" %'L'&I-'%'L'&I-'
>?%&?/I,A+?> OB'&I-' -L'
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+&A4 6?9
Ai R # $$i iAi R # $$i i
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Ai"a) Remo#e$$ing inAi"a) Remo#e$$ing in
AsthmaAsthma%
2
%
12
1%
2
%
0orrelation (et!een s+(epithelial layer thic3ness and asthma severity scorein 4 asthmatic patients-
.sthma severity score
% 1$4 1%
rs = 0.581p 0.001S
+(epithe
liallayerthic3ness
)&m*
0hetta 05ES6 19978 111$:$7
GINA 9BB9
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S)stemi, G$3,o,o"ti,oste"oi# 4Pa"ente"a$5
Systemic 'l+cocorticosteroid speed resol+tion o; e SE0ERE PERSISTENT
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TREATMENTTREATMENT
A%oi# o" ,ont"o$ t"igge"sA%oi# o" ,ont"o$ t"igge"s
STEP + INTERMITTENTSTEP + INTERMITTENT
A%oi# o" ,ont"o$ t"igge"sA%oi# o" ,ont"o$ t"igge"s
STEP 9+ MILD PERSISTENTSTEP 9+ MILD PERSISTENT
A%oi# o" ,ont"o$ t"igge"sA%oi# o" ,ont"o$ t"igge"s
STEP C+ MODERATE PERSISTENTSTEP C+ MODERATE PERSISTENTA%oi# o" ,ont"o$ t"igge"sA%oi# o" ,ont"o$ t"igge"s
STEP >+ SE0ERE PERSISTENTSTEP >+ SE0ERE PERSISTENT
ONTROLLER+#ai$) me#i,ations Inha$e# ste"oi# O" !ossi2$) ,"omone* o"a$
theo!h)$$ine o" anti-$e38ot"iene
RELIE0ERInha$e# :9-
agonist!"n
ONTROLLER+#ai$) me#i,ationsInha$e# ste"oi# an#$ong-a,ting2"on,ho#i$ato"
onsi#e" anti-
$e38ot"iene
RELIE0ERInha$e# :9-
agonist!"n
RELIE0ERInha$e# :9-
agonist!"n
RELIE0ERInha$e# :9-
agonist!"n
ONTROLLER+#ai$) m3$ti!$eme#i,ations
Inha$e# ste"oi#Long-a,ting
2"on,ho#i$ato"O"a$ ste"oi#
ONTROLLER+none
Ste!#onhen
,ont"o$$e#
Ste!#onhen
,ont"o$$e#
Ste! 3!if not ,ont"o$$e#4afte" ,he,8 on
inha$e" te,hni3ean# ,om!$ian,e5
Ste! 3!if not ,ont"o$$e#4afte" ,he,8 on
inha$e" te,hni3ean# ,om!$ian,e5
Patient e#3,ationessentia$ at e%e")
ste!
Re#3,e the"a!)if ,ont"o$$e# fo" at
$east C months
ontin3emonito"ing