ATTUALITA’ ED EVOLUZIONE NELLA GESTIONE CLINICA DELL’ASMA Aggiornamento Linee Guida GINA 2003 1/4/2004 Sala Congressi Hotel Michelangelo Sassuolo Prof. Leonardo M. Fabbri Clinica di Malattie dell’Apparato Respiratorio Università degli Studi di Modena e Reggio Emilia, Modena Global INitiative for Asthma 2003 www.ginasthma.com GINA Structure Executive Committee Chair: Paul O’Byrne, MD Dissemination Committee Science Committee Chair: Tan Wan-Cheng, MD Chair: Eric Bateman, MD GINA reports prepared during workshops conducted in cooperation with the U.S. National Heart, Lung, and Blood Institute, NIH and the World Health Organization. G lobal Initiative for Chronic O bstructive L ung D isease www.goldcopd.com Global Initiative on Obstructive Lung Disease EXECUTIVE COMMITTEE Chair: Romain Pauwels S.Buist, US P.Calverley, UK B.Celli, US L.Fabbri, Italy Y.Fukuchi, Japan L.Grouse, US S.Hurd, US C.Jenkins, Australia C.Lenfant, US J.Luna, Guatemala W.McNee, UK E.Nizankowska-Mogilnicka, Poland K.Rabe, NL R.Rodriguez Roisin, E P.Van Der Molen, NL N.Zhong, China Global Initiative on Obstructive Lung Disease SCIENTIFIC COMMITTEE Chair: Leonardo M. Fabbri P. Barnes, UK S. Buist, US P. Calverley, UK Y. Fukuchi, Giappone W. McNee, UK R. Pauwels, Belgium K. Rabe, Germany Roberto Rodrigues Roisin, Spain N. Zielinski, Poland Third Quarter, 2000: Publication Date from 2000/07/01 to 2000/09/30 Search COPD NOT ASTHMA: All Fields. Limits: All Adult: 19+ years, only items with abstracts, English, Clinical Trial, Human Sort by: Authors (20 citations) No star = Clinical Trial, One * = Randomized Clinical Trials (15 citations) Two ** = Randomized Clinical Trials and Core Clinical Journals (7 citations) ASSIGNMENTS, REVIEWER, PUBLICATION NUMBER Peter Barnes, 8 Sonia Buist, 16, 17 Leo Fabbri, 14, 20, 10, 19 Yoshi Fukuchi, 5, 7, 10, 12, 19, 20 Bill MacNee, 1, 5, 8, 15 Romain Pauwels, 16, 17 Klaus Rabe, 2, 3, 4, 11, 14 Roberto Rodriguez-Roisin, 2, 3, 4, 11, 13, 18 Jan Zielinski, 1, 7, 10, 15, 19 GOLD REPORT – Section 4 Page 32, left column, end of para 2, ORIGINAL TEXT …. tract inflammation57-61. It is likely that indoor air pollution derived from the burning of biomass fuels will prove to have similar effects. SUGGESTED REVISION …. tract inflammation57-61. It is likely that indoor air pollution derived from the burning of biomass fuels will prove to have similar effects. Also bacterial colonization contributes to the airway inflammation in patients with stable COPD. The degree of inflammation also relating to the bacterial load and to the bacterial species (Hill at et al, 2000). Consequences of such colonization and enhanced inflammation on morbidity and lung function is not clear Hill AT, Campbell EJ, Hill SL, Bayley DL, Stockley RA. Association between airway bacterial load and markers of airway inflammation in patients with stable chronic bronchitis. Am J Med 2000 Sep;109(4):288-95 PATIENTS AT HIGH RISK OF DEATH AFTER LUNG-VOLUME–REDUCTION SURGERY National Emphysema Treatment Trial Research Group N Engl J Med 2001; 345: to be published on October 11 Patients at High Risk of Death after Lung-Volume-Reduction Surgery 1 NATIONAL EMPHISEMA TREATMENT TRIAL RESEARCH GROUP Probability of death 0,9 0,8 P < 0.001 0,7 0,6 Surgery 0,5 Medical therapy 0,4 0,3 0,2 0,1 0 0 6 12 18 24 30 36 42 Months since Randomization New Engl J Med 2001; to be published next Oct 11 Levels of evidence Level Source A Randomized clinical trials (RCT). Several, consistent B Randomized clinical trials (RCT). Few, inconsistent C Non-randomized clinical trials. Small and/or observational studies D Opinion of experts INSTITUTE OF SCIENTIFIC INFORMATION (ISI) ISI JOURNAL CITATION REPORTS http://jcrweb.com/ Impact Factor Number of Citations in 2002 Number of articles 2000-2001 IMPACT FACTOR 2002 Medicine, General & Internal: 1) New Engl J Med 2) JAMA – J Am Med Assoc 3) Lancet 4) Ann Intern Med 5) Annu Rev Med 6) Brit Med J 7) Arch Intern Med 8) Medicine 31.74 16.78 15.39 11.41 7.95 7.58 6.74 5.18 IMPACT FACTOR 2002 Respiratory System 1) Am J Resp Crit Care 2) Am J Resp Cell Mol 3) Thorax 4) Am J Physiol-Lung C 5) Chest 6) Eur Respir J 7) J Thorac Cardiov Sur 8) Sarcoidosis Vasc Dif 6.56 4.17 4.08 3.90 2.97 2.94 2.84 2.83 Le linee guida GINA in Italia: passare dalla teoria ai fatti Prof. L.M. Fabbri Processo di aggiornamento delle linee guida Trattamento farmacologico: 2003-2004 Asma grave/BPCO Nuovi farmaci antiasmatici Le linee guida GINA in Italia: passare dalla teoria ai fatti Prof. L.M. Fabbri Processo di aggiornamento delle linee guida Trattamento farmacologico: 2003-2004 Asma grave/BPCO Nuovi farmaci antiasmatici Global INitiative for Asthma 2003 www.ginasthma.com GINA Structure Executive Committee Chair: Paul O’Byrne, MD Dissemination Committee Science Committee Chair: Tan Chen Wan, MD Chair: Eric Bateman, MD GINA reports prepared during workshops conducted in cooperation with the U.S. National Heart, Lung, and Blood Institute, NIH and the World Health Organization. Science Committee E. Bateman, South Africa, Chair P. Barnes, UK J. Bousquet, France W. Busse, USA J. Drazen, USA M. FitzGerald, Canada P. Gibson, Australia S. Holgate, UK J. Kips, Belgium P. O’Byrne, Canada K. Ohta, Japan S. Pedersen, Denmark E. von Mutius,Germany Le linee guida GINA in Italia: passare dalla teoria ai fatti Prof. L.M. Fabbri Processo di aggiornamento delle linee guida Trattamento farmacologico: 2003-2004 Asma grave/BPCO Nuovi farmaci antiasmatici Management of asthma: updating the GINA guidelines Mild Intermittent Avoidance of risk factors, immunotherapy Short-acting beta-2 agonists as needed Mild Persistent Low-dose inhaled steroids Moderate Persistent Moderate Persistent (Severe?) Severe Persistent (Very severe?) Combination of long-acting beta2 agonists with low dose inhaled steroids Combination with higher doses inhaled corticosteroids, theophylline, antileukotrienes Systemic steroids Stepwise Approach to Asthma Therapy Controlled by inhaled short-acting beta-2 agonists prn Step 1: Mild Intermittent Asthma Controller Reliever • Not required • Inhaled beta2-agonist prn <3-4x a day • Inhaled beta2-agonist or Cromolyn or Leukotriene modifier prior to exercise or exposure to antigen Avoid or Control Triggers START – study outline Part A – Budesonide therapy Adults Budesonide 400 g once daily + usual asthma therapy Part B Children (6–10 yrs) Budesonide 200 g once daily + usual asthma therapy Adults Budesonide 400 g once daily + usual asthma therapy Part A – Reference therapy Children (6–10 yrs) Budesonide 200 g once daily + usual asthma therapy Adults and Children Placebo once daily + usual asthma therapy Year Visit 0 1 1 2 3 4 5 6 2 7 8 3 4 5 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Pauwels R et a. Lancet 2003; 371: 1071-1076 START Conclusions • Long-term, once-daily treatment with low-dose budesonide decreases the risk of severe exacerbations by 44% and improves asthma control compared with placebo in patients with recent onset, mild persistent asthma. Pauwels R et a. Lancet 2003; 371: 1071-1076 Stepwise Approach to Asthma Therapy Controlled by low-dose inhaled steroids Step 2: Mild Persistent Asthma Controller Reliever • Daily inhaled corticosteroid (200-500 mcg) • Cromolyn, Nedocromil, sustained release Theophylline • Consider Leukotriene Modifiers • Inhaled beta2-agonist prn <3-4x a day • Inhaled beta2-agonist or Cromolyn or Leukotriene modifier prior to exercise or exposure to antigen Avoid or Control Triggers Effects of Inhaled Beclomethasone Dipropionate in Clinical Asthma PC20 methacholine (mg/ml) Asthmatic symptoms 100 6 4 mg/ml Severity 10 1 2 0,1 0 Pre-BD 6 wk 0,01 Pre-BD 6 wk Bronchial Submucosa number of cells/mm2 of submucosa Bronchial Function mast cells eosinophilsT lymphocytes 760 720 240 200 160 120 80 40 0 Pre-BD6 wk Pre-BD6 wk Pre-BD6 wk Djukanovic et al, Am Rev Respir Dis 1992 Mar;145(3):669-74 LONG-ACTING b2-AGONIST MONOTHERAPY VS CONTINUED THERAPY WITH INHALED CORTICOSTEROIDS IN PATIENTS WITH PERSISTENT ASTHMA A Randomized Controlled Trial Patients with persistent asthma well controlled by low doses of triamcinolone cannot be switched to salmeterol monotherapy without risk of clinically significant loss of asthma control. Lazarus SC et al. JAMA 2001; 285: 2583-2593 Mean % change from baseline in FEV1 Low-dose Fluticasone is More Effective of Montelukast in Mild Persistent Asthma 30 25 20 * * * * * * * * 15 10 FP 88 µg BID 5 MON 10 mg BID 0 Baseline 4 8 12 16 20 24 Endpoint Treatment week Busse W et al., J Allergy Clin Immunol 2001; 107: 461-468 Low Dose Inhaled Budesonide and Formoterol in Mild Persistent Asthma . The OPTIMA Randomized Trial Paul M. O‘Byrne, Peter J. Barnes, Roberto Rodriguez-roisin, Eva Runnerstrom,Thomas Sandstrom, Klas Svensson, and Anne Tattersfield O’Byrne et al. Am. J. Respir. Crit. Care Med. 2001;164 1392-1397 Proportion Time to first severe exacerbation Budesonide 34/226 200 44/227 Budesonide 200 + Formoterol 79/237 Placebo Days O’Byrne et al. Am. J. Respir. Crit. Care Med. 2001;164 1392-1397 Rate for poorly controlled days 0.15 0.144 0.10 0.083 0.073 Rate 0.05 0.00 Placebo Budesonide 200 Budesonide + Formoterol O’Byrne et al. Am. J. Respir. Crit. Care Med. 2001;164 1392-1397 Mometasone furoate administered once daily is as effective as twice-daily administration for treatment of mild-to-moderate persistent asthma _________________________________________________ This is the first study demonstrating that a total daily dose of 400 g of mometasone furoate (MF) administered by dry powder inhaler is an effective treatment for patients with mild-tomoderate persistent asthma previously taking only b2-agonists Kemp et al, J Allergy Clin Immunol. 2000 Sep;106(3):485-92 Stepwise Approach to Asthma Therapy Controlled by inhaled steroids plus long-acting bronchodilators Step 3: Moderate Persistent Asthma Controller Reliever • Add long acting bronchodilators to low dose inhaled steroids • Inhaled beta2-agonist prn <3-4x a day • Inhaled beta2-agonist or Cromolyn or Leukotriene • Increase the dose of inhaled modifier prior to exercise or corticosteroids 800-2,000g exposure to antigen • Add leukotriene modifiers if control is not achieved Avoid or Control Triggers Addition of salmeterol to inhaled BDP is superior to increased dose of BDP in persistent asthma *p<0.05, **p<0.01, ***p<0.001 vs BDP 35 30 Salmeterol 50 g bid + BDP 200 g bid ** ** *** 25 * ** 20 *** 15 10 BDP 500 g bid 5 0 0 3 6 9 12 15 18 21 Time (weeks) BDP, beclomethasone dipropionate; ICS, inhaled corticosteroid PEF, peak expiratory flow Greening et al. Lancet 1994 Change in FEV1 (% predicted) Addition of salmeterol to inhaled BDP is superior to increased dose of BDP in moderate/severe asthma 10 9 8 * * ** ** Salmeterol 50 g bid + BDP 500 g bid 7 6 *p<0.001, **p<0.05 5 4 3 BDP 1000 g bid 2 1 0 0 2 8 16 24 Weeks of treatment BDP, beclomethasone dipropionate Woolcock et al. Am J Respir Crit Care Med 1996 Adapted with permission Changes in FEV1 during the study FEV1 (% of predicted) 90 85 80 75 Higher-dose budesonide plus formoterol Lower-dose budesonide plus formoterol Higher-dose budesonide Lower-dose budesonide -1 0 1 2 3 6 9 12 Month FACET Pauwels RA et al., N Engl J Med 1997 Estimates of severe exacerbation rates BUDH: - 49% (p<0.001) BUD200 h=0.91 BUD200+F h=0.67 BUD800 h=0.46 BUD800+F h=0.34 p=0.031 FORM: - 26% (p=0.014) Pauwels RA et al., N Engl J Med 1997 Estimates of mild exacerbation rates BUDH: - 37% (p<0.001) BUD200 h=35.4 BUD200+F h=21.3 BUD800 h=22.3 BUD800+F h=13.4 FORM: - 40% (p=0.001) FACET p=0.76 Pauwels RA et al., N Engl J Med 1997 Classification of Asthma Severity CLASSIFY SEVERITY Clinical Features Before Treatment Symptoms Nighttime Symptoms PEF STEP 4 Severe Persistent Continuous Limited physical Frequent activity ≤60% predicted Variability >30% STEP 3 Moderate Persistent Daily >1 time week Use b2-agonist daily Attacks limit activity 60-80% predicted Variability >30% STEP 2 Mild Persistent ≥1 time a week but <1 time a day >2times a months ≥80% predicted Variability 20-30% ≤2 times a month ≥80% predicted Variability <20% <1 time a week STEP 1 Intermittent Asymptomatic and normal PEF between attacks One of the features of severity is sufficient to place a patient in that category Treatment Management of Asthma Oral steroids Long-acting bronchodilators and/or LTRA Inhaled steroids Short-acting b2 agonists prn Severity of asthma IMMUNOTHERAPY ? PREVENTION Treatment Options for Patients Not Controlled on Inhaled Steroids Patients not controlled on inhaled steroids Add long-acting beta2-agonists Increase the dose of inhaled steroid Add theophylline Add leukotriene receptor antagonists Montelukast + Budesonide vs higher-dose budesonide 440 Montelukast + budesonide 800 µg (n=433) Budesonide 1600 µg (n=425) 430 420 AM PEF 410 (L/min) p=0.367 between groups during the last 10 weeks of the 12-week treatment period 400 390 Days relative to start of trial -14 -7 0 7 14 21 28 35 42 48 56 63 70 77 84 Run-in Price et al., Thorax 2003 COMPARISON OF INHALED SALMETEROL AND ORAL ZAFIRLUKAST IN PATIENTS WITH ASTHMA In patients with persistent asthma, most of whom currently using inhaled corticosteroids, treatment with inhaled salmeterol provided significantly greater improvement that oral zafirlukast in overall clinical control over the 4-week treatment period Busse WW et al. J Allergy Clin Immunol 1999; 103: 1075-80 A ONE-YEAR COMPARATIVE TRIAL OF MONTELUKAST AND FLUTICASONE VS SALMETEROL AND FLUTICASONE IN PROTECTING AGAINST ASTHMA ATTACKS The study demonstrates the equal clinical benefit of including montelukast or salmeterol in asthma therapy for protection against asthma exacerbations of patients inadequately controlled by inhaled corticosteroids. Biermer L t al. BMJ 2003; in press ADDITION OF LEUKOTRIENE ANTAGONISTS TO THERAPY IN CHRONIC PERSISTENT ASTHMA: A RANDOMISED DOUBLE-BLIND PLACEBO-CONTROLLED TRIAL Used as additional therapy in a hospital outpatient clinic setting, montelukast did not provide such additional benefit in patients with moderate or severe asthma Robinson DS et al Lancet 2001; 357: 2007-11 Le linee guida GINA in Italia: passare dalla teoria ai fatti Prof. L.M. Fabbri Processo di aggiornamento delle linee guida Trattamento farmacologico: 2003-2004 Asma grave/BPCO Nuovi farmaci antiasmatici Differences between asthma and COPD ASTHMA Sensitizing agent COPD Noxious agent Asthmatic airway inflammation CD4+ T-lymphocytes COPD airway inflammation CD8+ T-lymphocytes Marcrophages Eosinophils Neutrophils Completely reversible Airflow limitation limitation Airflow Completely irreversible COPD A Asthma B B C D Fabbri LM et al Am J Respir Crit Care Med 2003;167 418-424 Management of COPD and asthma: GOLD and GINA guidelines ASTHMA Mild Intermittent COPD b2 prn Mild persistent iGCS Moderate persistent Combination Mild b2 prn Moderate LABA Severe Combination LABA+iGCS Severe persistent Oral GCS LABA+iGCS Very severe Oxygen, Sx Surgery Le linee guida GINA in Italia: passare dalla teoria ai fatti Prof. L.M. Fabbri Processo di aggiornamento delle linee guida Trattamento farmacologico: 2003-2004 Asma grave/BPCO Nuovi farmaci antiasmatici TREATMENT OPTIONS IN ASTHMA CURRENT OPTIONS Inhaled corticosteroids Long acting beta2-agonists Leukotriene receptor antagonists FUTURE OPTIONS Better corticosteroids and bronchodilators Phosphodiesterase inhibitors Anti-IgE FUTURISTIC OPTIONS Mediator antagonists Non-steroidal antiinflammatory agents Chemokine and chemokine receptor antagonists Gene therapy Modified by P.J. Barnes, 2003 IgE AND ITS INHIBITION IN ATOPY FcRI IL-4, IL-13 Mast cell Histamine Cys-LTs PGD2 FcRII (CD23) Y IgE Macrophage Chronic inflammation B lymphocyte rhuMAb-E25, omalizumab Modified by P.J. Barnes, 2003 T lymphocyte Eosinophil ANTI-IgE IN STEROID-DEPENDENT ASTHMA omalizumab: iv. 2x weekly x 12 weeks then reduction over 8 weeks Oral steroids % Patients 80 Placebo Anti-IgE (low dose) Anti-IgE (high dose) 60 40 20 L0 L >50% reduction Milgrom H et al: NEJM 1999 Discontinuing EFFECT OF ANTI-IgE IN ASTHMA 100 Moderate to severe allergic asthma p<0.001 Omalizumab sc 28wks 80 Placebo FEV1, PEF Exacerbations (58%) 60 p<0.001 40 20 0 Median BDP dose reduction (%) Complete BDP withdrawal (%) Soler M et al: Eur Respir J 2001 POSITION OF ANTI-IgE IN THE TREATMENT OF ASTHMA • • Patients with more severe asthma steroid-dependent, steroid-resistant, brittle Patients with severe concomitant allergic diseases • Poor compliance with existing therapy ? • Cover for immunotherapy ? Modified by P.J. Barnes, 2003 Management of asthma: updating the GINA guidelines Mild Intermittent Avoidance of risk factors, immunotherapy Short-acting beta-2 agonists as needed Mild Persistent Low-dose inhaled steroids Moderate Persistent Moderate Persistent (Severe?) Severe Persistent (Very severe?) Combination of long-acting beta2 agonists with low dose inhaled steroids Combination with higher doses inhaled corticosteroids, theophylline, antileukotrienes Systemic steroids Le linee guida GINA in Italia: passare dalla teoria ai fatti Prof. L.M. Fabbri Processo di aggiornamento delle linee guida Trattamento farmacologico: 2003-2004 Asma grave/BPCO Nuovi farmaci antiasmatici ATTUALITA’ ED EVOLUZIONE NELLA GESTIONE CLINICA DELL’ASMA Aggiornamento Linee Guida GINA 2003 Prof. Leonardo M. Fabbri Clinica di Malattie dell’Apparato Respiratorio Università degli Studi di Modena e Reggio Emilia, Modena