out with albuterol?
TRANSCRIPT
![Page 1: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/1.jpg)
Out with Albuterol?Rethinking strategies in Mild Asthma
TAY L O R T H O O F T, P H A R M D, B C P S
P H A R M AC I S T C L I N I C I A N - E S S E N T I A H E A LT H
S T. M A RY ’ S D E T RO I T L A K E S C L I N I C
PA R K R A P I D S C L I N I C
![Page 2: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/2.jpg)
Disclosures
No financial closures
No personal conflicts of interest
Will discuss off-label use of medications
![Page 3: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/3.jpg)
Objectives
• Describe the rationale for the changes in the management of asthma
• Identify treatment recommendations for the management of asthma in adults using the 2020 Global Initiative on Asthma (GINA) strategy
• Recognize barriers to the implementation of the GINA strategy
![Page 4: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/4.jpg)
Common Abbreviations
• ICS: Inhaled Corticosteroid
• LABA: Long-acting Beta Agonist
• SABA: Short-acting Beta agonist
• FEV1: Forced Expiratory Volume 1 second
• GINA: Global Initiative for Asthma
• DPI: Dry Powder Inhaler
• HFA: Hydrofluoroalkane
![Page 5: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/5.jpg)
KNOWLEDGE CHECK!
17-year-old female patient is diagnosed with mild asthma today. Which of
the following are appropriate treatment options?
a) Fluticasone/salmeterol twice daily
b) Fluticasone/salmeterol as needed
c) Budesonide/formoterol as needed
d) B and C
![Page 6: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/6.jpg)
KNOWLEDGE CHECK!
Which of the following beta-agonist bronchodilators has the fastest onset of
action?
a) Albuterol
b) Formoterol
c) Salmeterol
d) A and B
![Page 7: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/7.jpg)
KNOWLEDGE CHECK!
Which of the following Classes of medications can help decrease the risk of
asthma exacerbations?
a) Inhaled Corticosteroids (ICS)
b) Long-Acting Beta Agonists (LABA)
c) Short-Acting Beta Agonists (SABA)
d) B and C
![Page 8: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/8.jpg)
What we know about asthma
• Asthma is a disease of airway inflammation and hyperresponsiveness• SABA helps decrease symptoms, but does not decrease inflammation
• Inflammation increases the risk of exacerbations
• Patients can become over reliant on SABA because it relieves their symptoms• ICS non-adherence is common
• Patients with mild asthma are still at risk of sever adverse events
• 30-37% adults experience acute exacerbations resulting in emergency department visit or hospital admission
![Page 9: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/9.jpg)
GINA: Global Initiative for Asthma
STRATEGY not a guideline
First major update in terms of treatment strategy in 30 years
![Page 10: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/10.jpg)
©2020 Global Initiative for Asthma, reprinted with permission. Available from www.ginasthma.org
![Page 11: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/11.jpg)
Definitions and Differences
A S T H M A C O N T RO L
• Extent to which the manifestations of asthma can be observed in the patient, or have been reduce or removed by treatment
• Many studies describe a discordance between provider’s assessment and patient’s assessment
A S T H M A S E V E R I T Y
• Assessed retrospectively from the level of treatment required to control symptoms
• Not static, can change over months or years
![Page 12: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/12.jpg)
![Page 13: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/13.jpg)
©2020 Global Initiative for Asthma, reprinted with permission. Available from www.ginasthma.org
![Page 14: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/14.jpg)
©2020 Global Initiative for Asthma, reprinted with permission. Available from www.ginasthma.org
![Page 15: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/15.jpg)
Management of Mild Asthma
Traditional Management
• SABA as needed
GINA 2020
• ICS/formoterol as needed
• SABA as needed
![Page 16: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/16.jpg)
Pharmacology- why formoterol? Agent Classification Initial Response Peak Response Duration
Albuterol SABA 5 minutes 47-56 minutes 3-6 hours
Levalbuterol SABA 5-10 minutes 76-78 minutes 3-6 hours
Formoterol LABA 1-3 minutes 60-180 minutes 8-12 hours
Salmeterol LABA 30-48 minutes 120-180 minutes 12 hours
Vilanterol LABA 27 minutes 360 minutes undefined
![Page 17: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/17.jpg)
©2020 Global Initiative for Asthma, reprinted with permission. Available from www.ginasthma.org
![Page 18: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/18.jpg)
©2020 Global Initiative for Asthma, reprinted with permission. Available from www.ginasthma.org
![Page 19: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/19.jpg)
NOVEL-START
NOVEL SYMBICORT (BUDESONIDE/FORMOTEROL)TURBUHALER ASTHMA REL IEVER THERAPY
![Page 20: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/20.jpg)
Primary Outcome
• Annualized rate of asthma exacerbations per patient
• Urgent medical consultation
• Prescription for systemic glucocorticosteroids
• An episode of high Beta-agonist use
![Page 21: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/21.jpg)
Design
Mild Asthma
Albuterol Daily Budesonide plus Albuterol as needed
Budesonide/Formoterol as needed
![Page 22: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/22.jpg)
Results
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45Annualized Exacerbation Rate
Albuterol Budesonide plus PRN albuterol Budesonide/formoterol PRN
![Page 23: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/23.jpg)
Results
0
5
10
15
20
25Number of Severe Exacerbations
Albuterol Budesonide plus PRN albuterol Budesonide/formoterol PRN
![Page 24: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/24.jpg)
Results
0
50
100
150
200
250
Mean daily dose of budesonide (mcg)
Albuterol Budesonide plus PRN albuterol Budesonide/formoterol PRN
![Page 25: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/25.jpg)
Caveats to NOVEL-START
• Formulation differences of budesonide/formoterol
• Age Limitations
• Previous related trials had expanded population down to 12 years of age or older
• Focused on budesonide/formoterol exclusively
![Page 26: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/26.jpg)
Barriers to Implementation of GINA
HEALTHCARE PROVIDERS
• Knowledge
• Resources
• Resistance to change
• FDA approval
PAT IENTS
• Costs
• Low health literacy
• Lack of agreement with recommendations
![Page 27: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/27.jpg)
Out with Albuterol
WHAT’S THE VERDICT?
![Page 28: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/28.jpg)
KNOWLEDGE CHECK!
Which of the following beta-agonist bronchodilators has the fastest onset of
action?
a) Albuterol
b) Formoterol
c) Salmeterol
d) A and B
![Page 29: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/29.jpg)
KNOWLEDGE CHECK!
Which of the following would NOT be appropriate reliever therapy for a patient with mild asthma per GINA 2020 recommendations?
a) Albuterol as needed
b) Budesonide/Formoterol as needed
c) Beclomethasone/formoterol as needed
d) Budesonide/Salmeterol as needed
![Page 30: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/30.jpg)
Key Takeaways
• Asthma is an airway disease characterized by chronic inflammation
• ICS therapy is the primary medication intervention shown to reduce exacerbation risk
• PER GINA, Inhaled corticosteroid plus formoterol combinations used as needed are now the recommended rescue inhaler for all patients > 12 years of age with asthma
• SABA monotherapy (IE albtuerol, levalbuterol) is no longer the preferred reliever therapy, but can be an alternative reliever
• Be mindful of barriers that exist for both you and your patients in the management of asthma
![Page 31: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/31.jpg)
Clinical Pearls
• ICS/formoterol combinations can be used as needed as a reliever therapy in mild asthma
• This is specific to formoterol, not all LABA’s
• Define “control” with patients when discussing their asthma• Frequent use of SABA is not well controlled• ACT questionnaire within EPIC for assessing control
• Inhaler names and contents can be complicated!• Allergy and Asthma Network printout of Inhalers
![Page 32: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/32.jpg)
References• Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2020. • Kuprys-Lipinska, Kolacinska-Flont, Kuna. New Approach to intermittent and mild asthma
therapy: evolution or revolution in the Gina Guidelines? Clin Transl Allergy; 2020.• Micromedex Solutions. Drug Monograph; Albuterol. • Micromedex Solutions. Drug Monograph; Levalbuterol. • Micromedex Solutions. Drug Monograph; Formoterol. • Micromedex Solutions. Drug Monograph; Salmeterol.• Micromedex Solutions. Drug Monograph; Vilanterol.• Beasley, Holliday, Reddel, Braithwaite, et al. Controlled Trial of Budesonide-Formoterol as
Needed for Mild Asthma. NEJM; 2019. • National Heart, Lung, and Blood Institute. 2020 Focused Updates to the Asthma Management
Guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group
• Bateman, Reddel, O’byrne, Barnes, et al. As-Needed Budesonide-formoterol versus Maintenance Budesonide in Mild Asthma. NEJM; 2018.
![Page 33: Out with Albuterol?](https://reader033.vdocuments.net/reader033/viewer/2022050512/62721baf899a8a30b6698e69/html5/thumbnails/33.jpg)
Questions?