Holistic Management of Asthma Orapan Pochanukoon, MD. Associate Professor of Allergy and Immunology Thammasat University THAILAND

Chronic disease management Long-term asthma management Outline of My Talk Chronic disease management Long-term asthma management Compliance and adherence Asthma education

เด็กอาย ุ1 ปีครึ่งมีอาการหายใจเสียงดังตอนนอน มีเสมหะครืดคราด ไม่ไอ หายใจเหนื่อย กรนบางครั้งนอนแล้วบางครั้งเหนื่อย กระสับกระส่าย มีประวัติเป็นหวัดบ่อยหลังไป nursery แพทย์วินิจฉัยว่าเป็นโรคหืดจะให้ยาพ่นสเตียรอยด์แต่มารดากลัว จึงมาปรึกษา ท่านคิดถึงโรคอะไร จะให้การรักษาอย่างไร

ผู้ป่วยหญิงไทยอาย ุ30 ปี มีการไอมา 3 เดือนไอแห้งๆตลอดทั้งวัน บางครั้งไอจนปัสสาวะราด นอนไม่หลับ ไม่ค่อยหอบแต่แน่นหน้าอกบ่อย เคยนอนโรงพยาบาลพ่นยาหลายครั้งอาการไม่ดีขึ้น ได้รับยา ICS, INCs, ATBs, ATH, anti-cough, GERD, antidepressants, sleep pills, prednisolone, oral bronchodilators

Differential Diagnoses of Chronic Cough Infancy Early Childhood Late Childhood Adult GERD Infection Congenital Mal. CHD Passive Smoking Environment Asthma Post-viral AHR Passive smoking Foreign body Bronchiectasis Post-natal drip Smoking Tuberculosis Psychogenic cough

Determining the cause of chronic cough (non-smoker) Post-nasal drip in up to 30% Cough-variant asthma in up to 20% Gastro-esophageal reflux disease Less common causes: bronchiectasis, diffuse parenchyma disease, ACE inhibitors, psychogenic cough

Parental reports of the allergy symptoms Meltzer EO et al. J Allergy Clin Immunol 2009.

Disease management and treatment Chronic disease management-Asthma diagnosis symptoms assessment control Disease management and treatment control comorbidities PRO QoL Adherence

Long-term management of asthma Controller medications Step up and down regimens Education

ยาที่ใช้ในการรักษาโรคหืด Step 1 Step 2 Step 3 Step 4 Step 5 Low-dose ICS plus sustained-release theophyline Sustained release theophyline Low-dose ICS plus leukotriene modifier Anti-IgE treatment Leukotriene modifier Medium- or high-dose ICS Oral glucocorticosteroid (lowest dose) Medium- or high-dose ICS plus long-acting ß2-agonist Low-dose ICS plus long-acting ß2-agonist Low-dose inhaled ICS Add one or more Select one Controller options As needed rapid-acting ß2-agonist Asthma education Environmental control 1-5% GINA and Thai Guideline 2011.

Controllers Options for Asthma Agent Effect on AR Oral administration Anti-inflammatory effects Side effects ICS X   ICS+LABAs Theophylline LTRAs 

Treatment options in uncontrolled asthma Mild asthma AS with AR Viral induced wheeze EIA in young children LTRA ICS+LABA Theophylline Anti-IgE ICS+LTRA Poor compliance Steroids phobia

Treatment options in uncontrolled asthma ICS LTRA Theophylline Anti-IgE ICS+LABA Severe asthma Atopic asthma

จะให้การรักษาอย่างไร เด็กอาย ุ1 ปีครึ่งมีอาการหายใจเสียงดังตอนนอน มีเสมหะครืดคราด ไม่ไอ หายใจเหนื่อย กรนบางครั้งนอนแล้วบางครั้งเหนื่อย กระสับกระส่าย มีประวัติเป็นหวัดบ่อยหลังไป nursery แพทย์วินิจฉัยว่าเป็นโรคหืดจะให้ยาพ่นสเตียรอยด์แต่มารดากลัว จึงมาปรึกษา ท่านคิดถึงโรคอะไร จะให้การรักษาอย่างไร

Montelukast for children with OSA

OSA in children Prevalent of OSA in children is 2-3% The most common treatment is adenotonsillectomy Cys LT receptor was elevated in the tonsillar tissues of children with OSA Montelukast may provide an intervention alternative to adenotonsillectomy

Adenoid size significantly decreased with montelukast

Montelukast treatment resulted in a significant improvement in the obstructive apnea index A 12 week treatment with daily oral montelukast effectively reduced the severity of OSA and the magnitude of the underlying adenoidal hypertrophy in children with nonsevere OSA

ผู้ป่วยหญิงไทยอาย ุ30 ปี มีการไอมา 3 เดือนไอแห้งๆตลอดทั้งวัน บางครั้งไอจนปัสสาวะราด นอนไม่หลับ ไม่ค่อยหอบแต่แน่นหน้าอกบ่อย CXR, PEFR, Film PNS-normal 2 weeks after LTRA

ผู้ป่วยอายุ 50 ปีเป็นโรคหืดมาตั้งแต่อายุ30 ปี ได้ยาสเตียรอยด์พ่นแต่ใช้ไม่สม่ำเสมอ ปีที่ผ่านมาหอบบ่อยขึ้นได้รับ prednisoloneปีละ 3-4ครั้ง มาด้วยมีอาการปวดหลังมากหลังหกล้ม

ข้อใดเป็นผลข้างเคียงของสเตียรอยด์กิน Kidney failure Osteoporosis Proximal muscle weakness (myopathy) Cataracts Glaucoma

ผลข้างเคียงของ systemic steroids

N Engl J Med 2011;365:62-70.

การป้องกันผลข้างเคียงของ systemic steroid ผู้ป่วยที่ได้รับสเตียรอยด์กินเกิน3เดือน (> 5MKD) ผู้ป่วยที่ได้รับสเตียรอยด์กิน/ฉีดเกิน3ครั้งต่อปี ข้อแนะนำในผู้ป่วยที่ได้รับ systemic steroid บ่อย -วัดความดันทุก 6 เดือน -ตรวจภาวะเบาหวาน -ตรวจ bone mineral density -ให้ calcium (1,200-1,500 mg/day) and vitamin D (800-1,000 unit/day)

Risk factors for Glucocorticoids-induced osteoporosis Advance age Low BMI (<24) Underlying disease: RA, chronic pulmonary disease Smoking, excessive alcohol consumption, frequent falls, family history of hip fracture high glucocorticoid dose (high current or cumulative dose, long duration of therapy) Low bone mineral density Here is our asthma care team, include with doctor specialist in allergist, chest medicine and emergency medicine, nurse, pharmacist, rehabtherapist. You can see the woman in the middle, she is the president of thammasat asthma club cause she is the founder. N Engl J Med 2011;365:62-70.

Long term asthma management Consider inhaler change Fix nest appointment Step-down therapy Incorrect Therapy step up Check: Minimal symptoms Leading a normal life Taking usual exercise Low inhaled β-agonist use No additional treatment Check inhaler technique Correct No Yes Assess compliance And aggravating factors

Median inhaled corticosteroid use (%) Issues with Current Therapies Reported Compliance vs. Actual Use of Inhaled Corticosteroids 1/Milgrom, p 1052, Table 1, L1-3 95.4 100 80 Median inhaled corticosteroid use (%) 58.4 Slide B.8 Although ICS are widely used in the treatment of childhood asthma, compliance may be less than optimal. A prospective study specifically assessed compliance in 24 asthmatic children 8 to 12 years of age who required ICS and beta2 agonists for control and who were thought to be compliant. Although patient diaries reported a compliance rate of 95.4% with ICS (i.e., that 95.4% of prescribed doses were taken), electronic monitoring of MDIs revealed that fewer than 60% of doses were actually taken. Moreover, only 31.8% of prescribed doses were taken at the correct time of day. Overall, 92% of patients exaggerated their corticosteroid use. It was concluded that not only did these children fail to comply with therapy, but they misrepresented their use and did so with the tacit approval of their parents.1 60 1/Milgrom, p 1052, Table 1, L1-3; p 1054, C2, ¶1, L2-12; p 1056, C2, ¶2, L1-5 40 31.8 20 (n=24) Reported use Actual use Actual use at correct time Reported compliance is not always a reflection of actual use Adapted from Milgrom H et al J Allergy Clin Immunol 1996;98(6, pt 1):1051–1057. Reference 1. Milgrom H, Bender B, Ackerson L et al. Noncompliance and treatment failure in children with asthma. J Allergy Clin Immunol 1996;98(6, pt 1):1051–1057.

B.9 Poor compliance can lead to poor outcomes Issues with Current Therapies Adherence/Compliance Issues Can Affect Outcomes 1/Milgrom, p 1053, Fig 2 (n’s); p 1055, C1, L4-9 Poor compliance can lead to poor outcomes 100 p=0.008 Slide B.9 Poor compliance has been strongly correlated with loss of asthma control.1 Of 8 children who required oral corticosteroid rescue in a 13-week study of 24 asthmatic children 8 to 12 years of age who required inhaled corticosteroids and beta agonists for control, only 13.7% of their prescribed doses of inhaled corticosteroid were taken, compared with a compliance rate of 68.2% for children with stable asthma, that is, children who did not require corticosteroid rescue (p=0.008). Five of eight children who required courses of oral corticosteroid during the study were among the least compliant, including two who were hospitalized.1 These findings suggest that inadequate control of asthma may reflect noncompliance, a problem that is widespread and that may not be confined to obviously uncooperative patients.1 80 68.2 1/Milgrom, p 1056, C2, ¶3, L1-8 p 1052, C2, ¶1, L1-6; p 1053, C2, ¶1, L9-10; p 1054, C2, ¶2, L1-4; p 1055, C1, L4-9; p 1056, C2, L8-11 p 1056, C2, ¶2, L10-14 60 Compliance (%) 40 20 13.7 Children with stable asthma* (n=16) Children requiring oral corticosteroid rescue (n=8) *Did not require oral corticosteroids Adapted from Milgrom H et al J Allergy Clin Immunol 1996;98(6, pt 1):1051–1057. B.9 Reference Milgrom H, Bender B, Ackerson L et al. Noncompliance and treatment failure in children with asthma. J Allergy Clin Immunol 1996;98(6, pt 1):1051–1057.

Days fully compliant (%) Issues with Current Therapies Preference/Compliance Issues: Montelukast vs. ICS 1/Maspero, p 97, C2, ¶3, L1-6 (dosages); p 99, Table 1 (n’s); p 100, C1, ¶1, L7, C2, L1-4 6-month extension study in 124 children 6–14 years of age p<0.001 100 98 Slide B.11 The children in the study were more compliant with montelukast than with beclomethasone. The mean percentage of days during which patients were fully compliant was 98% for montelukast and 83% for beclomethasone, representing a statistically significant difference of 15% (p<0.001).1 95 1/Maspero, p 100, C1, ¶1, L7, C2, L1-4 Days fully compliant (%) 90 85 83 80 75 Montelukast 5 mg* (n=83) Beclomethasone 300 µg** (n=40) *One chewable tablet once daily at bedtime **Two 50 µg puffs three times daily Adapted from Maspero JF et al Curr Med Res Opin 2001;17:96–104. Reference 1. Maspero JF, Dueñas-Meza E, Volovitz B et al. Oral montelukast versus inhaled beclomethasone in 6- to 11-year-old children with asthma: Results of an open-label extension study evaluating long-term safety, satisfaction, and adherence with therapy. Curr Med Res Opin 2001;17:96–104.

Randomized Controlled Trials RCTs and Real-World Studies Provide Complementary Information to Help Improve Asthma Care 1/Price, p 4, C1, ¶2, L1-3 2/Holgate, p 1438, C1, ¶2, L1-5 p 3, C2, ¶3, L5-9 p 1438, C1, ¶1, L1-8 3/Herland, p 17, C1, ¶3, L1-4 4/Travers, p 219, C1, ¶1, L13-23 p 1438, C1, ¶1, L22-25 5/Naqvi, p 646, C1, ¶3, L7-11 6/Hawkins, p 1107, C2, L15-18 p 1438, C1, ¶1, L18-20 7/Tomlinson, p 282, C1, ¶1, L6-8; p 285, C1, ¶1, L1-3; p 286, C2, ¶2, L12-17 8/Thomson, p 749, C1, ¶1, L6-13, C2, ¶2, L13-16 9/Zwarenstein, p 1, Table 1 10/Wells, p 8, C1, ¶2, L1-4,7-10 1/Price, p 4, C1, ¶2, L1-3 11/Silverman, p 117, Table 2 RCTs: Information provided/ Setting/ Patient population: Real-World Studies: 2/Zwarenstein, Footnote: 3/Silverman, Randomized Controlled Trials Real-World Studiesa Information provided Efficacy1 Effectiveness2 Setting Controlled environment1 Real-world practice2 Patient population Patients meeting strict inclusion and exclusion criteria “Everyday” patients2 The findings of real-world trials and RCTs provide complementary information to help formulate strategies that can help to improve asthma care.1,2 RCTs study a narrowly defined patient population in a controlled setting, thereby establishing the relative efficacy of treatment, that is, the benefit of the treatment under ideal conditions.1 Patients enrolled in RCTs to evaluate interventions for asthma typically have asthma according to American Thoracic Society criteria, have forced expiratory volume in 1 second (FEV1) of >50% and <85% of predicted, have reversibility of >12% in the last 12 months, and are nonsmokers with no significant comorbidities.2 Therefore, these studies generally exclude many of the types of patients who are seen in everyday practice,2–4 such as patients with β-agonist reversibility of <12% (which may vary in different patient populations)2,5,6 and smokers.2,7,8 Real-world or pragmatic studies evaluate the effects of treatments on health outcomes under conditions approximating those used in normal clinical practice, thereby evaluating the effectiveness of an intervention when used in the real-world setting.9 Patients enrolled in these trials typically are selected on the basis of the clinical indication of interest, without further inclusion or exclusion criteria.9 Thus, real-world studies are more likely than RCTs to include patients representative of those encountered in daily clinical practice.2,9 In general, the results of RCTs are true to the study population and setting, whereas those of real-world studies can be generalized to other populations and settings.10 Therefore, the findings of pragmatic trials can be a valuable complement to the findings from RCTs.1,2 However, observational studies are not randomized and do not have control groups, which can lead to the possibility for selection bias, and may show correlations without directly proving causation.11 RCTs=randomized controlled trials. aNote that observational studies are not randomized and do not have control groups, which can lead  to the possibility for selection bias and may show correlations without directly proving causation.3 1. Price D et al. BMC Pulm Med. 2006;6(suppl 1):S6. 2. Zwarenstein M et al. BMJ. 2008;337:a2390. 3. Silverman SL. Am J Med. 2009; 122(2):114–120. Slide 31 1. Price D et al. BMC Pulm Med. 2006;6(suppl 1):S6. 2. Holgate S et al. Eur Respir J. 2008;32:1433–1442. 3. Herland K et al. Respir Med. 2005;99(1):11–19. 4. Travers J et al. Thorax. 2007;62(3):219–223. 5. Naqvi M et al. J Asthma. 2007;44(8):639–648. 6. Hawkins GA et al. Am J Respir Crit Care Med. 2006;174(10):1101–1109. 7. Tomlinson JEM et al. Thorax. 2005;60(4):282–287. 8. Thomson NC. Am J Respir Crit Care Med. 2007;175(8):749–750. 9. Zwarenstein M et al. BMJ. 2008;337:a2390. 10. Wells KB. Am J Psychiatry. 1999;156:5–10. 11. Silverman SL. Am J Med. 2009;122(2):114–120.

Heterogeneous, Real-World Population ELEVATE1 Heterogeneous, Real-World Population 1/Price: p1705A 1/Price (suppl): p3A; p4A (by omission) 1/Price: p1705A; p1698A Broad inclusion criteria allowed assessment of real-world effectiveness in patients seen in clinical practice. Smokers (1/4 of study population) Patients with COPD due to lack of requirement of bronchodilator reversibility (≈3% of study population) Patients with allergic rhinitis Patients with poor adherence Patients with poor inhaler technique The broad inclusion criteria used in the ELEVATE trials allowed assessment of real-world effectiveness for the heterogeneous group of patients seen in everyday clinical practice. Patients who smoked or had comorbidities, poor adherence, or poor inhaler technique were not excluded from study participation. In fact, smokers comprised almost 25% of the total population of both ELEVATE trials, with smokers older than 45 years of age accounting for 9% of the population in both trials. Further, bronchodilator reversibility was not required for enrollment, allowing the inclusion of patients with a mix of chronic obstructive pulmonary disease and asthma. Adherence and proper inhaler technique were not inclusion criteria although adherence was evaluated during the trial.1 1. Price D et al. N Engl J Med. 2011;364:1695–1707. Additional Information: Supporting online material is available at www.nejm.org/ doi/suppl/10.1056/NEJMoa1010846/suppl_file/nejmoa1010846_appendix.pdf. COPD=chronic obstructive pulmonary disease. 1. Price D et al. N Engl J Med. 2011;364:1695–1707. Slide 32

First-Controller Trial: Improvements in MiniAQLQ (Primary End Point) 1/Price: p1700A,B p1697D,E; p1698E p1698B,E; p1703B; p1704A Equivalence Criteria Meta Not Metb 6 Improvement 5.52 5.63 5 5.25 5.28 4.75 4.72 4 MiniAQLQ Score 3 2 Intention-to-treat analysis of the primary end point (MiniAQLQ score) at Month 2, the primary time point, showed that LTRA and ICS were equivalent as first controller therapy. Both the upper and lower values of the 95% CI for the mean between-group difference, adjusted for baseline values, fell within the prespecified boundary of 0.3 (that is, from –0.3 to +0.3).1 Equivalence was not proven at 2 years: the lower boundary of the 95% CI of the adjusted mean difference between groups was –0.35, which fell outside the predefined equivalence limit of 0.3.1 1 (n=148) (n=158) (n=122) (n=132) (n=145) (n=155) Baseline 2 Months 2 Years 1. Price D et al. N Engl J Med. 2011;364:1695–1707. Additional Information: Supporting online material is available at www.nejm.org/ doi/suppl/10.1056/NEJMoa1010846/suppl_file/nejmoa1010846_appendix.pdf. LTRA ICS Mean difference adjusted for baseline value (95% CI):a–0.02 (–0.24 to 0.20); b–0.11 (–0.35 to 0.13). 1. Price D et al. N Engl J Med. 2011;364:1695–1707. Slide 33

Add-On Therapy Trial: Improvements on MiniAQLQ (Primary End Point) ELEVATE1 Add-On Therapy Trial: Improvements on MiniAQLQ (Primary End Point) 1/Price: p1700D p1697E; p1698B; p1702C p1700D; p1702C; p1704B Equivalence Criteria Meta Not Metb 6 Improvement 5.43 5.42 5 5.09 5.04 4.63 4.41 4 MinAQLQ Score 3 2 The intention-to-treat analysis of the primary end point (MiniAQLQ score) at Month 2, the primary time point, showed that LTRA and LABA were equivalent to each other as add-on therapy to baseline ICS. Both the upper and lower values of the 95% CI for the mean between-group difference adjusted for baseline values, fell entirely within the prespecified limit of 0.3 (that is, from –0.3 to +0.3).1 Equivalence was not proven at 2 years: the lower boundary of the 95% CI of the adjusted mean difference between groups was –0.32, which fell outside the predefined equivalence limit of 0.3.1 1 (n=170) (n=182) (n=153) (n=156) (n=169) (n=181) Baseline 2 Months 2 Years LTRA + ICS LABA + ICS 1. Price D et al. N Engl J Med. 2011;364:1695–1707. Additional Information: Supporting online material is available at www.nejm.org/ doi/suppl/10.1056/NEJMoa1010846/suppl_file/nejmoa1010846_appendix.pdf. Mean difference adjusted for baseline value (95% CI): a–0.10 (–0.29 to 0.10); b–0.11 (–0.32 to 0.11). 1. Price D et al. N Engl J Med. 2011;364:1695–1707. Slide 34

Change in AM PEF Asthma+AR Patients: Using Rhinitis Meds§ Post Hoc Analysis Weeks § Intranasal steroids or antihistamines or other treatments for rhinitis * Montelukast 10 mg once-daily along with budesonide 400 g twice-daily. ** Budesonide 800 g twice-daily

Singulair Timeline snoring Asthma PED 2-5y PED 6mo-2y SAR PAR EIB Wheeze (1999) (2001) (2003) (2004) (2005) (2006) (2008) snoring 1999 2001 2003 2005 2007 2009 2011 2000 2002 2004 2006 2008 2010 Guideline GINA ARIA PRACTAAL GINA PED (2004) (2007) (2008) (2009) SAR = Seasonal Allergic Rhinitis PAR = Perennial Allergic Rhinitis EIB = Exercise – Induced Bronchoconstriction

Dosing in Children Dosing in Children and adults Source A (WPC), p 1, §III, ¶3-5; p 2, ¶1; p 8, § XVIIIb, ¶2, L1-3 Children 6 months to 2 years of age One 4 mg oral granule package mixed with food taken once daily in the evening Children 2 to 5 years of age One 4 mg cherry- flavored chewable tablet in the evening Children 6 to 14 years of age One 5 mg cherry- flavored chewable tablet in the evening Patients 15 years of age and older One 10 mg tablet in the evening Slide I.2 The leukotriene receptor antagonist montelukast provides convenient once-daily administration in the evening and is very well tolerated. Montelukast is available in 4 mg packets of oral granules for pediatric patients 6 months to 2 years of age and cherry-flavored, chewable tablets for pediatric patients 2 to 14 years of age (4 mg for children 2–5 years and 5 mg for children 6–14 years). Montelukast is also available in a 10 mg tablet for adults 15 years of age and older. Easy to administer and very well tolerated Source A (WPC), p 1, §III, ¶1, L1; p 4, §XI, ¶1, L1-3; p 1, §III, ¶3-5; p 2, ¶1; p 8, § XVIIIb, ¶2, L1-3 I.2

กรณี LTRA ต้อง taper off ยาหรือไม่ เมื่อไหร่หยุดยา การลดยาในผู้ป่วยโรคหืด เมื่อไหร่ต้องลดยา ลดตัวไหนก่อน -ICS+LABA, ICS+LTRA กรณี LTRA ต้อง taper off ยาหรือไม่ เมื่อไหร่หยุดยา

เมื่อไหร่ต้องลดยา ควรลดยาหลังไม่มีอาการอย่างน้อย3-6เดือน รีบลดยากรณีมีผลข้างเคียงจากยา ลดยาช้ากรณีอาการรุนแรง ดูสิ่งที่ผู้ป่วยแพ้และอากาศก่อนลดยา

Step down regimen (ICS+LABA) Watashi wa Orapan desu ICS LABA ICS LABA off

Step down regimen (ICS+LABA) AS with AR LTRA ICS LTRA LTRA Watashi wa Orapan desu ICS ICS off

Early onset atopic asthma with normal lung function low-medium dose ICS Cluster 1 medium-dose ICS Cluster 2 Early onset atopic asthma with mild airflow limitation Late onset asthma with normal lung function medium/high ICS co-morbidities Cluster 3 Lung function (%FEV1) High-dose ICS Systemic steroids Cluster 4 Early onset atopic asthma with advance airflow limitation Duration of Asthma Fitzpartick et al. JACI 2011; 127: 382-9.

Asthma death ผู้ป่วยหญิงอาย 50 ปี เป็นหวัด หอบมา 3-4วัน วันสุดท้ายแย่ลง เสียชีวิตระหว่างทางมาโรงพยาบาล ประวัติอดีต หอบทุก1-2เดือน ได้รับยา ICS+LABA ใช้ ventolin เดือนละหลอด ไม่มีการ check compliance, ไม่มีการสอน asthma action plan

Reasons for Non-adherence complexity of treatment, S/E patient education difficult to access cost/reimbursement Possible avoidance patients features chronicity Pt/HCW partnership Impact on adherence

The potential effect of personality on adherence interventions High effect on adherence Shared decision making Phone calls addressing medication beliefs Individualised inhaler instructions Tailored / targeted / individualised educational interventions Drug presentation style Repeated inhaler instructions Low cost High cost Patient/provider interaction not focusing expressed personal needs Asthma education focusing general management Individualised problem-solving addressing adherence barriers Self-management illness model Low effect on adherence The potential effect of personality on adherence interventions

Asthma Education Phenotype of non-adherence patient How to give asthma education

Asthma self-management topics asthma education -allergen avoidance -chronic but treatable Nature of disease -reliever -controller Nature of treatment Use of treatment -inhaler -peak flow meter Self-monitoring -action plan -management of exacerbation

BTS/GINA guideline for action plan “In primary care, people with asthma should be reviewed regularly by a nurse or doctor with appropriate training in asthma management, written action plan”

Keys components to asthma action plan Recognizing attack Assessing severity Initial treatment When to get help According to asthma guideline, the goal of asthma treatment is no exacerbation and no loss work. The results of a study in Thailand show that asthma symptom is still uncontrolled in large number of patients as you can see that 15% of patients were admitted, 20% need ER visit and 24% were absent from work due to asthmatic attack.

Asthma action plan: priority patients Those having frequent exacerbation Those requiring frequent courses of steroid tablets Users of high-dose ICS ED/hospitalization Risk of developing severe/fatal asthma

Asthma Education www.tuasthmaclub.com 1.Asthma action plan http://youtu.be/Plb7KM0gQHU 2.Asthma treatment http://youtu.be/sbsrzLbjnAc 3. Allegen avoidance http://youtu.be/rFHV912Ykuo www.tuasthmaclub.com

The five R’s for teaching Reach agreement on goals for treatment -keep it simple -set priorities -specific action plan Rehearse asthma management skills: taking medicine, monitor symptoms Repeat message Reinforce appropriate behavior Review results