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Astımda inhaler steroidlerle erken tedavi doğal seyri etkiler mi?

Astımda inhaler steroidlerle erken tedavi doğal seyri etkiler mi?. Dr. Haluk Türktaş Gazi Üniversitesi Göğüs Hastalıkları Anabilim Dalı Ankara. İnhaler steroid tedavisi ile. Astım atak riskinde azalma Sistemik steroid kullanımında azalma Daha çok semptomsuz gün

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Astımda inhaler steroidlerle erken tedavi doğal seyri etkiler mi?

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  1. Astımda inhaler steroidlerle erken tedavi doğal seyri etkiler mi? Dr. Haluk Türktaş Gazi Üniversitesi Göğüs Hastalıkları Anabilim Dalı Ankara

  2. İnhaler steroid tedavisi ile • Astım atak riskinde azalma • Sistemik steroid kullanımında azalma • Daha çok semptomsuz gün • Daha az acil servis başvurusu • Daha az hastane yatışı • Daha iyi solunum fonksiyon testi • Daha iyi astım kontrolü

  3. Asthmatic Steroid-treated asthmatic

  4. Astımda inhaler steroidlerle erken tedavi doğal seyri etkiler mi?

  5. Erken tedavi girişiminin gerekçeleri • Astımda solunum fonksiyonlarında progresif azalma söz konusudur • Solunum fonksiyonlarında azalmanın temel nedeni inflamasyona sekonder oluşan kalıcı yapısal değişikliklerdir • Astımın erken dönemlerinde de inflamasyon gösterilmiştir • Hiç semptom olmaksızın inflamasyon olabilir

  6. 50 40 30 20 10 0 140 120 100 80 60 40 20 0 Erken inhaler steroid Geç inhaler steroid PEF (L/dk) PEF de değişme (L/dk) Birinci hafta Altıncı hafta Onikinci ay Sabah Akşam Sabah Akşam Sabah Akşam <6 ay 6-12 ay 1-2 yıl 2-5 yıl 5-10 yıl >10 yıl Tedavi öncesi astım semptomlarının süresi Haahtela T N Engl J Med 1994; 331: 700 Selroos O Chest 1995: 108; 1228 ERKEN BAŞLANAN İNHALER STEROİDLERİN ASTIMIN DOĞAL SEYRİNE ETKİSİ

  7. Long-Term Effects of Budesonide or Nedocromil in Children with Asthma The Childhood Asthma Management Program Research Group (CAMP Study) New Eng J Med 2000;343:1054-63 1041 children with mild to moderate asthma, 5-12 (8.9) years of age, treated 4-6 years. Primary outcome post bronchodilator FEV1

  8. Transient early wheezing Late onset wheezing Persistent wheezing Wheezing prevelance 0 3 6 11 Age (years) Martinez F Eur Respir J 12:3s 1998

  9. Outcome of Asthma and Wheezing in the First 6 Years of Life Follow-up through Adolescence Wayne J. Morgan et al Am J Respir Crit Care Med 2005;172:1253-1258

  10. Long-term inhaled corticosteroids in preschool children at high risk for asthma (PEAK study) Theresa W Guilbert et al, N Engl J Med2006;354:1985-97 nTarget childrenMean age(y)TreatmentDurationPrimary outcome 285 Positive asthma 3.0 FLU 100gx2 2 years Episode-free days during third predictive index and per day year off study medication >3 episode of wheeze last year

  11. Intermittent inhaled corticosteroids in infants with episodic wheezing (PAC study) Hans Bisgaard et al, N Engl J Med2006;354:1998-2005 nTarget childrenMean age(y)TreatmentDurationPrimary outcome 294 Maternal asthma 1.7 2 week course 3 years Development of persistent of budesonide wheezing during trial 400 g per day for each episode

  12. Secondary prevention of asthma by the use of inhaled fluticasone in wheezy infants (IFWIN study) • Clare S Murray et all, Lancet2006;368:754-762 • nTarget childrenMean age(y)TreatmentDurationPrimary outcome • Parental atopy and 0.9 FLU 100g twice Up to 4 years Lung function, BHR and • one prolonged or daily stepped down prevalence of doctor • two doctor confirmed diagnosed asthma • episode of wheezing • The groups did not differ significantly in • Physician diagnosed asthma • Lung function • Airway hyperreactivity

  13. Astımda erken tedavi çalışmaları inhaler steroidlerin kullanıldığı sürece etkili olduğunu, hastalığın doğal seyrini değiştirmediğini göstermektedir

  14. X

  15. Decline in Lung Function in the Busselton Health Study The Effects of Asthma and Cigarette Smoking n:9317, 1966-1981....1994 Alan L. James et al Am J Respir Crit Care Med 2005;171:109-114

  16. Asthma control and steroid doses 5 years after early or delayed introduction of inhaled corticosteroids in asthma: a real-life study O. Selroos et al Respir Med 2004;98:254-262 Early treatment group: symptoms for <2 years, n:253 Delayed treatment group: symptoms for >2 years, n: 51 Dose of inhaled steroids % of predictive FEV1, PEF Early treatment Delayed treatment

  17. Asthma control and steroid doses 5 years after early or delayed introduction of inhaled corticosteroids in asthma: a real-life study O. Selroos et al Respir Med 2004;98:254-262 Early treatment Delayed treatment

  18. Effects of Early Intervention With Inhaled Budesonide on Lung Function in Newly Diagnosed Asthma (START study) Paul M. O’Byrne, Chest 2006;129:1478-1485 5-66 years old, 7165 patients, asthma duration<2 years, 3 years treatment with budesonide 400 g (200 g for children <11 years old) -0.62% -1.79% -2.11% -2.68%

  19. Effects of Early Intervention With Inhaled Budesonide on Lung Function in Newly Diagnosed Asthma (START study) Paul M. O’Byrne, Chest 2006;129:1478-1485 NS NS P<0.001

  20. Inhaled corticosteroids and decline of lung function in community residents with asthma Peter Lange et al Thorax 2006;61:100-104 1994-2003 With ICS (n:44) Without ICS (n:190) 25 ml per year P<0.001 P<0.001 51 ml per year A 15-year follow-up study of ventilatory function in adults with asthma Peter Lange et al (Copenhagen City Heart Study) N Engl J Med 1998;339:1194-2000 1976-1994 1.7 1.5 1.3 1.1 0.9 0.7 0.5 0.3 No asthm a (n:16.441) Asthma (n:1095) FEV1 decline Height-Adjusted FEV1 (litre) 22 ml per year 38 ml per year 20 30 40 50 60 70 80 Age (yr)

  21. 20.6 ml/yr Lung function decline in asthma: association with inhaled corticosteroids, smoking and sex A Dijkstra et al Thorax 2006;61:105-110 122 moderate to severe asthmatic patients diagnosed 1963-75 and re-eaxamined in 1991-99. Medain follow up period of 23 years

  22. Airway Inflammation Is Present during Clinical Remission of Atopic Asthma Leon M Van Den Toorn et al Am J Respir Crit Care Med 2001;164:2107-2113 Control Remission

  23. İKSler hastalık yükünü azaltırlar • Astım atak riskinde azalma • Sistemik steroid kullanımında azalma • Daha çok semptomsuz gün • Daha az acil servis başvurusu • Daha az hastane yatışı • Daha iyi solunum fonksiyon testi • Daha iyi astım kontrolü

  24. 2.5 2.0 1.5 1.0 0.5 0.0 5 4 3 2 1 0 Yüz milyon doz Astım mortalitesi 100.000 de 1973 75 77 79 81 83 85 87 89 91 93 Yıl 2.5 2.0 1.5 1.0 0.5 0.0 Suissa S N Engl J Med 2000:343;332 Suissa S J Clin Epidemiol 1997:50;1079 Astım ölüm oranı 0 1 2 3 4 5 6 7 8 9 10 11 12 Yıllık inhaler steroid kullanımı (kutu) İNHALER STEROİDLERİN ASTIM MORTALİTESİNE ETKİSİ

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