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Grazie per aver scelto di utilizzare a scopo didattico questo materiale delle Guidelines 2011 libra. Le ricordiamo che questo materiale è di proprietà dell’autore e fornito come supporto didattico per uso personale.

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slide1

Grazie per aver scelto di utilizzare a scopo didattico questo materiale delle Guidelines 2011 libra.Le ricordiamo che questo materiale è di proprietà dell’autore e fornito come supporto didattico per uso personale.

slide2

Is a uniform definition of severity, control and risk possible in chronic diseases ?1- A novel concept of chronic diseases2- The example of asthma3- Tentative uniform definition4- Needs for a uniform definition

slide3

Is a uniform definition of severity, control and risk possible in chronic diseases ?1- A novel concept of chronic diseases2- The example of asthma3- Tentative uniform definition4- Needs for a uniform definition

slide4

Socio-economic

determinants

Life style - environment

Risk and protective factors

Tobacco smoking, Pollutants

Allergens, Nutrition, Infections

Physicalexercise, Others

slide5

Socio-economic

determinants

Life style - environment

Risk and protective factors

Tobacco smoking, Pollutants

Allergens, Nutrition, Infections

Physicalexercise, Others

Genes

slide6

Socio-economic

determinants

Life style - environment

Risk and protective factors

Tobacco smoking, Pollutants

Allergens, Nutrition, Infections

Physicalexercise, Others

Genes

Biological expression of chronicdiseases

Transcripts, proteins, metabolites

Target organ local inflammation

Systemic inflammation

Cell and tissue remodelling

Clinical expression of chronicdiseases

Co-morbidities

Severity of co-morbidities

Persistence, remission

Long-termmorbidity

Responsiveness - sideeffects to treatment

slide7

Socio-economic

determinants

Life style - environment

Risk and protective factors

Tobacco smoking, Pollutants

Allergens, Nutrition, Infections

Physicalexercise, Others

Genes

Biological expression of chronicdiseases

Transcripts, proteins, metabolites

Target organ local inflammation

Systemic inflammation

Cell and tissue remodelling

Ageing

Clinical expression of chronicdiseases

Co-morbidities

Severity of co-morbidities

Persistence, remission

Long-termmorbidity

Responsiveness - sideeffects to treatment

slide8

Socio-economic

determinants

Life style - environment

Risk and protective factors

Tobacco smoking, Pollutants

Allergens, Nutrition, Infections

Physicalexercise, Others

Genes

Systems biology on

precisephenotypes

Biological expression of chronicdiseases

Transcripts, proteins, metabolites

Target organ local inflammation

Systemic inflammation

Cell and tissue remodelling

Ageing

Clinical expression of chronicdiseases

Co-morbidities

Severity of co-morbidities

Persistence, remission

Long-termmorbidity

Responsiveness - sideeffects to treatment

slide9

Socio-economic

determinants

Life style - environment

Risk and protective factors

Tobacco smoking, Pollutants

Allergens, Nutrition, Infections

Physicalexercise, Others

Health promotion

Primary prevention

Genes

Systems biology on

precisephenotypes

Biological expression of chronicdiseases

Transcripts, proteins, metabolites

Target organ local inflammation

Systemic inflammation

Cell and tissue remodelling

  • Personalized medicine
  • Primary prevention
  • Secondary prevention
  • Tertiary prevention
  • Treatment

Ageing

Clinical expression of chronicdiseases

Co-morbidities

Severity of co-morbidities

Persistence, remission

Long-termmorbidity

Responsiveness - sideeffects to treatment

slide10

Classical phenotypes

Novel phenotypes

Hypothesis-driven

Discovery driven

Patient with chronic disease

Co-morbidities

(standardized assessment)

CVD

COPD

Diabetes

Assessment of co-morbities

and severity

Severity of co-morbidities

(standardized assessment)

Classical phenotypes in

patients with severe defined diseases

and co-morbidities

Novel phenotypes in individual

patients with severe co-morbidities

of chronic diseases

Responsiveness to treatment

Follow up

Responsiveness to treatment

Follow up

slide11

Classical phenotypes

Novel phenotypes

Hypothesis-driven

Discovery driven

Patient with chronic disease

Co-morbidities

(standardized assessment)

CVD

COPD

Diabetes

Assessment of co-morbities

and severity

Severity of co-morbidities

(standardized assessment)

Classical phenotypes in

patients with severe defined diseases

and co-morbidities

Novel phenotypes in individual

patients with severe co-morbidities

of chronic diseases

Responsiveness to treatment

Follow up

Responsiveness to treatment

Follow up

slide12

Classical phenotypes

Novel phenotypes

Hypothesis-driven

Discovery driven

Patient with chronic disease

Co-morbidities

(standardizedassessment)

CVD

COPD

Diabetes

Assessment of co-morbities

and severity

Severity of co-morbidities

(standardized assessment)

Classical phenotypes in

patients with severe defined diseases

and co-morbidities

Novel phenotypes in individual

patients with severe co-morbidities

of chronic diseases

Responsiveness to treatment

Follow up

Responsiveness to treatment

Follow up

slide13

Is a uniformdefinition of severity, control and risk possible in chronicdiseases ?1- A novel concept of chronicdiseases2- The example of asthma

slide14

Asthma severity - GINA 2002

Asthmaseverity

  • Control
  • Symptoms
  • Functional limitation
  • over 2-4 weeks
  • Exacerbations over 6-12 mo
classification of asthma gina 1998
Classification of asthma: GINA 1998

Current treatment step

Step 1

No controller

Step 2

<500 BDP

Step 3

200–1000 BDP + LABA

Step 4

>1000 BDP + LABA + other

Clinical features

Severe persistent

Moderate persistent

Step 1

Symptoms <1 x week

Nocturnal symptoms ≤2x month

Lung function normal between episodes

Intermittent

Mild persistent

Step 2

Symptoms >1 x week

Nocturnal symptoms <1 x week

Lung function normal between episodes

Severe persistent

Severe persistent

Moderate persistent

Mild persistent

Step 3

Symptoms daily

Nocturnal symptoms ≥1 x week

FEV1 60–80% predicted

Moderate persistent

Severe persistent

Severe persistent

Severe persistent

Severe persistent

Severe persistent

Step 4

Symptoms daily

Frequent nocturnal symptoms

FEV1 <60% predicted

Severe persistent

Severe persistent

slide16

Asthma control - GINA 2006

Asthma control

  • Control
  • Symptoms
  • Functional limitation
  • over 2-4 weeks
  • Exacerbations over 6-12 mo
slide19

Asthma severity- NAEPP3 (NHLBI)

Asthmaseverity

  • Control
  • Symptoms
  • Functional limitation
  • over 2-4 weeks
  • Exacerbations over 6-12 mo
  • Future risks
  • Asthma exacerbations
  • Lung functionloss
  • Lung growth in children
  • Adverse reactionsfrommedications)

Responsiveness to treatment

slide21

Definition of severe asthma

(Geneva, 6-7 April 2009)

slide22

Asthma severity

WHO definition

Bousquet J et al, J Allergy Clin Immunol 2010

Asthmaseverity

  • Control
  • Symptoms
  • Functional limitation
  • over 2-4 weeks
  • Exacerbations over 6-12 mo
  • Future risks
  • Asthma exacerbations
  • Lung function loss
  • Lung growth in children
  • Adverse reactions from medications)
  • Level of treatment
  • Inhalation technique
  • Compliance

Responsiveness to treatment

slide24

Is a uniformdefinition of severity, control and risk possible in chronicdiseases ?1- A novel concept of chronicdiseases2- The example of asthma3- Tentative definition

slide26

Uniform severity of chronic diseases

Diagnosis of chronic disease

Underdiagnosis

Short-term

(eg exacerbation)

Long-term

(eg remodelling)

Assess and regularlyreview CONTROL

RISK

Risks due to

co-morbidities

Side effects from

treatment

slide28

Uniform severity of chronic diseases

Diagnosis of chronic disease

Underdiagnosis

Patient with uncontrolled chronic disease

NO

Is treatment/prevention effective ?

Short-term

(eg exacerbation)

Long-term

(eg remodelling)

Assess and regularlyreview CONTROL

RISK

Risks due to

co-morbidities

Side effects from

treatment

slide30

Uniform severity of chronic diseases

Diagnosis of chronic disease

Underdiagnosis

Patient with uncontrolled chronic disease

NO

Is treatment/prevention effective ?

Short-term

(eg exacerbation)

Untreated

severe disease

Is treatment available and affordable ?

Long-term

(eg remodelling)

Assess and regularly review CONTROL

RISK

Risks due to

co-morbidities

Side effects from

treatment

slide32

Uniform severity of chronic diseases

Diagnosis of chronic disease

Underdiagnosis

Patient with uncontrolled chronic disease

NO

Is treatment/prevention effective ?

Short-term

(eg exacerbation)

Untreated

severe disease

Is treatment available and affordable ?

Long-term

(eg remodelling)

Treat according to guidelines

Assess and regularly review CONTROL

RISK

Possible risk

due to other

disease

Check if diagnosis is correct

OR if there are other associated diseases

Risks due to

co-morbidities

Side effects from

treatment

slide33

Re-check

asthma diagnosis

No asthma

OR

Asthma PLUS another condition

causing current symptoms

NO

Diagnosis

Severe asthma

due to occupational expoure

to isocyanates

slide34

Re-check

asthma diagnosis

No asthma

OR

Asthma PLUS another condition

causing current symptoms

NO

Visit for coarse voice due to high dose ICS (and dyspnea) in a severe asthmatic

FEV1: 1.78 l (72%), post-ß2: 1.92 (+5%), FEV1/FVC: 66%

slide36

Uniform severity of chronic diseases

Diagnosis of chronic disease

Underdiagnosis

Patient with uncontrolled chronic disease

NO

Is treatment/prevention effective ?

Short-term

(eg exacerbation)

Untreated

severe disease

Is treatment available and affordable ?

Long-term

(eg remodelling)

Treat according to guidelines

Assess and regularly review CONTROL

RISK

Possible risk

due to other

disease

Check if diagnosis is correct

OR if there are other associated diseases

Risks due to

co-morbidities

Check co-morbidies, risk factors

compliance and/or treatment administration

Difficult-to-treat

disease

Side effects from

treatment

slide38

Uniform severity of chronic diseases

Diagnosis of chronic disease

Underdiagnosis

Patient with uncontrolled chronic disease

NO

Is treatment/prevention effective ?

Short-term

(eg exacerbation)

Untreated

severe disease

Is treatment available and affordable ?

Long-term

(eg remodelling)

Treat according to guidelines

Assess and regularly review CONTROL

RISK

Possible risk

due to other

disease

Check if diagnosis is correct

OR if there are other associated diseases

Risks due to

co-morbidities

Check co-morbidies, risk factors

compliance and/or treatment administration

Difficult-to-treat

disease

Side effects from

treatment

Treat to the highest recommended dose

Severe disease controlled

with optimal treatment

slide40

Uniform severity of chronic diseases

Diagnosis of chronic disease

Underdiagnosis

Patient with uncontrolled chronic disease

NO

Is treatment/prevention effective ?

Short-term

(eg exacerbation)

Untreated

severe disease

Is treatment available and affordable ?

Long-term

(eg remodelling)

Treat according to guidelines

Assess and regularly review CONTROL

RISK

Possible risk

due to other

disease

Check if diagnosis is correct

OR if there are other associated diseases

Risks due to

co-morbidities

Check co-morbidies, risk factors

compliance and/or treatment administration

Difficult-to-treat

disease

Side effects from

treatment

Treat to the highest recommended dose

Severe disease uncontrolled

despite optimal treatment

Severe disease controlled

with optimal treatment

slide42

Is a uniformdefinition of severity, control and risk possible in chronicdiseases ?1- A novel concept of chronicdiseases2- The example of asthma3- Tentative uniformdefinition4- Needs for a uniformdefinition

slide43

Applicability of the definition

  • Public health: to improve the quality of allergy care,
  • but also to optimize health care planning and policies.
  • Clinical practice: simplicity for physicians
  • Clinical trials
  • Research: Well characterized approved phenotypes
  • Epidemiologic studies: Well characterized approved phenotypes
  • Drug development
  • Applicable to developed and developing countries
  • Registries
slide44

One step in the phenotype complexity

By courtesy from J Kiley

slide45

One step in the phenotype complexity

By courtesy from J Kiley