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CHRONIC ASTHMA GUIDELINES IN ADOLESCENTS & ADULTS 2007
Gillian Ainslie, Elvis Irusen, Bob Mash, Michael Pather, Angeni Bheekie,
Pat Mayers, Hilary Rhode
Asthma Guidelines Implementation Project
Guidelines for the
management of chronic
asthma in adolescents and
adults
Lalloo U, Ainslie G, Wong M, Abdool-Gaffar S, Irusen E,
Mash R, Feldman C, O'Brien J and Jack C
Working Group of the South African Thoracic Society
S.A. Fam Pract 2007;49(5): 19-31
www.safpj.co.za
Levels of Evidence
Aims of the Guideline
• to improve asthma care for the greatest number through uniform treatment protocols
• to use the most efficacious and cost-effective drug combinations
• to facilitate teaching of doctors and other health care workers
• to empower patients to understand their disorder, and the types & goals of therapy
Key Features of New Guidelines
• Emphasis on defining & achieving control of asthma
• The positioning of leukotriene blockers in the treatment of chronic asthma
• New evidence on the safety & optimal use of asthma medications
• The ongoing need to emphasize the use of anti-inflammatory medication as the foundation of asthma treatment
2006 GINA Goals
of Asthma Management
Achieve and maintain control of symptoms
Maintain normal activity levels including exercise
Maintain pulmonary function as close to normal as possible
Prevent asthma exacerbations
Avoid adverse effects from asthma medications
Prevent asthma mortality
a
b
c
d
e
f
Essential steps in the Management of
Asthma to Achieve Control:
Establish the diagnosis of asthma
Assess severity
Implement asthma treatment
Set goals for control of asthma
Prevent/avoidance measures
Pharmacotherapy
Achieve and monitor control
a
b
c
d
A.
ASTHMA DIAGNOSIS
STEP 1
Suspect asthma on basis of
symptoms and signs,
particularly if there is variability
STEP 2
Search for associated factors such as:
a. Atopy - allergic rhinitis, conjunctivitis, eczema
b. Family history of asthma or other allergic disorders
c. Onset of, or presence of, symptoms during childhood
d. Identifiable triggers for symptoms and relieving factors such as improvement with a bronchodilator or deterioration with exercise
e. Exposure to known asthma sensitizers in the workplace
f. Reversibility shown on lung function tests
g. Optional tests include:
Full blood count to check the eosinophil count
Total serum IgE
Skin prick tests or RAST in blood to look for evidence of atopy
Methacholine or histamine or exercise challenge tests
Diagnostic lung function values
Reversibility:
An increase of FEV1 of >12% and 200ml, 15-30min after the
inhalation of 200-400mcg salbutamol, or a 20% improvement
in PEF from baseline.
Hyper-responsiveness:
Methacholine/histamine challenge
Exercise: A fall of 20% in PEF (or 15% in FEV1) measured
5-10 minutes apart – before and then after cessation of exercise
(e.g. running for 6 minutes)
Diurnal Variation:
Diurnal Variation in PEF of more than 20%
Distinguishing between COPD and asthma when FEV shows obstruction:
Improvement of FEV1 from baseline (>12% and 200ml)
after a 2 week trial of oral prednisone (40mg daily)
Differentiating asthma and COPD
Other causes of airway obstruction
Causes of occupational asthma
B.
ASSESSMENT OF
SEVERITY OR CONTROL
C.
ASTHMA TREATMENT
• Preventative/Avoidance Measures
• Pharmacotherapy
Preventative/Avoidance Measures
A. Avoid exposure to personal and second-hand tobacco smoke
B. Avoid contact with furry animals
C. Reduce pollen exposure
D. Reduce exposure to house dust mite
E. Avoid sensitisers and irritants (dust and fumes) which aggravate or cause asthma, especially in the workplace
F. Avoid food and beverages containing preservatives
G. Avoid drugs that aggravate asthma such as beta-blockers (including eye drops) and aspirin and non-steroidal anti-inflammatory drugs
PHARMACOTHERAPY
(A) RELIEVERS :
Act only on airway smooth muscle spasm
i.e. Cause BRONCHODILATION
symptoms acutely - cough
- SOB
- wheeze/tightness
Take when necessary
PHARMACOTHERAPY
(B) CONTROLLERS : underlying INFLAMMATION
and/or cause prolonged bronchodilation
i.e. • mucosal swelling
• secretions
• irritability of smooth muscle
Take regularly, even when well
For ALL asthmatics, except mild intermittent
ASTHMA DRUG CLASSIFICATION
All patients should be prescribed inhaled, short-acting ß2
agonists such as salbutamol; 200mcg (2 puffs) as needed for
use as symptom relief for acute asthma symptoms
(Evidence A).
All patients should receive inhaled corticosteroids as baseline
asthma treatment except those classified as mild intermittent
asthma (Evidence A).
Key prescribing recommendations
Inhaled Corticosteroids
Mainstay of Rx of chronic asthma
symptoms & lung function decline
• give twice daily regularly
• direct lung delivery = lower dose
• use of spacers delivery & side effects
• safe 1000µg BDP/day (800µg Bud/day)
Inhaled Corticosteroids
Beclomethasone
• Beclate • Becotide • Becloforte
• Clenil • Viarox • Aerobec
Budesonide
• Inflammide • Budeflam
Fluticasone
• Flixotide • Flomist
Equivalent doses of inhaled steroid
RECOMMENDED ADD-ON Rx
1. Add a LABA if asthma is not well controlled on low
dose ICS (Evidence A). This option is preferred to
doubling the dose of ICS; however, not all patients
respond to LABAs. Never use LABAs alone.
2. An alternative is to double the dose of ICS or add
leukotriene modifiers (Evidence A) or slow-release
theophyllines (Evidence B)
3. Oral corticosteroids should only be used as a
maintenance treatment with extreme caution.
4. Referral to a specialist is recommended when asthma
is difficult to control
Long-Acting Beta-2 Agonists
Salmeterol
Formoterol
Combined with steroid
• Serevent
• Oxis
• Foradil
• Foratec
• Seretide
• Symbicord
Long-Acting Beta-2 Agonists
• cause bronchodilation for 12+ hours
• give twice daily regularly
• delayed onset of action - Salmeterol
Patients with poor control despite moderate dose of
inhaled steroids especially when:
They should not be used as monotherapy but in
combination with inhaled steroids.
Indications for
Long-Acting Beta-Agonists
• nocturnal asthma
• wide variation in am & pm PEF
• exercise-induced asthma
Leukotriene Receptor Antagonists
Montelukast - Singulair
Zafirlukast - Accolate
Advantages:
• Unique mode of action
• Oral form and “one dose fits all”
• Add-on effect when used with inhaled steroids
• Anti-inflammatory and anti-bronchoconstrictor
STEP-WISE Rx of ASTHMA
Only an option for those with mild
intermittent asthma at diagnosis or who
remain consistently well-controlled and
treatment is progressively reduced
STEP 1: • Inhaled beta-agonist PRN
STEP-WISE Rx of ASTHMA
Start patients with mild chronic persistent
asthma at this step
STEP 2: • Inhaled beta-agonist PRN
• Low dose inhaled corticosteroid
250-500ug/day (BDP equivalent)
STEP-WISE Rx of ASTHMA
STEP 3: • Inhaled beta-agonist PRN &
• Low dose inhaled corticosteroid 250-500ug/day (BDP
equivalent) &
• Inhaled long-acting beta-agonist (PREFERRED)
OR
• Low dose inhaled corticosteroid 250-500ug/day (BDP
equivalent) &
• Oral leukotriene modifier
OR
• Moderate dose inhaled corticosteroid 500-1000ug/day (BDP
equivalent)
STEP-WISE Rx of ASTHMA
STEP 4: • Inhaled beta-agonist PRN &
• Moderate dose inhaled corticosteroid
500-1000ug/day (BDP equivalent) &
• Inhaled long-acting beta-agonist (PREFERRED)
OR
• Moderate dose inhaled corticosteroid 500-1000ug/day
• Oral leukotriene modifier
OR
• Moderate dose inhaled corticosteroid 500-1000ug/day &
• Oral SR theophylline BD
STEP-WISE Rx of ASTHMA
STEP 5: • Inhaled beta-agonist PRN &
• High dose inhaled corticosteroid >1000ug/day (BDP
equivalent) &
• Inhaled long-acting beta-agonist
AND
• Oral leukotriene modifier
OR
• Oral SR theophylline BD
STEP-WISE Rx of ASTHMA
STEP 6: • Inhaled beta-agonist PRN &
• High dose inhaled corticosteroid >1000ug/day (BDP
equivalent) &
• Inhaled long-acting beta-agonist
PLUS
• Oral leukotriene modifier
PLUS
• Oral SR theophylline BD
AND/OR
• Long term oral corticosteroids
PLUS
• SPECIALIST REFERRAL
Treatment Choices
Depend on:
• availability
• cost
• efficacy in individual patients
• patient preference
• side effect profile
Cost Compromises
• oral steroids vs. inhaled steroids
~ long-term side effects: “save now, pay later”
• oral theophylline vs. inhaled beta-agonists
~ less effective, more side effects, titration difficult
• short-acting vs. long-acting theophyllines
• short-acting vs. long-acting beta-agonists
• oral vs. inhaled long-acting beta-agonists
~ less effective, more side effects
• MDIs ± spacers vs. dry powder devices
Therapy to avoid!
• sedatives & hypnotics
• cough syrups
• anti-histamines
• duplication of same type (eg. Ventolin + Berotec)
• combination tablets
• immunosuppressive drugs
• immunotherapy
• maintenance oral prednisone >10mg/day
Asthma
Treatment
Algorithm
Asthma Treatment Algorithm
D.
ACHIEVE AND MONITOR
CONTROL
Routine Asthma Questions
1) How many times/week do asthma symptoms (cough, wheeze, SOB) affect you during the day?
2) How many times/week do asthma symptoms disturb your sleep?
3) How many times/week do you use your relievers?
4) Has asthma caused time off work/school or interfered with your usual activities?
5) Have you needed to attend as an emergency
since your last visit / over the last year?
Assessing control
Monitor Asthma Control
Managing partly/uncontrolled patients
• Check the inhaler technique
• Check adherence and understanding of medication
• Consider aggravation by:
– Exposure to triggers/allergens at home or work
– Co-morbid conditions: GI reflux, rhinitis/sinusitis, cardiac
– Medications: Beta-blockers, NSAIDs, Aspirin
• Consider stepping up treatment
• Consider need for short course oral steroids
• Review self-management plan
ASSESS GOOD INHALER TECHNIQUE
RINSE MOUTH AFTER INHALATION OF CORTICOSTEROIDS
ASSESS GOOD SPACER TECHNIQUE
RINSE MOUTH AFTER INHALATION OF CORTICOSTEROIDS
PREDICTED PEF RATES
IN ADULT WOMEN
PREDICTED PEF RATES IN
IN ADULT MALES
Self-management plan
• Realistic goals of treatment in terms of symptom relief and/or PEF
• Advice on how to recognise changes in the asthma (via symptoms and/or peak flow rates) and when to make adjustments to treatment according to a predetermined schedule
• Written instructions on treatment which include the class, name, strength, dose and frequency of each of the asthma medications prescribed
• Instruction on when and how to initiate short courses of oral prednisone
• Details on how to obtain access to medical care in emergencies
• The use of a PEF meter and chart, particularly in those requiring stabilisation or patients who have had a recent exacerbation or deterioration
• Arrangements for a Medic-Alert bracelet for patients on high-dose inhaled or oral corticosteroids, known drug hypersensitivities (like aspirin and penicillin) and brittle asthma
Indications for Oral Steroid
Short Course
• progressive worsening over days
• acute deterioration
• repeated night wakening
• failure of maximum other Rx
Oral Steroid Short Course
• prednisone 30-40mg x 7-14 days
• once daily morning dose
• no weaning of dose unless long term use
• inhaled steroids maintained or started
• step up maintenance Rx
Reasons for referral to a specialist
Managing the well controlled patient
As soon as good control:
• Reduce oral steroids first, then stop
• Reduce relievers before controllers
When good control for 3+ months:
• Reduce inhaled steroids
Contacts and resources
National Asthma Education Programme
(South Africa)
http://www.asthma.co.za
PO Box 72128, Parkview, 2122
Fax: 011 678 3069
Tel: 011 643 2755
Mail: [email protected]
Other sites offering educational material include:
• Full text of guidelines on chronic adult asthma ~ www.safpj.co.za
• SA Thoracic Society ~ www.pulmonology.co.za
• Allergy Society of South Africa (ALLSA) ~ www.allergysa.org
• The Global Initiative for Asthma ~ www.ginasthma.org
• National Asthma campaign (UK) ~ www.asthma.org.uk
• National Heart, Blood and Lung Institute (US) ~ www.nhlbi.nih.gov
• Medic Alert ~ 021 425 7328
Asthma Guidelines Implementation Project (South Africa)
Ms Hilary Rhode, Family Medicine and Primary Care
PO Box 19063, Tygerberg, 7505
Fax: 021 938 9153
Tel: 021 938 9169
Mail: [email protected]
This 2007 asthma guideline update was developed following a meeting with a working group constituted by the S.A. Thoracic Society. The working group was chaired by Prof. U.G. Lalloo.
The contribution by the working group is gratefully acknowledged.
– Meetings were held with the working group, 2-3 July 2005, subsequently the editorial board was convened and met on 30 March 2007 to develop and finalise this guideline document.
– The meetings were sponsored by the National Asthma Education Programme (NAEP) of the S.A. Thoracic Society. This was possible through unrestricted educational grants to NAEP from the S.A. Thoracic Society, GSK, Astra-Zeneca, MSD, Altana Madaus and Boeringher Ingelheim.
– The document is viewed as a living document that will be updated periodically.
