ASTHMA MANAGEMENT PHARMACOLOGICAL
THERAPY
Presented by:
Hengameh Raissy, PharmD
Four Components of Asthma Management
• Assessment and Monitoring• Control of Factors Contributing to
Asthma Severity• Education for a Partnership in
Asthma Care• Pharmacological Therapy
NAEPP. EPR-3, page 1.
Asthma Classification Schemes
Stepwise Approach to Asthma Therapy
Asthma Medications and Delivery Devices
New/Complementary/Alternative
This lesson will cover:
• Asthma is a chronic inflammatory disorder of the airways
• A key principle of therapy is regulation of chronic airway inflammation
What is Asthma?
– Bronchospasm is what you see as cough and wheeze
– Inflammation is what you don’t see but is at the center of the process
Pathophysiology of Asthma
INFLAMMATION
Airway Hyperresponsiveness
Airflow Limitation
Environmental Risk Factors Genetic Predisposition
SymptomsCough Wheeze Shortness of Breath
Adapted with permission from Stephen T. Holgate, MD, D. Sc.
bronchospasm
Precipitants
The Pharmacological Treatment of Asthma can focus on one or both aspects of the disease…
The Chronic disease:
• Intermittent• Mild Persistent• Moderate Persistent• Severe Persistent
The Acute (exacerbating) Disease:
• Mild • Moderate• Severe• Respiratory Failure
Asthma: The Chronic Disease
Classification of Severity
Stepwise Approach to
Therapy
Assessment of Control
The Risk of Asthma in a Wheezing Child 0-3 years: Modified Asthma Predictive Index
Major Criterion
• Parental history of asthma
• Physician-diagnosed atopic dermatitis
• Allergic sensitization to ≥1 aeroallergen
Minor Criterion
• Wheezing unrelated to colds
• Blood eosinophils ≥4%• Allergic sensitization to
milk, eggs, or peanuts
- strict API = NPV ≥ 95% no asthma
+strict API = 9.8x likely to have active asthma when 6-13y/o +loose API= 5.5x likely to have active asthma when 6-13 y/o
Guilbert TW, et al JACI 2004
OR
In the past 12 months, >3 episodes of wheezing with at least
Components of Severity Intermittent
Persistent
Mild Moderate Severe
Impairment
Symptoms 2 days/week>2
days/week but not daily
Daily Throughout the day
Nighttime awakenings
None 1-2x/ month 3-4x/month >1x/ week
B-agonist use (not prevention of EIB)
2 days/week>2
days/week but not daily
Daily Several times per day
Activity limits None Minor Limitation
Some Limitation
Extremely Limited
Risk Exacerbations requiring OSC 0-1/yr
2 exacerbations in 6 months requiring oral systemic corticosteroids, or 4 wheezing episodes/ 1 year
lasting >1 day AND risk factors for persistent asthma
Classifying Asthma Severity: 0 – 4 years The Chronic Disease
Classifying severity in children who are not currently taking long-term control medication.
Step 1
Preferred:SABA PRN
Step 2
Preferred:Low-dose
ICS
Alternative:Cromolyn
or Montelukast
Step 3
Preferred:
Medium-dose ICS
Step 5Preferred:
High-dose ICS + either
LABA or Montelukast
Step 6Preferred:
High-doseICS + either
LABA or Montelukast
OSC
Step 4Preferred:
Medium-dose ICS +
either LABA or
Montelukast
Initial Therapies / Stepwise Approach: Asthma Patients 0-4 Years of Age
ICS = inhaled corticosteroid; LABA = long-acting beta2-agonist; OSC = Oral Systemic Corticosteroids.; SABA = inhaled short-acting beta2-agonist.
Consider consult
Recommend consult
Mild Moderate Severe
A
DD
D
D
Intermittent Persistent
Each Step: Patient education, environmental control, management of co morbidities
If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up
Step Down If Possible
(and asthma is well controlled
at least 3 months)
Step Up If Needed
(first, check adherence,
inhaler technique,
environmental control)
AssessControl
Assessing Control: 0 – 4 years
Components of Control
Classification of Asthma Control
Well Controlled
Not Well Controlled
Very Poorly Controlled
Impairment
Symptoms 2 days/wk >2 days/wk Throughout the day
Nighttime awakenings 1x/month >1x/month >1x/week
Activity limits None Some limitation Extremely limited
B-agonist use (not prevention of EIB)
2 days/week >2 days/week Several times per day
Risk
Exacerbations requiring OSC 0-1/year 2-3/year >3/year
Treatment-related adverse effects
Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Components of Severity Intermittent
Persistent
Mild Moderate Severe
Impairment
Symptoms 2 days/wk
>2 days/wk but not daily Daily Throughout
the day
Nighttime awakenings 2x/month 3-4x/month >1x/wk but
not nightly Often 7x/wk
B-agonist use (not prevention of EIB)
2 days/wk >2 days/wkbut not daily Daily Several times
per day
Activity limits None Minor limitation
Some Limitation
Extremely limited
Lung FunctionFEV1
FEV1/FVC>80%>85%
80%>80%
60 – 80%75 - 80%
<60%<75%
Risk Exacerbations requiring OSC 0-1/yr 2/year
Classifying Asthma Severity: 5 – 11 years The Chronic Disease
Classifying severity in children who are not currently taking long-term control medication.
Step 1
Preferred:SABA PRN
Step 2
Preferred:Low-dose
ICS
Alternative:Cromolyn
LTRANedocromil
or theophylline
Step 3
Preferred
Medium-dose ICS
OR
Low-dose ICS + either LABA, LTRA
or theophylline
Step 5Preferred:
High-dose
ICS + LABA
Alternative: High dose
ICS + either LTRA or
theophylline
Step 6
Preferred:High-dose
ICS + LABA + OSC
Alternative: High dose
ICS + either LTRA or
Theophylline +OSC
Step 4Preferred:
Medium-dose
ICS + LABA
Alternative:Medium-dose ICS +either LTRA
or theophylline
Initial Therapies / Stepwise Approach:Asthma Patient 5-11 Years of Age
PersistentIntermittent
Each Step: Patient education, environmental control, management of co morbidities
Steps 2-4: Consider subcutaneous allergen immunotherapy for patients with allergic asthma
Consider consult
Recommend consult
Mild Moderate Severe
A
B
B
B
D
ICS = inhaled corticosteroid; LABA = long-acting beta2-agonist; LTRA= leukotriene receptor antagonist; OSC = Oral Systemic Corticosteroids; SABA = short-acting beta2-agonist.
Step Down If Possible
(and asthma is well controlled
at least 3 months)
Step Up If Needed
(first, check adherence,
inhaler technique,
environmental control)
AssessControl
Asthma Control: 5 – 11 years
Components of Control
Classification of Asthma Control
WellControlled
Not Well Controlled
Very PoorlyControlled
Impairment
Symptoms 2 days/wk but not more than once on
each day>2 days/wk or multiple
times 2 days/wk Throughout the day
Nighttime awakenings 1x/month ≥2x/month ≥2x/week
Activity limits None Some limitation Extremely limited
B-agonist use (not prevention of EIB)
2 days/wk >2 days/wk Several times per day
Lung function• FEV1 or PF• FEV1/FVC
80% >80%
60 – 80% 75-80%
<60% <75%
Risk
Exacerbations requiring OSC 0-1/year ≥2/year
Reduction inlung growth Evaluation requires long-term follow-up
Treatment-related adverse effects
Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Classifying Asthma Severity: 12 and older
Components of Severity Intermittent
Persistent
Mild Moderate Severe
Impairment
Normal FEV1/FVC:8-19yrs 85%20-39yrs 80%40-59yrs 75%60-80yrs 70%
Symptoms 2 days/wk >2 days/wkbut not daily Daily Throughout
the day
Nighttime awakenings
2x/month 3-4x/month >1x/wk but not nightly Often 7x/week
B-agonist use (not prevention of EIB)
2 days/week >2 days/wk but not daily, and not more than 1x on any day
Daily Several times per day
Activity limits None Minor limitation
Some Limitation
Extremely limited
Lung FunctionFEV1
FEV1/FVC>80%
normal80%
normal>60 -80%
reduced 5%<60%
reduced >5%
Risk Exacerbations requiring OSC 0-1/yr 2/yr
The Chronic Disease
Classifying severity for patients who are not currently taking long-term control medication.
Step 1
Preferred:SABA PRN
Step 6
Preferred:High-dose
ICS + LABA + OSC
And
Consider Omalizumab for
patients who have allergies
Initial Therapies /Stepwise Approach: Asthma Patients > 12 Years of Age
ICS = inhaled corticosteroids; OSC = Oral Systemic Corticosteroids; SABA = short-acting beta2-agonist; LABA = long-acting beta2-agonist; LTRA= leukotriene receptor antagonist.
PersistentIntermittent
Each Step: Patient education, environmental control, management of co morbidities
Steps 2-4: Consider subcutaneous allergen immunotherapy for patients with allergic asthma
Consider consult
Recommend consult
Mild Moderate Severe
Step Down If Possible
(and asthma is well controlled
at least 3 months)
Step Up If Needed
(first, check adherence,
inhaler technique,
environmental control)
AssessControl
A
A/B/D
B/D
B
B
Step 1
Preferred:SABA PRN
Step 2
Preferred:Low-dose ICS
Alternative:Cromolyn
LTRA or
theophylline
Step 3
Preferred:Medium-dose
ICS or
Low-dose ICS + LABA
Alternative: Low dose ICS
+LTRA,
theophylline or zileuton
Step 5
Preferred:High-dose ICS + LABA
And
Consider Omalizumab for patients who have allergies
Step 4
Preferred:Medium-dose ICS + LABA
Alternative: medium dose ICS + LTRA, theophylline or zileuton
Asthma Control: 12 and older
Components of Control
Classification of Asthma Control
WellControlled
Not WellControlled
Very PoorlyControlled
Impairment
Symptoms 2 days/week >2 days/week Throughout the day
Nighttime awakenings 2x/month 1-3x/week >4x/week
Activity limits None Some limitation Extremely limited
B-agonist use (not prevention of EIB)
2 days/week >2 days/week Several times per day
Lung function FEV1 or PF >80% FEV1 or PF = 60 -80% FEV1 or PF <60%
QOL indicator ACT ≥20 ACT =16-19 ACT ≤15
Risk
Exacerbations requiring OSC 0-1/year > 2/ year
Reduction in lung growth Evaluation requires long-term follow-up
Treatment-related adverse effects
Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
• Severity assessment has been simplified and lung function measurement is emphasized
• Lower doses of systemic corticosteroids (OCS); 1mg/kg may be enough
• Education on site and as part of discharge plan • Initiation of controller inhaled corticosteroids
(ICS) for persistent asthma recommended • If hospitalized, ipratropium is not recommended
(2 studies)
What’s New: The ED / Hospital
NAEPP. EPR-3, pages 102-106.
Signs and Symptoms
Initial FEV1 or PF
Clinical Course
MildDyspnea only with activity; RR in young
PF/FEV1 > 70% Care @ home Relief w/ SABA
ModerateDyspnea interferes/limits usual activity
PF/FEV1 = 40-69% Office or ED visit Response to SABA OCS
SevereDyspnea at rest; interferes w/ conversation; In infants use exam
PF/ FEV1 < 40%
O2 sat < 90%
ED / Hospitalization + SABA response OCS Adjunctive therapy
Life Threatening
Too dyspneic to speak / perspiring
Hospitalization / ICU No relief SABA IV CS/ adjunctive
Severity Assessment of Acute Flares
Symptoms/Exam Lung Function
Mild -alert and oriented-speaks in sentences-expiratory wheezes; ↑ rr
PF or FEV1 >70%O2 sat > 95%
Moderate -agitated, not playful-speaks in phrases-wheeze; ↑ rr-may use access. muscles
PF or FEV1=40-69%O2 sat = 90-95%
Severe -breathless at rest-speaks in words-loud wheeze; ↑↑ rr
PF or FEV1 <40%O2 sat < 90%
Impending Failure
-altered consciousness-silent chest- ↑↑ rr or slowing rr
Classifying Severity- of Acute Disease (Asthma Exacerbations)
Managing Asthma: Acute Exacerbations
Impending respiratory failure: oxygen; iv access; alb/atrovent; bolus solumedrol; admit to ICU; prepare for intubation
Severe: oxygen; 3 albuterol nebs w/ atrovent or continuous albuterol; i.v. or oral methylpred 1-2 mg/kg admit to hospital
Moderate: oxygen; albuterol nebulization q 20 min x 3; oral corticosteroids 1-2 mg/kg for 3-5 days; treat co-morbidities
Mild: albuterol MDI (w/ spacer), or nebulizer treatment up to 3 times; consider oral corticosteroid
The Acute Disease
Medications
Inhaled Medication:
• In general, inhaled therapy is favored over systemic (oral) therapy for asthma
• The medication is delivered on site and avoids most adverse side effects
Pharmacological Therapy
NAEPP. EPR-3, page 216.
Metered-Dose
Inhaler (MDI)
Dry Powder Inhaler (DPI)
Spacer/Holding
Chamber
Spacer/Holding
Chamber and Face
Mask
Nebulizer
Inhaled Medication Delivery Devices
• Many MDIs used chlorofluorocarbons (CFCs) as propellants.
• CFCs were phased out globally in 2008 to protect the earth’s ozone layer
• Hydrofluroalkaline (HFA) inhalers are the non-CFC alternative
• DPIs (breath actuated Dry Powder Inhalers) are non-CFC compliant
Metered Dosed Inhalers
Transition to non-CFC containing inhalers:
Daily Long-Term Control:• Corticosteroids (inhaled and systemic)• Long-acting beta2-agonists (salmeterol,
formoterol) when in combination with ICS• Leukotriene modifiers (montelukast)• Leukotriene inhibitors (zileuton)• Mast cell stabilizers (cromolyn or nedocromil)• Methylxanthines (theophylline)
Overview of Asthma Medications
Inhaled Corticosteroids (ICS):• Most effective long-term-control therapy for
persistent asthma• Risk for adverse events is minimal at
recommended low/medium inhaled doses• Risk depends on dose and delivery method
Long-Term Control
• Benefit of daily use:– Reduced airway inflammation– Improved lung function – Reduced use of quick-relief medicine– Fewer symptoms and exacerbations
• In usual doses ICS do not provide short-term relief
• Must be used daily for full benefit
Inhaled Corticosteroids
Ra t
e R
a ti o
for
Dea
t h f
r om
Ast
hma
No. of Canisters of Inhaled Corticosteroids per Yr.
2.5
2.0
1.5
1.0
0.5
0.01 2 3 4 5 6 7 8 9 10 11 12
Low-dose ICS and the Prevention ofDeath from Asthma
Suissa S et al. N Engl J Med. 2000;343:332-336.
Effects of Inhaled Steroids on Airway Inflammation
J Allergy Clin Immunol. 1992;90:32-42.
Pre– and post–3-month treatment with budesonide (BUD) 600 mcg b.i.d.
E = Epithelium; BM = Basement Membrane
Possible Dose-Dependent side effects:• Oral candidiasis (thrush)• Dysphonia• Reflex cough and bronchospasm• Slowed linear growth velocity• Decreases in bone mineral density• Dermal thinning and skin bruising• Ocular effects: glaucoma, cataracts
Inhaled Corticosteroids
CAMP Trial and Follow-up Design
RoutineCare
Randomize
Treatment Trial Transition
5 visits 3 visits per year
2 visits
Study RxDiscontinued
2 - 4 months
4 – 6 years
4 months
Screeningand
Baseline
13 years
Follow-up
Enroll in follow-up study Refer back to PCP for Rx
per NAEPP guidelinesNedocromilBudesonidePlacebo
Enrollment in trial: Dec 1993 – Sept 1995
1,041 children age 5-13 years at randomization
Mild to moderate persistent asthma
1-4 visits per year
Change in Bone Densityat End of CAMP Trial
0.17 0.180.17
0.0
0.1
0.2
0.3
0.4
0.5
g/cm
2
Budesonide vs. Placebo = - 0.01, P = 0.53Nedocromil vs. Placebo = - 0.01, P = 0.15
Budesonide Nedocromil Placebo (n = 304) (n = 306) (n = 410)
Mean Obtained Adjusted Adult Height
0
50
100
150
Total Females Males
Bud
Ned
Plbo
-1.2 cm(-1.9 to -0.5)
-1.8 cm(-2.9 to -0.7)
-0.8 cm(-1.8 to 0.2)
cm
*Means adjusted for race/ethnicity, clinic, and age, asthma duration and severity, skin test reactivity, and height at trial entry. Total panel also adjusted for sex.
Bud–Plbo diff.: (95% CI)
Bud by sex interactio, P=0.10
Bud vs Plbo: P=0.001 P=0.001 P=0.10 Ned vs Plbo: P=0.61 P=0.26 P=0.98
ICS Metabolism
Reduce potential for adverse events by:
• Rinsing mouth• Using lowest dose possible that results in
control• Use in combination with long-acting
beta2-agonists (LABA) or a leukotriene modifier if moderate/severe disease
Inhaled Corticosteroids
Comparative Dosages:
HFA ≠ DPI ≠ MDI ≠ respules
• Preparations are not equivalent per puff or per microgram
• Comparative doses are estimated.– Few data directly compare preparations
Inhaled Corticosteroids
Chemical Structure of Inhaled Corticosteroids
Mometasone (Asmanex)
Beclomethasone (QVAR)
Budesonide (Pulmicort) Flexhaler: 90, 180
40, 80 ug/puff
110, 220 ug/puff
Budesonide (Pulmicort) .5mg, 1.0mg
110 ug/puff
220 ug/puff44 ug/puff
Fluticasone (Flovent HFA)
Inhaled Corticosteroids
Drug Low Dose Medium Dose High Dose
Beclomethasone HFA 80-240 mcg 240-640 mcg >640 mcg
Budesonide DPI 200 - 600 mcg 600 -1200 mcg >1200 mcg
Mometasone DPI 220 mcg 440 mcg 440-880 mcg
Fluticasone 88 - 264 mcg 264 - 660 mcg >660 mcg
Triamcinolone 400 -1,000 mcg 1,000 - 2,000 mcg >2,000 mcg
Estimated Comparative Daily Dosages of Inhaled Corticosteroids for Adults
Long-Acting Beta2-Agonists (LABA)salmeterol (serevent), formoterol (foradil)
• May be beneficial when added to inhaled corticosteroids as an adjunct
• Do not have anti-inflammatory properties alone• Asthma may worsen if used as mono-therapy• LABA’s are not recommended for use as mono-
therapy for long term control of persistent asthma
• Not appropriate for quick relief
• 28 week, randomized, double-blind, placebo-controlled; 164 patients; 12 - 65 yrs. old
• Persistent asthmatics controlled on Triamcinolone 400 mcg bid
Use of Salmeterol Alone to Treat Asthma
JAMA 2001;285:2583-93.
Treatment Failure Rate
Treatment arms:
1. Placebo
2. Change to Salmeterol
3. Continue ICS
Is there a problem with inhaled long-acting B-adrenergic agonists (LABA)?
Harold Nelson, MD
• LABA’s by themselves have no significant anti-inflammatory effects and should be used with ICS
• When used with ICS most studies have not identified an increased risk of death or near death from asthma
• Re-analysis of the pattern of asthma deaths suggest that in patients with limited access to care, symptomatic relief provided by LABA’s may result in delays in seeking medical care in the face of increasing airway inflammation
J Allergy Clin Immunol Jan. 2006
Leukotriene Modifiers• Mechanisms
– 5-LO inhibitors –zileuton (Zyflo)– Cysteinyl LeukoTriene Receptor Antagonists
montelukast (Singulair), zafirlukast (Accolate)
• Indications– Monotherapy in mild persistent asthma– Add-on therapy in moderate to severe persistent
asthma
Long-Term Control
Combination Therapy
• MDI• 100/5 mcg• 200/5 mcg
• Patients 12 and older
Dulera
Momestasone Furoate
Formoterol Fumarate
Combination Therapy
• MDI• 80/4.5 mcg• 160/4.5 mcg
• Patients 12 and older
Symbicort
Budesonide
Formoterol Fumarate
Advair®
DPI Doses:100/50* mcg250/50 mcg500/50 mcg
-DPI: Breath Actuated Dry Powder Inhaler
- MDI HFA
- Fluticasone propionate and samleterol
*approved > 4 yrs
The rest of the doses are approved for 12 years and older
MDI doses45/21 mcg115/21 mcg230/21 mcg
Why use fixed combinations?
• The asthmatic who needs moderate persistent therapy and who has failed on appropriate doses of inhaled corticosteroids
• The challenging patient– Facilitate compliance– Decrease the number of inhalation devices – Improve patient inventory control
DO NOT use unless both medications are necessary to control asthma….
Currently Approved Controller Therapy for Asthma in Children
FDA-Approved Ages (Years) for Use in Children0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Triamcinolone
Flunisonide
Fluticasone and Salmeterol DPI
Nebulized Budesonide
Budesonide DPI
Montelukast
Beclomethasone HFA
Mometasone DPI
Budesonide and Formoterol DPI
Role of Leukotrienes in Asthma
Mucus Transport
Airway Smooth MuscleInflammatory Cells
(e.g. Mast Cells,Eosinophils)
AirwayEpithelium
Sensory Nerves(C-Fibers)
LTD4EdemaEdema
BloodVessel
Increased Mucus
Secretion
Increased Mucus
Secretion
Decreased Mucus Transport Decreased Mucus Transport
EosinophilInflux
EosinophilInflux
Epithelial Cell Damage Epithelial Cell Damage
Cationic Protein Release ,
Contraction &Contraction & Proliferation
Adapted from Hay DWP et al. Trends Pharmacol Sci 1995;16:304-309
• Oral pharmacokinetics:– Rapidly and well absorbed– Not affected by food ingestion– Minimal accumulation with multiple dosing
• No dosage adjustments required based on:– Renal insufficiency– Mild to moderate hepatic insufficiency– The elderly
• Anecdotal Reports: Recent reports about behavioral side effects
Montelukast (Singulair)
Cherry-Flavored Chewable Tablets
4 mg 5 mg
Ages 2–5 Ages 6–14
Montelukast (SINGULAIR™†) (montelukast sodium, MSD)
• Administered once daily ( bedtime)
• Available for adults and children as young as 6 months
†Trademark of Merck & Co., Inc., Whitehouse Station, NJ, USA
Film-Coated Tablet
10 mg
Ages 15 years
Granule Packets
4mg
Ages 6 mos–5yrs
C.A.I.R
Dosing Regimen in Adults and Children
• Urgent control of Inflammation– Systemic corticosteroids (IV or PO)
• Burst Tx (PO) or hospitalization/ER (IV)
• As-needed: Quick Relief– Short-acting (selective) beta2-agonists (albuterol,
pirbuterol, levalbuterol)– Anticholinergics (Ipratropium bromide)
Short-acting Asthma Medications
ProAir Proventil HFA Ventolin HFA
Albuterol HFA
Levalbuterol (Xopenex HFA)
Pirbuterol (Maxair)
Quick Relief Beta2-agonists
Ne
bu
lizer
So
luti
on
s
Short-Acting Beta2-Agonistsalbuterol* (Proventil, Ventolin, ProAir), pirbuterol** (Maxair),
levalbuterol*** (Xopenex)
• Most effective medication for relief of acute bronchospasm (more so than anticholinergics)
• Effective as a pre exercise medication• More than one canister per month suggests inadequate
asthma control
Quick Relief
* available as HFA MDI and in several nebulizer forms
* * available as breath actuated brand name MDI
* * * available as HFA MDI or liquid for nebulization
(.31mg, .63mg, 1.25mg)
Short-Acting Beta2-Agonists:
• Regularly scheduled use is not generally recommended– May lower effectiveness and increase side effects– May increase airway hyper-responsiveness
• Using >2 canisters per month-risk factor for death
NAEPP. EPR-3, page 377.
Older adults:• Older adults esp. those with ischemic heart disease may
show Increased sensitivity to B-agonists (tremor, tachycardia)• Systemic corticosteroids can provoke:
– confusion – agitation – changes in glucose metabolism
• Inhaled corticosteroids– May be associated with dose-dependent reduction in bone mineral
content– Physician may consider concurrent treatment with
• Calcium supplements and Vitamin D• Bone-sparing medications (e.g. bisphosphonates)
Special Considerations
Patients with other medical issues:• Medications for other diseases may exacerbate
asthma– NSAIDs (ASA induced asthma)– Nonselective beta-blockers– Beta-blockers found in some eye drops– ACE inhibitors
Special Considerations
Transient narrowing of the airways associated with:• Physical exertion• Coughing, wheezing or shortness of breath occurring
within 10-15 minutes of starting exercise: • Exercise duration = 2-8 min. (85-95% max HR)• Maximal at 8-15 minutes post exercise• Diagnosis = 12-15% drop in FEV1 (7% in elite
athlete)
Special Considerations
Exercise Induced Asthma (EIA)Exercise Induced Bronchospasm (EIB)
Occurrence:• 90% of asthmatics • 40% of patients with allergic rhinitis• 22% of 1998 Olympic athletes• 9% of persons with EIB have no hx of asthma or
allergies• 10-50% of asthmatics on ICS still display EIB
Exercise Induced Asthma
Management Strategies:• Short-acting inhaled beta2-agonists used shortly
before exercise last 2 to 3 hours• Salmeterol may prevent EIB for 10 to 12 hours• Cromolyn if side effects a concern• A lengthy warm-up period before exercise • An aerobic conditioning program• Long-term-control therapy, if appropriate• Avoid asthma triggers during exercise
Managing Exercise-Induced Asthma
Over-The-Counter (OTC) Asthma Medicines:• Always include OTC’s in medical history• OTC products may provoke asthma (ASA)• Short acting bronchodilators (e.g. Primatene
mist): not a substitute for prescription medicines– Often indicate need for physician referral– Very short acting and non-selective
Special Considerations
Subcutaneous Allergy Immunotherapy•Consists of small injections of relevant allergens in increasing concentrations over a 3-6 month build-up followed by maintenance injections every 2-4 weeks over 3-5 years•beneficial effects occur over months (not immediately)•Reports have concluded that over time it can prevent the development of new sensitivities to allergens•Controlled studies have demonstrated reduction in asthma symptoms caused by exposure to cat, dust mites, mold, ragweed, and grass•Sublingual therapy has yet to be proven as effective
Subcutaneous Allergy Immunotherapy
Subcutaneous Allergen Immunotherapy is considered for:
Patients with persistent asthma if evidence is clear of a relationship between symptoms and exposure to an allergen
Candidates for immunotherapy are generally > 5 years of age
Administration should occur in an office prepared to treat a systemic allergic reaction
NAEPP. EPR-3, page 177.
Newer Therapy
Anti-IgE Therapy – Omalizumab (Xolair)
• Humanized IgG (5% murine)• Binds IgE regardless of specificity• Does not activate complement• Rarely has caused anaphylaxis
• Indicated for adults and adolescents(>12) with severe persistent asthma inadequately controlled on high-dose ICS and LABA
• Selected patients must have a positive skin test or in vitro reactivity to aeroallergens
• Dosed every 2-4 weeks; SQ dosing• May allow these patients to improve control,
decrease dose of ICS and decrease reliance on oral corticosteroids
Xolair (Omalizumab)
• Use of Alternative medicines may result in:– allergic reactions– intensification of drug side effects
• Users may not be aware of:– potency– contaminants– covert additives– Recommended that clinician ask patient about
complementary and alternative medicine use (CAM)
Alternative Therapies
NAEPP. EPR-3, pages 240 - 244.
40% of pts who use non-provider prescribed therapies do not report alternative medication use because they are not asked or because they do not think it is important for their medical provider to know (Eisenberg 2001).
According to the 2007 NAEPP EPR-3:
Insufficient evidence to recommend the following for asthma management:
Chiropractic therapy
Acupuncture
Hypnosis
Homeopathy and herbal medicine
Breathing techniques
Yoga
NAEPP. EPR-3, pages 240 - 242.
However, some people find these therapies helpful:
Acupuncture
• may relax and calm breathing
Biofeedback
• may help control involuntary physical responses
Hypnosis
• may allow more self discipline through suggestion
Massage, relaxation, art/music therapy, yoga
• may reduce anxiety and help to relax
Potential for Allergic Responses• Daisy family• Horse chestnut• Natural plant salicylates• Royal jelly
Alternative Medicines
Willow bark
Royal Jelly
Echinacea
Intensification of Drugs• CNS stimulants
– Ma huang (ephedra)– Ginseng– Yohimbe– Goldenseal– Gingko
• Potentiate steroids– Licorice
Alternative Medicines
Ginseng
Deactivation of Drugs• Decreases theophylline levels
– St John’s wort
• Decreases prednisolone levels– xiao hu tang– sho-saiko-to
Alternative Medicines
St. John’s Wort
• Focus is on treating inflammation• Severity classification of the chronic disease
determines therapy• Inhaled corticosteroids are the best therapy for
treatment of persistent disease• New therapies on the horizon …. Updates on the
guidelines are the best resources
Asthma Pharmacological Therapy
ASTHMA MANAGEMENT PHARMACOLOGICAL
THERAPY:
CASE STUDIES
Presented by:
19 mo old with nighttime cough and 3 spells in last 6 months treated with oral corticosteroids (OCS)
• He is thought to have intermittent asthma. What do you think?
• What is the best treatment?• His mom has asthma and he has milk allergy. Will
he have asthma when older?
Case Study #1
Mild – Moderate Persistent
Inhaled Corticosteroids - Asthma education
Very Likely
3 year old on montelukast who wakes up at night once per week with cough
• Is he controlled?• What should be done?
Case Study #2
Not well controlled
Switch to Inhaled Corticosteroid
Assess adherence; evaluate for co morbidities; educate
Follow-up in 2-6 weeks
6 year old with daily cough, FEV1=80%, FEV1/FVC=76%
• How severe is her asthma?
• What medications should be prescribed?
• Anything else?
Case Study #3
Moderate Persistent
Budesonide DPI 180 2 puffs bid or Budesonide 180 1 puff bid with Montelukast 5 mg or Advair 100/50 1 puff bid—consider black box warning Check technique
Write an action plan; Provide asthma self-management education; assess triggers; consider referral to an asthma specialist Bring her back in 2-6 weeks
15 year old who uses albuterol 3 times each basketball game/practice despite daily fluticasone
• What could the physician do next to help?
Case Study #4
Check pre and post spirometry
Perform exercise challenge
Consider more in depth studies and co morbidities
Consider asthma specialist consultation
You could try combination therapy but the work-up is most important
13 month old infant (3rd episode) with inspiratory and expiratory wheeze, RR=60, O2 Sat=90% after 1 hour in
the emergency department
• Is this asthma?
• He’s had 2 treatments, what next?
• Should he be in the hospital?
Case Study #5
Of course
Oral corticosteroids; evaluate for co-morbidities
Probably; need more family/personal history
Barbara Chilmonczyk, MD Allergy and Asthma Associates of Maine; AH! Asthma Health Program Director, MaineHealth and the Barbara Bush Children’s Hospital @ Maine Medical Center, Portland, ME (207) 662-3325
Rhonda Vosmus, RRT-NPS, AE-CAsthma Education Specialist Maine Medical Center and MaineHealth, Portland, ME
(207) 662-4515
Janice H. Howell, MD, FRCPC, FAAPFaculty Physician, Medical Education-Pediatrics, Orlando FL (321) 841-2121
Chris Garvey, FNP, MSN, MPA, FAACVPRManager Pulmonary and Cardiac Rehabilitation Seton Medical Center
(650) 991-6776
Donna Beal, MPH, CHES Regional Program Director ALACA Santa Barbara, CA (805) 963-1426
NIH. NAEPP Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, October 2007.
Acknowledgements
We will breathe easier when the air in everyAmerican community is clean and healthy.
We will breathe easier when people are free from the addictivegrip of cigarettes and the debilitating effects of lung disease.
We will breathe easier when the air in our public spaces andworkplaces is clear of secondhand smoke.
We will breathe easier when children no longerbattle airborne poisons or fear an asthma attack.
Until then, we are fighting for air.