Download In the name of God Asthma

In the name of God
Asthma
By: E. Salehifar (PharmD, BCPS)
Asthma: Background
At least 15 million Americans have asthma
Annually cost > 12 & billion
Asthma is the leading cause of lost school
days in children and a common cause of lost
work days among adults
Mortality is rising for unknown reason
After TB and HIV, Asthma had much more rise
in incidence during the past 2 decades in Iran
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Pulmonary diseases
Obstructive diseases •
Asthma –
COPD (Bronchitis, Emphysema) –
Restrictive diseases •
Pulmonary fibrosis –
Pneumonia –
Khyphoscoliosis –
Definition
A chronic inflammatory disease that causes •
recurrent episodes of wheezing,
breathlessness, chest tightness, and cough
particularly at night and in the early morning
Airflow obstruction is reversible •
The inflammation causes bronchial •
hyperresponsiveness
Allergens:
Aeroalergenes
Viruses
pets
Smoke
Exercise
Wood dust
Chemicals
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•
Asthma
COPD
Bronchitis •
Emphysema •
Fibrosis
Overlap!
Etiology
Childhood-onset •
Genetic predisposition for IgE-mediated •
response to common aeroallergens (tree and
grass pollen, pets, …) called as “Atopy”
Positive family history •
Adult-onset •
Many adults have a negative family history and •
negative skin tests
Some may have nasal polyps, ASA sensitiity & •
sinusitis
Workplace allergens (wood dusts, chemicals) •
Allergy, Asthma
Pathophysiology
Inflammatory cells •
Eosinophils, Th2 Lymphocyte, Mast cells, –
Macrophages, Neutrophis
Inflamatory mediators •
Leucotrienes (LTD4, LTE4), Interleukines (IL-4, –
IL-5), Histamine, prostaglandines (PGD2, PGE2)
Pathophysiology
Pathophysiology
Airway changes
Symptoms
Classical symptoms •
Expiratory wheezing •
Coughing •
Dyspnea •
Chest tightness or a chronic cough without •
wheezing in some patients
Wide variety in symptoms •
Classification
Symptoms
Nighttime
Symptoms
Lung Function
Step 4
Continual
symptoms
Frequent
FEV1 or PEF ≤60%
PEF variability >30%
Step3
Daily symptoms
>1 time/week
60%< FEV1 or PEF <80%
PEF variability >30%
Step 2
3-6 times/week
3-4 times/month
FEV1 or PEF≥80%
PEF variability 20-30%
Step 1
≤2 times/week
≤2 times/month
FEV1 or PEF≥80%
PEF variability <20%
Classification
Step 4: Severe Persistent
Step 3: Moderate Persistent
Step 2: Mild Persistent
Step 1: Mild Intermittent
Only patients in step 1 doesn't need daily medication, other –
patients should receive Anti-inflammatory drugs
Salbutmol (Spray) is indicated for quick relief not for –
long- term control and use of salbutamol >2/week may
indicate need to anti-inflammatory drugs
A rescue course of systemic corticosteroid may be needed at –
any time and at any step!
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Pulmonary Function Tests
Spirometry (FEV1/FVC) •
Peak expiratory flow (PEF) •
ABG (pH, PO2, PCO2, HCO3, SPO2) •
Spirometers
Peak flow meter
Spirometer
Mild Obstruction
Severe Obstruction
Restrictive Pattern
Peak flow meter
Obstructive versus Restrictive Airway
Disease
Parameter
FEV1
FVC
FEV1/FVC*
FEF 25%-75%
Obstructive
Restrictive
↓
Normal or ↓ •
Normal or ↓
↓ •
↓
Normal or ↑ •
↓
Normal, ↓, ↑ •
* normal: 85%
Limitations of Spirometry &
Peakflowmetry
Need complete patient’s corporation
Are unobtainable in severely ill patients (esp.
spirometry)
FEV1 and PEF are relatively insensitive to small
airway changes
Variations in PEF
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Nebulizers
Spacers
Treatment
Asthma Exacerbation •
Long-Term Control •
Treatment
Asthma Exacerbation
Salbutamol (Albuterol) (Ventolin®) –
MDI+Spacer: 4-8 puffs Q 20 min up to 4 hr, then every 1-4 hr as •
needed
Nebulizer: 2.5-5 mg Q 20 min for 3 doses, then 2.5-10 mg Q 1-4 hr •
as needed
Ipratropium bromide (Atrovent®) –
MDI: 4-8 puffs as needed (Should bee added to β2-agonist •
therapy)
Nebulizer: 0.5 mg Q 30 min for 3 doses then Q 2-4 hr as needed •
Tiotropium (Spirivia) inhal cap: 18 µg –
Corticosteroids (Prednisolone, Methyl –
prednisolone)
Prednisolone: 120-180 mg in 3-4 divided dose for 48 hr, then 60-80 •
Treatment
Long-Term Control Medications
Corticosteroids •
Inhaled C.: Beclomethasone (Becotide®), Fluticasone –
(Fluoxitide®)
Systemic C.: Prednisolone –
Long-acting β2-agonists •
Inhaled: Salmetrol (Serevent®) –
Oral: Salbutamol SR –
Cromolyn sodium & Nedocromil •
Leucotriene modifiers (Zileuton, Zafirlucast, Montelukast) •
Methylxanthines (Theophylline, Aminophylline) •
Fluticasone + Salmetrole •
(Seretide®)
Budesonide + Formoterol •
(Symbicort®)
‫کرومولین سدیم‬
‫• شروع اثر‬
‫– قطره بینی (‪ 1 :)20mg/ml‬تا ‪ 2‬هفته‬
‫– استنشاقی (‪ 2 :)Cap: 20 mg‬تا ‪ 6‬هفته (ورود به ریه‪ :‬کمتر از‬
‫‪)%8‬‬
‫• ‪ :Oral‬برای ‪ systemic mastocytosis‬و ‪( IBD‬تایید‬
‫نشده)‪.‬‬
Preferred Treatments
Stage 4: Inhaled Corticosteroids (High dose ) +
Salmetrol
Stage 3: Inhaled Corticosteroids (Low to Med. dose )
+ Salmetrol
Stage 2: Inhaled Corticosteroids (Low dose)
Stage 1: no daily medication needed
Theophylline SR or LT modifiers are alternative for –
Salmetrol
in Stage 2, Cromoly or Nedocromil, Theophylline SR or LT –
modifiers are alternatives
Salmetrol and LT modifiers has been added for managing –
young children (<5 yo) asthma
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•
Low/Mod/high Doses of
Inhaled Corticosteroids
Low Dose Mod.
Dose
High
Dose
Beclomethason
e
42 mcg/puff
4-12 puffs
12-20 puffs
> 20 puffs
Fluticasone
50 mcg/puff
2-4 puffs
4-10 puffs
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Fluticasone
125 mcg/puff
----------------
2-4 puffs
>4 puffs
Fluticasone
250 mcg/puff
----------------
----------------
>2 puffs
Budesonide
200 mcg/puff
200-400 mcg
400-600 mcg
> 600 mcg
Cost
Drug
Beclo 50
Beclo 250
Flixotide 50
Flixotide 125
Flixotide 250
Pulmicort
Seretide 50
Seretide 125
Seretide 250
Price (Rial)
40500 (200 puff)
65000 (200 puff)
160000 (120 puff)
180700 (60 puff)
335800 (60 puff)
286900 (100 dose)
250000 (120 puff)
335000 (120 puff)
466000 (120 puff)
‫بیمه ای بودن‬
+
58500 +
+
167000 +
270000 +
+
+
+
Cost
Drug
Salmetrol
Salmetrol
(Serevent)
Formoterol (Oxis)
Formoterol
(Foradil)
Ipratopium
(cipla)
Ipratopium
(Atrovent)
Spirivia
Price (Rial)
40000
226000
‫بیمه ای بودن‬
+
40000 +
314300 (60dose)
217500 (30 cap)
-
25500 (300 puff)
+
96500 (200 puff)
25500 +
858000 (30 cap)
-
Patient Education
Patient Education
‫هر نفسي كه فرو میرود ممد حیات است و‬
‫چون برآید مفرح ذات‪ ،‬پس در هر نفسي‬
‫دو نعمت موجود و بر هر نعمتي شكري‬
‫واجب!‬