Download Asthma Management

ASTHMA MANAGEMENT
PHARMACOLOGICAL
THERAPY
Presented by:
Martha Mullane CPNP AE-C
Rochester General Health SystemPharmacy
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.
This lesson will cover:
Asthma Classification Schemes
Stepwise Approach to Asthma Therapy
Asthma Medications and Delivery Devices
New/Complementary/Alternative
What is Asthma?
• Asthma is a chronic
inflammatory disorder of the
airways
• A key principle of therapy is
regulation of chronic airway
inflammation
– 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
Environmental Risk Factors
Genetic Predisposition
INFLAMMATION
Airway
bronchospasm
Hyperresponsiveness
Airflow
Limitation
Precipitants
Symptoms
Cough
Adapted with permission from Stephen T. Holgate, MD, D. Sc.
Wheeze Shortness of Breath
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
In the past 12 months, >3 episodes of wheezing with at least
Major Criterion
Minor Criterion
• Parental history of
• Wheezing unrelated to
asthma
OR colds
• Physician-diagnosed
• Blood eosinophils ≥4%
atopic dermatitis
• Allergic sensitization to
• Allergic sensitization to
milk, eggs, or peanuts
≥1 aeroallergen
+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
- strict API = NPV ≥ 95% no asthma
Guilbert TW, et al JACI 2004
Classifying Asthma Severity: 0 – 4 years
The Chronic Disease
Components of
Severity
Persistent
Intermittent
Mild
Moderate
Severe
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
 2 days/week
>2
days/week
but not daily
Daily
Several times
per day
None
Minor
Limitation
Some
Limitation
Extremely
Limited
Impairment
B-agonist use
(not prevention of EIB)
Activity limits
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
Initial Therapies / Stepwise Approach:
Asthma Patients 0-4 Years of Age
Recommend consult
D
Consider consult
A
Step 1
Preferred:
SABA PRN
Step 2
Preferred:
Preferred:
Low-dose
ICS
Mediumdose ICS
D
Step 6
D
Step 5
Preferred:
Step 4
Preferred:
Preferred:
High-dose
ICS + either
LABA or
Montelukast
High-dose
ICS + either
LABA or
Montelukast
(first, check
adherence,
inhaler
technique,
environmental
control)
OSC
Assess
Control
Mediumdose ICS +
either LABA
or
Montelukast
Alternative:
Cromolyn
or
Montelukast
Mild
Intermittent
Step 3
D
Step Up If
Needed
Step Down If
Possible
Moderate
Severe
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
ICS = inhaled corticosteroid; LABA = long-acting beta2-agonist; OSC = Oral
Systemic Corticosteroids.; SABA = inhaled short-acting beta2-agonist.
(and asthma is
well controlled
at least 3
months)
Assessing Control: 0 – 4 years
Components of
Control
Impairment
Well
Controlled
Not Well
Controlled
Very Poorly
Controlled
Symptoms
 2 days/wk
>2 days/wk
Throughout the day
Nighttime
awakenings
 1x/month
>1x/month
>1x/week
None
Some limitation
Extremely limited
 2 days/week
>2 days/week
Several times per
day
0-1/year
2-3/year
>3/year
Activity limits
B-agonist use (not
prevention of EIB)
Exacerbations
requiring OSC
Risk
Classification of Asthma Control
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: 5 – 11 years
The Chronic Disease
Components of
Severity
Impairment
Risk
Persistent
Intermittent
Mild
Moderate
Severe
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
 2 days/wk
>2 days/wk
but not daily
Daily
Several times
per day
Activity limits
None
Minor
limitation
Some
Limitation
Extremely
limited
Lung Function
FEV1
FEV1/FVC
>80%
80%
60 – 80%
<60%
>85%
>80%
75 - 80%
<75%
Exacerbations
requiring OSC
0-1/yr
(not prevention of EIB)
 2/year
Initial Therapies / Stepwise Approach:
Asthma Patient 5-11 Years of Age
B
B
Step 5
B
Step 4
Preferred:
Step 3
Preferred:
High-dose
Recommend consult
Consider consult
A
Step 1
Preferred:
SABA PRN
Step 2
Preferred
Preferred:
Low-dose
ICS
Mediumdose ICS
Alternative:
Cromolyn
LTRA
Nedocromil
or
theophylline
Mild
Intermittent
Mediumdose
Alternative:
Low-dose
MediumICS + either
dose ICS
LABA, LTRA
+either LTRA
or
or
theophylline
theophylline
Step 6
Preferred:
High-dose
ICS + LABA
+ OSC
ICS + LABA
ICS + LABA
OR
D
Alternative:
High dose
ICS + either
LTRA or
theophylline
Moderate
Alternative:
High dose
ICS + either
LTRA or
Theophylline
+OSC
Severe
Persistent
Each Step: Patient education, environmental control, management of co morbidities
Steps 2-4: Consider subcutaneous allergen immunotherapy for patients with allergic asthma
ICS = inhaled corticosteroid; LABA = long-acting beta2-agonist; LTRA=
leukotriene receptor antagonist; OSC = Oral Systemic Corticosteroids;
SABA = short-acting beta2-agonist.
Step Up If
Needed
(first, check
adherence,
inhaler
technique,
environmental
control)
Assess
Control
Step Down If
Possible
(and asthma is
well controlled
at least 3
months)
Asthma Control: 5 – 11 years
Components of
Control
Symptoms
Nighttime
awakenings
Impairment
Well
Controlled
Not Well
Controlled
Very Poorly
Controlled
 2 days/wk but not
>2 days/wk or multiple
more than once on
times  2 days/wk
each day
Throughout the day
1x/month
≥2x/month
≥2x/week
Activity limits
None
Some limitation
Extremely limited
B-agonist use
2 days/wk
>2 days/wk
Several times per day
(not prevention of EIB)
Lung function
• FEV1 or PF
• FEV1/FVC
Exacerbations
requiring OSC
Risk
Classification of Asthma Control
Reduction in
lung growth
Treatment-related
adverse effects
80%
>80%
60 – 80%
75-80%
0-1/year
<60%
<75%
≥2/year
Evaluation requires long-term follow-up
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
The Chronic Disease
Components of
Severity
Impairment
Normal
FEV1/FVC:
8-19yrs 85%
20-39yrs 80%
40-59yrs 75%
60-80yrs 70%
Risk
Persistent
Intermittent
Mild
Moderate
Severe
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/week
>2 days/wk but
not daily, and
not more than
1x on any day
Daily
Several times
per day
B-agonist use
(not prevention of EIB)
 2 days/week
Activity limits
None
Minor
limitation
Some
Limitation
Extremely
limited
Lung Function
FEV1
FEV1/FVC
>80%
80%
>60 -80%
<60%
normal
normal
reduced 5%
reduced >5%
Exacerbations
requiring OSC
0-1/yr
 2/yr
Initial Therapies /Stepwise Approach:
Asthma Patients > 12 Years of Age
B
Recommend consult
Consider consult
A/B/D
A
Step 2
Preferred:
Step 1
Low-dose ICS
Preferred:
SABA PRN
Intermittent
B/D
Step 5
Step 4
Preferred:
Step 3
Preferred:
Preferred:
Medium-dose
ICS + LABA
High-dose
ICS + LABA
Medium-dose
ICS
Cromolyn
LTRA
or
theophylline
Mild
Moderate
Step 6
Preferred:
High-dose
ICS + LABA +
OSC
And
And
or
Low-dose ICS
+ LABA
Alternative:
Low dose ICS
+
LTRA,
theophylline
or zileuton
Alternative:
B
Alternative:
medium dose
ICS + LTRA,
theophylline
or zileuton
Consider
Omalizumab
for patients
who have
allergies
Consider
Omalizumab for
patients who
have allergies
Severe
Persistent
Each Step: Patient education, environmental control, management of co morbidities
Steps 2-4: Consider subcutaneous allergen immunotherapy for patients with allergic asthma
ICS = inhaled corticosteroids; OSC = Oral Systemic Corticosteroids;
SABA = short-acting beta2-agonist; LABA = long-acting beta2-agonist;
LTRA= leukotriene receptor antagonist.
Step Up If
Needed
(first, check
adherence,
inhaler
technique,
environmental
control)
Assess
Control
Step Down If
Possible
(and asthma is
well controlled
at least 3
months)
Asthma Control: 12 and older
Components of
Control
Impairment
Well
Controlled
Not Well
Controlled
Very Poorly
Controlled
Symptoms
 2 days/week
>2 days/week
Throughout the day
Nighttime
awakenings
 1x/month
1-3x/week
>4x/week
Activity limits
None
Some limitation
Extremely limited
B-agonist use
 2 days/week
>2 days/week
Several times per day
(not prevention of EIB)
Risk
Classification of Asthma Control
Lung function
FEV1 or PF >80%
QOL indicator
ACT ≥20
Exacerbations
requiring OSC
0-1/year
FEV1 or PF = 60 -80%
FEV1 or PF <60%
ACT =16-19
ACT ≤15
> 2/ year
Reduction in lung
Evaluation requires long-term follow-up
growth
Treatmentrelated 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.
What’s New: The ED / Hospital
• 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)
NAEPP. EPR-3, pages 102-106.
Severity Assessment of Acute Flares
Signs and
Symptoms
Mild
Dyspnea only with
activity;
RR in young
Moderate
Dyspnea
interferes/limits
usual activity
Severe
Life
Threatening
Dyspnea at rest;
interferes w/
conversation;
In infants use exam
Too dyspneic to
speak / perspiring
Initial FEV1 or
PF
PF/FEV1 > 70%
PF/FEV1 = 40-69%
PF/ FEV1 < 40%
O2 sat < 90%
Clinical Course
 Care @ home
 Relief w/ SABA
 Office or ED visit
 Response to SABA
 OCS




ED / Hospitalization
+ SABA response
OCS
Adjunctive therapy
 Hospitalization / ICU
 No relief SABA
 IV CS/ adjunctive
Classifying Severity- of Acute Disease
(Asthma Exacerbations)
Mild
Moderate
Severe
Impending
Failure
Symptoms/Exam
Lung Function
-alert and oriented
-speaks in sentences
-expiratory wheezes; ↑ rr
-agitated, not playful
-speaks in phrases
-wheeze; ↑ rr
-may use access. muscles
-breathless at rest
-speaks in words
-loud wheeze; ↑↑ rr
PF or FEV1 >70%
O2 sat > 95%
-altered consciousness
-silent chest
- ↑↑ rr or slowing rr
PF or FEV1=40-69%
O2 sat = 90-95%
PF or FEV1 <40%
O2 sat < 90%
The Acute Disease
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
Medications
Pharmacological Therapy
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
NAEPP. EPR-3, page 216.
Inhaled Medication Delivery Devices
MeteredDose
Inhaler
(MDI)
Dry
Powder
Inhaler
(DPI)
Spacer/
Holding
Chamber
Spacer/
Holding
Chamber
and Face
Mask
Nebulizer
Metered Dosed Inhalers
Transition to non-CFC containing inhalers:
• Many MDIs used chlorofluorocarbons
(CFCs) as propellants.
• CFCs are being phased out globally 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
Overview of Asthma Medications
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)
Long-Term Control
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
Inhaled Corticosteroids
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
• 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
Effects of Inhaled Steroids on Airway Inflammation
Pre– and post–3-month treatment with budesonide (BUD) 600 mcg b.i.d.
E = Epithelium; BM = Basement Membrane
J Allergy Clin Immunol. 1992;90:32-42.
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
Chemical Structure of Inhaled Corticosteroids
Inhaled Corticosteroids
40, 80 ug/puff
Beclomethasone (QVAR)
Budesonide (Pulmicort) Flexhaler: 90, 180
110 ug/puff
44 ug/puff
Mometasone (Asmanex)
110, 220 ug/puff
220 ug/puff
Fluticasone (Flovent HFA)
Budesonide (Pulmicort)
.5mg, 1.0mg
Estimated Comparative Daily Dosages of
Inhaled Corticosteroids for Adults
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
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 monotherapy for long term control of persistent
asthma
• Not appropriate for quick relief
Use of Salmeterol Alone to Treat Asthma
• 28 week, randomized, double-blind, placebocontrolled; 164 patients; 12 - 65 yrs. old
• Persistent asthmatics controlled on
Triamcinolone 400 mcg bid
Treatment Failure Rate
Treatment arms:
JAMA 2001;285:2583-93.
1.
Placebo
2.
Change to Salmeterol
3.
Continue ICS
Is there a problem with inhaled long-acting Badrenergic agonists (LABA)?
Harold Nelson, MD
• LABA’s by themselves have no significant antiinflammatory 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
Long-Term Control
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
Role of Leukotrienes in Asthma
Cationic Protein Release ,
Decreased Mucus Transport
Mucus Transport
Epithelial Cell Damage
Airway
Epithelium
Increased
Mucus
Secretion
Edema
Eosinophil
Influx
LTD4
Sensory Nerves
(C-Fibers)
Contraction &
Proliferation
Blood
Vessel
Inflammatory Cells
(e.g. Mast Cells,
Eosinophils)
Adapted from Hay DWP et al. Trends Pharmacol Sci 1995;16:304-309
Airway Smooth Muscle
Montelukast (Singulair)
• 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
Dosing Regimen in Adults and Children
Montelukast (SINGULAIR™†) (montelukast sodium, MSD)
• Administered once daily ( bedtime)
• Available for adults and children as young as 6 months
C.A.I.R
Granule Packets
Cherry-Flavored
Chewable Tablets
4 mg
4mg
Ages 2–5
Ages 6 mos–5yrs
†Trademark
of Merck & Co., Inc., Whitehouse Station, NJ, USA
5 mg
Ages 6–14
Film-Coated Tablet
10 mg
Ages  15 years
Combination Therapy
DPI budesonide and formoterol
HFA MDI (Symbicort)
DPI fluticasone and salmeterol (Advair)
HFA MDI (Advair)
Beclomethasone HFA (QVAR)
Mometasone DPI (Asmanex)
combined with either: salmeterol or formoterol
DPI or HFA inhaled corticosteroid and
a leukotriene receptor antagonist
Advair®
fluticasone plus salmeterol
Breath Actuated Dry Powder Inhaler
Doses:
100/50*
250/50
500/50
*approved > 4 yrs
Serevent
Flovent
salmeterol
fluticasone
Why use fixed combinations?
DO NOT use unless both medications are
necessary to control asthma….
• 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
Currently Approved Controller Therapy for
Asthma in Children
Montelukast
Budesonide and
Formoterol DPI
Nebulized Budesonide
Budesonide DPI
Fluticasone and Salmeterol DPI
Mometasone DPI
Beclomethasone HFA
Flunisonide
Triamcinolone
0
1
2
3
4
5
6
7
8
9
10
11
12
FDA-Approved Ages (Years) for Use in Children
13 14
15
Inhaled Corticosteroids
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
Short-acting Asthma Medications
• 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)
Quick Relief Beta2-agonists
Albuterol HFA
Nebulizer Solutions
ProAir
Proventil HFA
Ventolin HFA
Levalbuterol (Xopenex HFA)
Pirbuterol (Maxair)
Quick Relief
Short-Acting Beta2-Agonists
albuterol* (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
*
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.
Special Considerations
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
Exercise Induced Asthma (EIA)
Exercise Induced Bronchospasm (EIB)
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)
Exercise Induced Asthma
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
Managing 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
Special Considerations
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
Subcutaneous Allergy Immunotherapy
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 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
Xolair (Omalizumab)
• 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
Alternative Therapies
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).
• 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)
NAEPP. EPR-3, pages 240 244.
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
Alternative Medicines
Potential for Allergic Responses
• Daisy family
• Horse chestnut
• Natural plant salicylates
• Royal jelly
Royal Jelly
Echinacea
Willow bark
Alternative Medicines
Intensification of Drugs
• CNS stimulants
–
–
–
–
–
Ma huang (ephedra)
Ginseng
Yohimbe
Goldenseal
Gingko
• Potentiate steroids
– Licorice
Ginseng
Alternative Medicines
Deactivation of Drugs
• Decreases theophylline levels
– St John’s wort
• Decreases prednisolone levels
– xiao hu tang
– sho-saiko-to
St. John’s Wort
Asthma Pharmacological Therapy
• 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 MANAGEMENT
PHARMACOLOGICAL
THERAPY:
CASE STUDIES
Presented by:
Kristine Schwandt, RPh
RGH- Pharmacy
Case Study #1
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?
Mild – Moderate Persistent
• What is the best treatment?
Inhaled Corticosteroids - Asthma education
• His mom has asthma and he has milk allergy. Will
he have asthma when older?
Very Likely
Case Study #2
3 year old on montelukast who wakes up at
night once per week with cough
• Is he controlled?
Not well controlled
• What should be done?
Switch to Inhaled Corticosteroid
Assess adherence; evaluate for co
morbidities; educate
Follow-up in 2-6 weeks
Case Study #3
6 year old with daily cough, FEV1=80%,
FEV1/FVC=76%
• How severe is her asthma?
Moderate Persistent
• What medications should be prescribed?
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
• Anything else?
Write an action plan; Provide asthma self-management education;
assess triggers; consider referral to an asthma specialist
Bring her back in 2-6 weeks
Case Study #4
15 year old who uses albuterol 3 times each
basketball game/practice despite daily fluticasone
• What could the physician do next to help?
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
Case Study #5
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?
Probably; need more family/personal history
• He’s had 2 treatments, what next?
Oral corticosteroids; evaluate for co-morbidities
• Should he be in the hospital?
Of course
Acknowledgements
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-C
Asthma Education Specialist Maine Medical Center and MaineHealth, Portland, ME
(207) 662-4515
Janice H. Howell, MD, FRCPC, FAAP
Faculty Physician, Medical Education-Pediatrics, Orlando FL (321) 841-2121
Chris Garvey, FNP, MSN, MPA, FAACVPR
Manager 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.
We will breathe easier when the air in every
American community is clean and healthy.
We will breathe easier when people are free from the addictive
grip of cigarettes and the debilitating effects of lung disease.
We will breathe easier when the air in our public spaces and
workplaces is clear of secondhand smoke.
We will breathe easier when children no longer
battle airborne poisons or fear an asthma attack.
Until then, we are fighting for air.