Download Asthma

Asthma - Treatment
UCI INTERNAL MEDICINE
MINI-LECTURE SERIES
BY KEVIN COOK
Objectives
 Understand severity scoring vs. control in guiding
the treatment of asthma
 Discuss the utility of the “asthma ladder” in step up
and step down therapy
 Introduce new therapies used in patients with
refractory asthma
Asthma Severity vs. Control
 Severity - the intrinsic intensity of the disease
process



Dictates which step to initiate treatment
Intermittent symptoms require rescue medication
Persistent symptoms require controller medication
 Control - the degree to which the goals of therapy are
met

prevent symptoms/exacerbations, maintain normal lung
function and activity levels
Assessing Severity
Class
Daytime
symptoms
Nocturnal
symptoms
Intermittent
2x or less per week
2x or less per mo
Mild Persistent
>2x per week
>2x per mo
Moderate
Persistent
Daily
>1x per week
Severe Persistent
Continual
Frequent
All patients classified in a “persistent” asthma category
will require initiation of controller medications
Assessing Control - The Asthma Ladder
High dose ICS + LABA
AND oral corticosteroid
Step 5
High dose ICS + LABA
Step 4
Medium dose ICS + LABA
Step 3
Low dose ICS + LABA
OR Medium dose ICS
Step 2
Low dose ICS
Step 1
SABA as needed
Step Up Therapy
Step 6
Step Down Therapy
Intermittent
Asthma
Persistent
Asthma
Asthma Step Ladder
Assessing Control – Should I Step Up?
Well
controlled
Not well
controlled
Poorly
controlled
Daytime symptoms
2x or less per
week
>2x per week
daily
Night awakenings
2x or less per
month
>2x per month
>3x per week
SABA use
2x or less per
week
>2x per week
daily
FEV1 or peak flow
>80%
60-80%
<60%
Recommendation
Maintain
current step
Step up 1,
reevaluate 2-6
weeks
Step up 1-2,
Consider short
course of oral
steroids,
reevaluate in 2
weeks
Case Study
A 24 y/o patient with mild persistent asthma was initially well controlled with
low dose inhaled corticosteroid. Today he returns for follow up. He is now
complaining of increasingly frequent episodes of shortness of breath, using
his short-acting beta agonist 3 times per week. Which of the following
statements is correct regarding management of this patient?
a) continue current management as symptoms require beta agonist less than
once daily
b) add a long acting beta agonist
c) increase to medium dose inhaled corticosteroid
d) add tiotropium
e) B or C
Assessing Control – Should I Step Up?
Well
controlled
Not well
controlled
Poorly
controlled
Daytime symptoms
2x or less per
week
>2x per week
daily
Night awakenings
2x or less per
month
>2x per month
>3x per week
SABA use
2x or less per
week
>2x per week
daily
FEV1 or peak flow
>80%
60-80%
<60%
Recommendation
Maintain
current step
Step up 1,
reevaluate 2-6
weeks
Step up 1-2,
Consider short
course of oral
steroids,
reevaluate in 2
weeks
Assessing Control - The Asthma Ladder
High dose ICS + LABA
AND oral corticosteroid
Step 5
High dose ICS + LABA
Step 4
Medium dose ICS + LABA
Step 3
Low dose ICS + LABA
OR Medium dose ICS
Step 2
Low dose ICS
Step 1
SABA as needed
Step Up Therapy
Step 6
Step Down Therapy
Intermittent
Asthma
Persistent
Asthma
Asthma Step Ladder
Case Study
A 24 y/o patient with mild persistent asthma was initially well controlled with
low dose inhaled corticosteroid. Today he returns for follow up. He is now
complaining of increased shortness of breath and using his short-acting beta
agonist 3 times per week. Which of the following statements is correct
regarding management of this patient?
a) continue current management as symptoms require beta agonist less than
once daily
b) add a long acting beta agonist
c) increase to medium dose inhaled corticosteroid
d) add tiotropium
e) B or C
On step 6 and still not well controlled?
 Alternative diagnoses such as COPD, left ventricular failure,
localized obstruction, cystic fibrosis and/or vocal cord
dysfunction should be ruled out
 Omalizumab - anti-IgE therapy in patients with allergic asthma
(works by binding IgE so that it cannot complex with allergens to
stimulate immune cells
 Bronchial thermoplasty – heat applied directly to the airways by
bronchoscopy to reduce the airway smooth muscle mass and
attenuate bronchoconstriction
Summary
 Initial treatment of asthma requires assessment of severity
 Longitudinal treatment requires assessment of control with
the use of the “asthma ladder” for step up and step down
therapy
 Persistent symptoms require controller medication: start
with ICS and add LABA if still not controlled
 Seek consultation if high dose ICS are required
References
 National Asthma Education and Prevention
Program, Third Expert Panel on the Diagnosis and
Management of Asthma. Expert Panel Report 3:
Guidelines for the Diagnosis and Management of
Asthma. Bethesda (MD): National Heart, Lung, and
Blood Institute (US); 2007 Aug.Available from:
http://www.ncbi.nlm.nih.gov/books/NBK7232/
 Scialla, Timothy. “Asthma Summary 2013”. Hopkins
Modules.