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is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible bronchoconstriction. Factors that can contribute to asthma or airway hyperreactivity may include any of the following: Environmental allergens (eg, house dust mites; animal allergens, especially cat and dog; cockroach allergens; and fungi) Viral respiratory tract infections Exercise, hyperventilation Chronic sinusitis or rhinitis Aspirin or nonsteroidal anti-inflammatory drug (NSAID) Use of beta-adrenergic receptor blockers (including ophthalmic preparations) Obesity Environmental pollutants, tobacco smoke Irritants (eg, household sprays, paint fumes) Emotional factors or stress Perinatal factors Epidemiology. Asthma affects 5-10% of the population or an estimated 23.4 million persons, including 7 million children. Mortality/Morbidity: About 4000 deaths occur from asthma annually in the US. Asthma involves: bronchoconstriction, airway edema and inflammation, airway hyperreactivity, airway remodeling. Asthma severity is categorized as Intermittent, Mild persistent, Moderate persistent, Severe persistent. The term status asthmaticus describes severe, intense, prolonged bronchospasm that is resistant to treatment. Shortness of breath, especially with exertion or at night Wheezing is a whistling or hissing sound when breathing out Coughing may be chronic, is usually worse at night and early morning Pulsus paradoxus, tachypnea, tachycardia Visible efforts to breathe (use of neck and suprasternal muscles, upright posture, pursed lips, inability to speak) The expiratory phase of respiration is prolonged Treatment includes control of triggers, drug therapy, monitoring, patient education, treatment of acute exacerbations. Asthma medications are generally divided into 2 categories: quick relief (also called reliever medications); long-term control (also called controller medications). QUICK RELIEF MEDICATIONS are used to relieve acute asthma exacerbations and to prevent exerciseinduced asthma or exercise-induced bronchospasm symptoms. These medications include Short-acting beta agonists (SABAs) Anticholinergics (used only for severe exacerbation) Systemic corticosteroids. Short-acting beta2 agonists (SABAs) Albuterol sulfate. Dosing and Uses: 0.5 mL of 0.5% solution (2.5 mg) nebulized q4-8hr PRN. Inhaler: 2 puffs inhaled PO q4-6hr. Tablets: 2-4 mg PO TID/QID; 32 mg/day maximum. Short-acting beta2 agonists (SABAs) Pirbuterol. Dosing and Uses: Autohaler: 1-2 actuations q4-6hr PRN, no more than 12 actuations/day. Levalbuterol. Dosing and Uses: Neb Solution: 1.25-2.5 mg q20min for 3 doses, then 1.25-5 mg q1-4hr PRN. MDI: 4-8 puffs q20min for up to 4 hr, then q1-4hr PRN. Anticholinergic Agent Ipratropium Dosing and Uses: Inhaler: 8 actuations q20 min PRN for up to 3 hr. Nebulizer: 500 mcg q20 min for 3 doses; then PRN. Systemic steroids. In acute asthma exacerbation, early use of systemic corticosteroids often aborts the exacerbation, decreases the need for hospitalization, prevents relapse, and speeds recovery. Prednisone. Dosing and Uses: 40-60 mg q 6 h or q 8 h for 48 h, then 60–80 mg/day 40–60 mg IV has no advantage over oral administration if GI function is normal. Systemic steroids. Prednisolone. Dosing and Uses: 5-60 mg PO qDay Methylprednisolone. Dosing and Uses: 2-60 mg/day divided QD/QID PO. Long-term control medications include Inhaled corticosteroids (ICSs), Mast cell stabilizers, Long-acting beta agonists (LABAs), Combination inhaled corticosteroids and long-acting beta agonists, Methylxanthines, Leukotriene antagonists, Immunomodulators. Inhaled corticosteroids are indicated for long-term suppression, control, and reversal of inflammation and symptoms. Ciclesonide Receiving Bronchodilators or Inhaled Corticosteroids: 80 mcg inhaled PO BID initially; may increase to 160 mcg BID. Receiving Oral Corticosteroids: 80 mcg inhaled PO BID initially; may increase to 320 mcg BID. Inhaled corticosteroids Beclomethasone. Dosing and Uses: 40-80 mcg inhaled PO BID if never used corticosteroid inhalers before; 40-160 mcg inhaled PO BID if used corticosteroids inhalers before; 320 mcg inhaled PO BID highest recommended dose. Inhaled corticosteroids Fluticasone inhaled. It is available as a metered-dose inhaler aerosolized product (HFA) or DPI (Diskus). Dosing and Uses. Flovent HFA inhaler: Initial 88 mcg (2 puffs) inhaled PO BID; may increases to max 440 mcg inhaled PO BID. Flovent Diskus: Initial 100 mcg inhaled PO BID; may increases to max 500 mcg BID Inhaled corticosteroids Budesonide inhaled Dosing and Uses. 360 mcg inhaled PO BID; in some patients, may initiate at 180 mcg BID; 720 mcg BID maximum. Mometasone Dosing and Uses. 220 mcg inhaled PO qDay/BID. Inhaled corticosteroids Triamcinolone inhaled. Dosing and Uses. Inhaler: 2 puffs (150 mcg) TID/QID; no more than 16 puffs/day. Discontinue if inadequate relief after 3 weeks. Flunisolide. Dosing and Uses. 2 actuations (160 mcg) inhaled PO BID; may titrate upward, not to exceed 4 actuations (320 mcg) BID. Long-acting β2-agonists are active for up to 12 h and are used for moderate and severe asthma but should never be used as monotherapy. Formoterol. Dosing and Uses: 12 mcg inhaled q12hr. Salmeterol. Dosing and Uses: 1 inhalation (50 mcg) BID OR. Arformoterol. Dosing and Uses: 15 mcg inhaled via nebulization BID. Not to exceed 30 mcg/day. Beta2-Agonist/Corticosteroid Combinations. Budesonide and formoterol [Symbicort]. Budesonide 80 mcg/formoterol 4.5 mcg or Budesonide 160 mcg/formoterol 4.5 mcg Dosing and Uses: Never treated with corticosteroids: 2 inhalations twice daily depending on severity of asthma. Previously treated with corticosteroids: budesonide 160 mcg/formoterol 4.5 mcg 2 inhalations BID. Beta2-Agonist/Corticosteroid Combinations Fluticasone and salmeterol. Dosing and Uses: 2 inhalations PO BID. Inhaled medium dose corticosteroids: 100 mcg/5 mcg – 2 inhalations PO BID; not to exceed daily dose of 400 mcg/20 mcg. Inhaled high dose corticosteroids: 200 mcg/5 mcg – 2 inhalations PO BID; not to exceed daily dose of 800 mcg/20 mcg. Beta2-Agonist/Corticosteroid Combinations Mometasone and formoterol. Dosing and Uses. Initial dose based on asthma severity. Diskus: initially 1 inhalation PO BID of 50/100 or 50/250. Not to exceed 1 inhalation PO BID of 50/500. Metered dose inhaler (HFA): 2 inhalations PO BID. Not to exceed 2 inhalations PO BID of 21/230. Mast cell stabilizers are given by inhalation prophylactically to patients with exercise-induced or allergen-induced asthma. Cromolyn sodium (Intal). Dosing and Uses: 200 mg PO QID; may double dose if effect not satisfactory within 2-3 weeks; not to exceed 400 mg PO QID. Leukotriene modifiers are taken orally and can be used for long-term control and prevention of symptoms in patients with mild persistent to severe persistent asthma. Zileuton Dosing and Uses: Extended Release: 1200 mg PO BID, within 1 hour after morning and evening meals. Conventional (discontinued): 600 mg PO QID. Methylxanthines are used for long-term control as an adjunct to β2-agonists. Theophylline. Dosing and Uses: Patients not currently taking theophylline: 5-7 mg/kg IV/PO; not to exceed 25 mg/min IV. Maintenance: 0.4-0.6 mg/kg/hr IV infusion or 4.8-7.2 mg/kg PO (SR) q12hr to maintain levels 10-15 mg/L. Monoclonal Antibody. An anti-IgE antibody developed for use in severely allergic patients with asthma who have elevated IgE levels. Omalizumab Dosing and Uses: 150-375 mg SC q2-4Weeks. Leukotriene Receptor Antagonist is a selective competitive inhibitor of LTD4 and LTE4 receptors. Indicated for chronic asthma treatment and prophylaxis Zafirlukast 20 mg PO BID. Montelukast. 10 mg tablet). 10 mg PO qEvening (use Asthma Management Pharmacotherapy is increased in a stepwise fashion until the best control of impairment and risk is achieved (step-up). Before therapy is stepped up, adherence, exposure to environmental factors (eg, trigger exposure), and presence of comorbid conditions are reviewed. These factors should be addressed before increasing drug therapy. Once asthma has been well controlled for at least 3 mo, drug therapy is reduced if possible to the minimum that maintains good control (step-down). Steps of Asthma Management Step 1 (starting point for intermittent asthma) Preferred Treatment Short-acting β2-agonist PRN Steps of Asthma Management Step II ( starting point for mild persistent asthma) Preferred Treatment Low-dose inhaled corticosteroid Alternate Treatment Mast cell stabilizer, leukotriene receptor antagonist, or theophylline Steps of Asthma Management Step III (starting point for moderate persistent asthma) Preferred Treatment Medium-dose inhaled corticosteroid or Low-dose inhaled corticosteroid plus long-acting β2-agonist Alternate Treatment Low-dose inhaled corticosteroid plus one of the following: a leukotriene receptor antagonist, theophylline or zileuton Steps of Asthma Management Step IV (starting point for severe persistent asthma ) Preferred Treatment High-dose inhaled corticosteroid plus long-acting β2-agonist and possibly omalizumab for patients with allergies Steps of Asthma Management Step IV (starting point for severe persistent asthma ) Preferred Treatment High-dose inhaled corticosteroid plus long-acting β2-agonist plus oral corticosteroid and possibly omalizumab for patients with allergies