Download sthma pharmacotherapy

Revised 2006
1
Goals of Therapy
 Therapy for chronic asthma is directed at suppressing the underlying inflammatory
response and normalizing pulmonary function.
 The goals of treatment for chronic asthma are to:
 Reduce impairment
 prevent chronic, troublesome symptoms
 require infrequent use (≤ 2 days a week) of inhaled SABA for quick relief of
symptoms
 maintain (near-) normal pulmonary function
 maintain normal activity levels, including exercise and other physical activities;
 meet patients’ & families’ expectations of and satisfaction with care
 Reduce risk
 prevent recurrent exacerbations
 minimize need for ER visits/hospitalizations
 prevent loss of lung function
 prevent reduced lung growth in children
 minimal adverse effects of therapy
A Four-PART PROGRAM
TO MANAGE AND
CONTROL ASTHMA
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk
Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
4
6
Component 2: Identify and Reduce
Exposure to Risk Factors
• Measures to prevent the development of asthma, and
asthma exacerbations by avoiding or reducing
exposure to risk factors should be implemented
wherever possible.
• Asthma exacerbations may be caused by a variety of
risk factors – allergens, viral infections, pollutants
and drugs.
• Reducing exposure to some categories of risk factors
improves the control of asthma and reduces
medications needs.
9
11
Reducing Exposure to
House Dust Mites
 Use bedding encasements
 Wash bed linens weekly
 Avoid down fillings
 Limit stuffed animals to
those that can be washed
 Reduce humidity level
13
Reducing Exposure to Cockroaches
Remove as many water and food sources as
possible to avoid cockroaches.
14
Reducing Exposure to Pets
• People allergic to pets should
not have them in the house.
• At a minimum, do not allow
pets in the bedroom.
15
Reducing Exposure to Mold
Eliminating mold may help control asthma exacerbations.
16
Component 3: Assess, Treat and
Monitor Asthma
18
Classification of Severity
20
Classifying Asthma Severity for Patients who Are Not Currently
Taking Long-Term Control Medications
21
New Guideline :Classification of asthma by severity is useful
when decisions are being made about management at the
initial assessment of a patient.
25
28
29
Asthma control
Aim for early control, with stepping up or down as required
Before initiating a new drug therapy:
• check compliance with existing therapies
• check inhaler technique
• eliminate trigger factors
• Environmental change
• Also consider alternative diagnoses
33
Component 3: Assess, Treat and
Monitor Asthma
• Depending on level of asthma control, the
patient is assigned to one of five treatment
steps
• Treatment is adjusted in a continuous cycle
driven by changes in asthma control status.
The cycle involves:
• - Assessing Asthma Control
• - Treating to Achieve Control
• - Monitoring to Maintain Control
35
37
38
For Children Older Than 5 Years, Adolescents and Adults
39
40
41
Treating to Maintain Asthma Control
 When control as been achieved,
ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
 Asthma control should be monitored
by the health care professional and
by the patient
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
 When controlled on medium- to high-dose
inhaled glucocorticosteroids: 50% dose
reduction at 3 month intervals (Evidence
B)
 When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)
• When controlled on combination inhaled
glucocorticosteroids and long-acting inhaled
β2-agonist, reduce dose of inhaled
glucocorticosteroid by 50% while
continuing the long-acting β2-agonist
(Evidence B)
• If control is maintained, reduce to low-dose
inhaled glucocorticosteroids and stop longacting β2-agonist (Evidence D)
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
 Rapid-onset, short-acting or longacting inhaled β2-agonist
bronchodilators provide temporary
relief.
 Need for repeated dosing over more
than one/two days signals need for
possible increase in controller therapy
Stepping up treatment in response to loss of control
• Use of a combination rapid and long-acting
inhaled β2-agonist (e.g., formoterol) and an
inhaled glucocorticosteroid (e.g.,
budesonide) in a single inhaler both as a
controller and reliever is effecting in
maintaining a high level of asthma control
and reduces exacerbations (Evidence A)
• Doubling the dose of inhaled
glucocorticosteroids is not effective, and is
not recommended (Evidence A)
Special Population
 Young children, especially 0-4 years
 many recommendations based on extrapolated data
 studies of ICS show improvement
 combination therapy inadequately studied
 Elderly
 osteoporosis risk increased with high dose ICS
 Pregnancy
 budesonide preferred ICS
 albuterol preferred for quick relief
Monitoring Therapy
 Regular follow up
 1 to 6 month intervals depending on control
 3 month interval if step down anticipated
 Evaluate asthma control
 symptoms
 lung function
 validated questionnaires
 medication adverse effects
 adherence, environmental control, comorbid condition
Question
 A 4-year-old Caucasian girl is newly diagnosed with severe
persistent asthma. The most appropriate longterm control
therapy for this patient would be:
A. Consider a short course of oral systemic corticosteroids and start
budesonide inhalation suspension, 0.5 mg nebulized twice a day.
B. Consider a short course of oral systemic corticosteroids and start
cromolyn sodium 1 mg/ inhalation, two puffs four times a day
C. Consider a short course of oral systemic corticosteroids and start
montelukast 4 mg granules sprinkled on food at bedtime
D. Consider a short course of oral systemic corticosteroids and start
montelukast 4 mg granules sprinkled on food at bedtime, and
budesonide inhalation suspension, 0.5 mg nebulized twice a day
Question
 LK is a 7-year-old African-American boy with moderate persistent asthma
who was started on fluticasone dry powder inhalers (DPI) 100 mcg/ inhalation,
two inhalations twice a day and albuterol hydrofluoroalkane (HFA) 90
mcg/inhalation, two inhalations twice a day. Four weeks after starting therapy,
he returns to the clinic for follow-up. At this time he states that he uses his
albuterol approximately once a week for symptoms, can participate in any
physical activity he desires, and wakes up approximately once a week at night
short of breath or coughing. His peak expiratory flow (PEF) is 81% of
predicted. His inhaler technique is appropriate and he adheres to his medication
therapy plan. Based on an evaluation of LK’s asthma control, which of the
following actions would be most appropriate?
Maintain his current medication regimen and reevaluate him in 1 to 6 months
B. Decrease his ICS dose to fluticasone DPI 100 mcg/ inhalation, one inhalation
twice a day
C. Add salmeterol 50 mcg/inhalation, one inhalation twice a day.
D. Increase the fluticasone dose to 250 mcg/inhalation, one inhalation twice a day
A.
e.g DRP in asthma
67
How Can a Pharmacist Help a Patient
With Asthma?
• Teach basic facts about asthma
• Assist with relevant environmental control measures
• Explain roles of medications
• Long-term control and quick-relief medications
• Help patients develop necessary skills
68
• Inhalers, spacers, symptom and peak flow monitoring,
early warning signs of attack