Pharmacological Therapy Presented by Hengameh Raissy Pharm D Four Components of Asthma Management Assessment and Monitoring Control of Factors Contributing to Asthma Severity Education for a Partnership in Asthma Care ID: 168027
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Slide1
Asthma Management Pharmacological Therapy
Presented
by:
Hengameh Raissy,
Pharm
DSlide2
Four Components of Asthma ManagementAssessment and MonitoringControl of Factors Contributing to
Asthma Severity
Education for a Partnership in Asthma Care
Pharmacological Therapy
NAEPP. EPR-3, page 1.Slide3
This lesson will cover:Slide4
Asthma is a chronic inflammatory disorder of the airwaysA key principle of therapy is regulation of chronic airway inflammationWhat is Asthma?
Bronchospasm is what you see as cough and wheeze
Inflammation is what you don’t see but is at the center of the processSlide5
Pathophysiology of Asthma
INFLAMMATION
Airway Hyperresponsiveness
Airflow Limitation
Environmental Risk Factors
Genetic Predisposition
Symptoms
Cough Wheeze Shortness of Breath
Adapted with permission from Stephen T. Holgate, MD, D. Sc.
bronchospasm
PrecipitantsSlide6
The Pharmacological Treatment of Asthma can focus on one or both aspects of the disease…Slide7
Asthma: The Chronic DiseaseSlide8
The Risk of Asthma in a Wheezing Child 0-3 years: Modified Asthma Predictive Index
- strict API = NPV ≥ 95% no asthma
+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
Guilbert TW, et al JACI 2004
OR
In the past 12 months, >3 episodes of wheezing with at leastSlide9
Components of Severity
Intermittent
Persistent
Mild
Moderate
Severe
Impairment
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
B-agonist use
(not prevention of EIB)
2 days/week
>2
days/week
but not daily
Daily
Several times
per day
Activity limits
None
Minor
Limitation
Some
Limitation
Extremely
Limited
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
Classifying Asthma Severity: 0 – 4 years
The Chronic Disease
Classifying severity in children who are not currently taking long-term control medication.Slide10
Step 1Preferred:SABA PRN
Step 2
Preferred:
Low-dose ICS
Alternative:
Cromolyn
or Montelukast
Step 3
Preferred:
Medium-dose ICS
Step 5
Preferred:
High-dose
ICS + either
LABA or
Montelukast
Step 6
Preferred:
High-dose
ICS + either
LABA or
Montelukast
OSC
Step 4
Preferred:
Medium-dose ICS +
either LABA
or Montelukast
Initial Therapies / Stepwise Approach:
Asthma Patients
0-4
Years of Age
ICS = inhaled corticosteroid; LABA = long-acting beta
2
-agonist; OSC = Oral Systemic Corticosteroids.; SABA = inhaled short-acting beta
2
-agonist.
Consider consult
Recommend consult
Mild
Moderate
Severe
A
D
D
D
D
Intermittent
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
Step Down If Possible
(and asthma is well controlled at least 3 months)
Step Up If Needed
(first, check adherence, inhaler technique, environmental control)AssessControlSlide11
Assessing Control: 0 – 4 yearsComponents of Control
Classification of Asthma Control
Well
Controlled
Not Well Controlled
Very Poorly
Controlled
Impairment
Symptoms
2 days/wk
>2 days/wk
Throughout the day
Nighttime awakenings
1x/month
>1x/month
>1x/week
Activity limits
None
Some limitation
Extremely
limited
B-agonist use
(not prevention of EIB)
2 days/week
>2
days/week
Several times per day
Risk
Exacerbations requiring OSC
0-1/year
2-3/year
>3/year
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. Slide12
Components of Severity
Intermittent
Persistent
Mild
Moderate
Severe
Impairment
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
(not prevention of EIB)
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
FEV
1
FEV
1
/FVC
>80%
>85%
80%
>80%
60 – 80%
75 - 80%
<60%
<75%
Risk
Exacerbations requiring OSC
0-1/yr
2/year
Classifying Asthma Severity: 5 – 11 years
The Chronic Disease
Classifying severity in children who are not currently taking long-term control medication.Slide13
Step 1
Preferred:
SABA PRN
Step 2
Preferred:
Low-dose ICS
Alternative:
Cromolyn
LTRA
Nedocromil or theophylline
Step 3
Preferred
Medium-dose ICS
OR
Low-dose ICS + either LABA, LTRA or theophylline
Step 5
Preferred:
High-dose
ICS + LABA
Alternative:
High dose ICS + either LTRA or
theophylline
Step 6
Preferred:
High-dose
ICS + LABA + OSC
Alternative:
High dose ICS + either LTRA or Theophylline +OSC
Step 4
Preferred:
Medium-dose
ICS + LABA
Alternative:
Medium-dose ICS +either LTRA
or theophylline
Initial Therapies / Stepwise Approach:
Asthma Patient
5-11
Years of Age
Persistent
Intermittent
Each Step:
Patient education, environmental control, management of co morbidities
Steps 2-4:
Consider subcutaneous allergen immunotherapy for patients with allergic asthma
Consider consult
Recommend consult
Mild
Moderate
Severe
A
B
B
B
D ICS = inhaled corticosteroid; LABA = long-acting beta2-agonist; LTRA= leukotriene receptor antagonist; OSC = Oral Systemic Corticosteroids; SABA = short-acting beta2-agonist.Step Down If Possible(and asthma is well controlled at least 3 months)Step Up If Needed(first, check adherence, inhaler technique, environmental control)AssessControlSlide14
Asthma Control: 5 – 11 yearsComponents of Control
Classification of Asthma Control
Well
Controlled
Not Well
Controlled
Very Poorly
Controlled
Impairment
Symptoms
2 days/wk but not more than once on each day
>2 days/wk or multiple times
2 days/wk
Throughout the day
Nighttime awakenings
1x/month
≥2x/month
≥2x/week
Activity limits
None
Some
limitation
Extremely limited
B-agonist use
(not prevention of EIB)
2 days/wk
>2
days/wk
Several times per day
Lung function
FEV
1
or PF
FEV
1
/FVC
80%
>80%
60 – 80%
75-80%
<60%
<75%
Risk
Exacerbations requiring OSC
0-1/year
≥2/year
Reduction in
lung growth
Evaluation requires long-term follow-up
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. Slide15
Classifying Asthma Severity: 12 and older
Components of Severity
Intermittent
Persistent
Mild
Moderate
Severe
Impairment
Normal FEV1/FVC:
8-19yrs 85%
20-39yrs 80%
40-59yrs 75%
60-80yrs 70%
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
B-agonist use
(not prevention of EIB)
2 days/week
>2 days/wk but not daily, and not more than 1x on any day
Daily
Several times per day
Activity limits
None
Minor
limitation
Some
Limitation
Extremely
limited
Lung Function
FEV
1
FEV
1
/FVC
>80%
normal
80%
normal
>60 -80%
reduced 5%
<60%
reduced >5%
Risk
Exacerbations requiring OSC
0-1/yr
2/yr
The Chronic Disease
Classifying severity for patients who are not currently taking long-term control medication.Slide16
Step 1Preferred:SABA PRN
Step 6
Preferred:
High-dose
ICS + LABA + OSC
And
Consider
Omalizumab
for patients who have allergies
Initial Therapies /Stepwise Approach:
Asthma Patients
>
12 Years of Age
ICS = inhaled corticosteroids; OSC = Oral Systemic Corticosteroids; SABA = short-acting beta
2
-agonist; LABA = long-acting beta
2
-agonist; LTRA= leukotriene receptor antagonist.
Persistent
Intermittent
Each Step
: Patient education, environmental control, management of co morbidities
Steps 2-4:
Consider subcutaneous allergen immunotherapy for patients with allergic asthma
Consider consult
Recommend consult
Mild
Moderate
Severe
Step Down If Possible
(and asthma is well controlled at least 3 months)
Step Up If Needed
(first, check adherence, inhaler technique, environmental control)
Assess
Control
A
A
/
B
/
D
B
/
D
B
B
Step 1
Preferred:
SABA PRN
Step 2
Preferred:
Low-dose ICS
Alternative:
Cromolyn
LTRA
or theophyllineStep 3Preferred:Medium-dose ICS orLow-dose ICS + LABAAlternative: Low dose ICS +LTRA, theophylline or zileutonStep 5Preferred:High-dose ICS + LABAAndConsider Omalizumab for patients who have allergiesStep 4Preferred:Medium-dose ICS + LABAAlternative: medium dose ICS + LTRA, theophylline or zileutonSlide17
Asthma Control: 12 and olderComponents of
Control
Classification of Asthma Control
Well
Controlled
Not Well
Controlled
Very Poorly
Controlled
Impairment
Symptoms
2 days/week
>2 days/week
Throughout the day
Nighttime awakenings
2x/month
1-3x/week
>4x/week
Activity limits
None
Some
limitation
Extremely limited
B-agonist use
(not prevention of EIB)
2 days/week
>2
days/week
Several times per day
Lung function
FEV
1
or PF >80%
FEV
1
or PF = 60 -80%
FEV
1
or PF <60%
QOL indicator
ACT ≥20
ACT =16-19
ACT ≤15
Risk
Exacerbations requiring OSC
0-1/year
>
2/ year
Reduction in lung growth
Evaluation requires long-term follow-up
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. Slide18
Severity assessment has been simplified and lung function measurement is emphasizedLower 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)
What’s New: The ED / Hospital
NAEPP. EPR-3, pages 102-106.Slide19
Signs and Symptoms
Initial FEV
1
or PF
Clinical Course
Mild
Dyspnea
only with activity;
RR in young
PF/FEV
1
>
70%
Care @ home
Relief w/ SABA
Moderate
Dyspnea
interferes/limits usual activity
PF/FEV
1
= 40-69%
Office or ED visit
Response to SABA
OCS
Severe
Dyspnea
at rest;
interferes w/
conversation;
In infants use exam
PF/ FEV
1
< 40%
O2 sat < 90%
ED / Hospitalization
+
SABA response
OCS
Adjunctive therapy
Life
Threatening
Too
dyspneic
to speak / perspiring
Hospitalization / ICU
No relief SABA
IV CS/ adjunctive
Severity Assessment of Acute FlaresSlide20
Symptoms/Exam
Lung Function
Mild
-alert and oriented
-speaks in sentences
-expiratory wheezes;
↑
rr
PF or FEV1
>
70%
O2 sat > 95%
Moderate
-agitated, not playful
-speaks in phrases
-wheeze;
↑
rr
-may use access. muscles
PF or FEV1=40-69%
O2 sat = 90-95%
Severe
-breathless at rest
-speaks in words
-loud wheeze;
↑↑
rr
PF or FEV1 <40%
O2 sat < 90%
Impending Failure
-altered consciousness
-silent chest
-
↑↑
rr or slowing rr
Classifying Severity- of Acute Disease
(Asthma Exacerbations)Slide21
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
The Acute DiseaseSlide22
MedicationsSlide23
Inhaled Medication:In general, inhaled therapy is favored over systemic (oral) therapy for asthmaThe medication is delivered on site and avoids most adverse side effects
Pharmacological Therapy
NAEPP. EPR-3, page 216.Slide24
Inhaled Medication Delivery DevicesSlide25
Many MDIs used chlorofluorocarbons (CFCs) as propellants.CFCs were phased out globally in 2008 to protect the earth’s ozone layerHydrofluroalkaline (HFA) inhalers are the non-CFC alternativeDPIs (breath actuated Dry Powder Inhalers) are non-CFC compliant
Metered Dosed Inhalers
Transition to non-CFC containing inhalers:Slide26
Daily Long-Term Control:Corticosteroids (inhaled and systemic)Long-acting beta2-agonists (salmeterol, formoterol) when in combination with ICSLeukotriene modifiers (montelukast)Leukotriene inhibitors (zileuton)
Mast cell stabilizers (cromolyn or nedocromil)
Methylxanthines (theophylline)
Overview of Asthma MedicationsSlide27
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
Long-Term ControlSlide28
Benefit of daily use:Reduced airway inflammationImproved lung function Reduced use of quick-relief medicineFewer symptoms and exacerbations
In usual doses ICS do not provide short-term relief
Must be used daily for full benefit
Inhaled CorticosteroidsSlide29
Rate Ratio for Death from Asthma
No. of Canisters of Inhaled Corticosteroids per Yr.
2.5
2.0
1.5
1.0
0.5
0.0
1 2 3 4 5 6 7 8 9 10 11 12
Low-dose ICS and the Prevention of
Death from Asthma
Suissa S et al.
N Engl J Med.
2000;343:332-336.Slide30
Effects of Inhaled Steroids on Airway InflammationJ Allergy Clin Immunol. 1992;90:32-42.
Pre– and post–3-month treatment with budesonide (BUD) 600 mcg b.i.d.
E =
Epithelium;
BM =
Basement MembraneSlide31
Possible Dose-Dependent side effects:Oral candidiasis (thrush)DysphoniaReflex cough and bronchospasm
Slowed linear growth velocity
Decreases in bone mineral density
Dermal thinning and skin bruising
Ocular effects: glaucoma, cataracts
Inhaled CorticosteroidsSlide32
CAMP Trial and Follow-up Design
Routine
Care
Randomize
Treatment Trial
Transition
5
visits
3 visits per
year
2
visits
Study Rx
Discontinued
2 - 4 months
4 – 6 years
4 months
Screening
and
Baseline
13 years
Follow-up
Enroll in follow-up study
Refer back to PCP for Rx per NAEPP guidelines
Nedocromil
Budesonide
Placebo
Enrollment in trial: Dec 1993 – Sept 1995
1,041 children age 5-13 years at randomization
Mild to moderate persistent asthma
1-4 visits
per yearSlide33
Change in Bone Densityat End of CAMP Trial
Budesonide vs. Placebo = - 0.01,
P
= 0.53
Nedocromil vs. Placebo = - 0.01,
P
= 0.15
Budesonide Nedocromil Placebo
(n = 304) (n = 306) (n = 410)Slide34
Mean Obtained Adjusted Adult Height
-1.2 cm
(-1.9 to -0.5)
-1.8 cm
(-2.9 to -0.7)
-0.8 cm
(-1.8 to 0.2)
cm
*
Means adjusted for race/ethnicity, clinic, and age, asthma
duration
and severity, skin test reactivity, and height at trial entry. Total panel also adjusted for sex.
Bud–Plbo diff.:
(95% CI)
Bud by sex
interactio
,
P=0.10
Bud
vs
Plbo
: P=0.001 P=0.001 P=0.10
Ned
vs
Plbo
: P=0.61 P=0.26 P=0.98Slide35
ICS MetabolismSlide36
Reduce potential for adverse events by:Rinsing mouthUsing lowest dose possible that results in controlUse in combination with long-acting
beta2-agonists (LABA) or a leukotriene modifier if moderate/severe disease
Inhaled CorticosteroidsSlide37
Comparative Dosages:HFA ≠
DPI
≠
MDI
≠ respulesPreparations are not equivalent per puff or per microgram
Comparative doses are estimated.
Few data directly compare preparations
Inhaled CorticosteroidsSlide38
Chemical Structure of Inhaled CorticosteroidsSlide39
Mometasone (Asmanex)
Beclomethasone (QVAR)
Budesonide (Pulmicort) Flexhaler: 90, 180
40, 80 ug/puff
110, 220 ug/puff
Budesonide (Pulmicort)
.5mg, 1.0mg
110 ug/puff
220 ug/puff
44 ug/puff
Fluticasone (Flovent HFA)
Inhaled CorticosteroidsSlide40
DrugLow DoseMedium 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
Estimated Comparative Daily Dosages of Inhaled Corticosteroids for AdultsSlide41
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 mono-therapy for long term control of persistent asthma
Not appropriate for quick reliefSlide42
28 week, randomized, double-blind, placebo-controlled; 164 patients; 12 - 65 yrs. oldPersistent asthmatics controlled on Triamcinolone 400 mcg bid
Use of Salmeterol Alone to Treat Asthma
JAMA 2001;285:2583-93.
Treatment Failure Rate
Treatment arms
:
Placebo
Change to Salmeterol
Continue ICSSlide43
Is there a problem with inhaled long-acting B-adrenergic agonists (LABA)?Harold Nelson, MD
LABA’s by themselves have no significant anti-inflammatory 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. 2006Slide44
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
Long-Term ControlSlide45
Combination TherapyMDI100/5 mcg
200/5 mcg
Patients 12 and older
Dulera
Momestasone
Furoate
Formoterol
FumarateSlide46
Combination TherapyMDI80/4.5 mcg
160/4.5 mcg
Patients 12 and older
Symbicort
Budesonide
Formoterol
FumarateSlide47
Advair®
DPI Doses
:
100/50
* mcg
250/50 mcg
500/50 mcg
-DPI: Breath
Actuated Dry Powder
Inhaler
MDI HFA
Fluticasone propionate
and
samleterol
*
approved
>
4
yrs
The rest of the doses are approved for 12 years and older
MDI doses45/21 mcg
115/21 mcg230/21 mcgSlide48
Why use fixed combinations?
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
DO NOT
use unless both medications are necessary to control asthma….Slide49
Currently Approved Controller Therapy for Asthma in Children
FDA-Approved Ages (Years) for Use in Children
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Triamcinolone
Flunisonide
Fluticasone and Salmeterol DPI
Nebulized Budesonide
Budesonide DPI
Montelukast
Beclomethasone HFA
Mometasone DPI
Budesonide and
Formoterol DPISlide50
Role of Leukotrienes in Asthma
Mucus Transport
Airway Smooth Muscle
Inflammatory Cells
(e.g. Mast Cells,
Eosinophils)
Airway
Epithelium
Sensory Nerves
(C-Fibers)
LTD
4
Edema
Blood
Vessel
Increased Mucus
Secretion
Decreased Mucus Transport
Eosinophil
Influx
Epithelial Cell Damage
Cationic Protein Release ,
Contraction &
Proliferation
Adapted from Hay DWP et al.
Trends Pharmacol Sci
1995;16:304-309Slide51
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
Montelukast (Singulair)Slide52
Cherry-Flavored Chewable Tablets
4 mg 5 mg
Ages 2–5 Ages 6–14
Montelukast (SINGULAIR™
†)
(montelukast sodium, MSD)
Administered once daily ( bedtime)
Available for adults and children as young as 6 months
†
Trademark of Merck & Co., Inc., Whitehouse Station, NJ, USA
Film-Coated Tablet
10 mg
Ages
15 years
Granule Packets
4mg
Ages 6 mos–5yrs
C.A.I.R
Dosing Regimen in Adults and ChildrenSlide53
Urgent control of InflammationSystemic 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)
Short-acting Asthma MedicationsSlide54
ProAir Proventil HFA Ventolin HFA
Albuterol HFA
Levalbuterol
(Xopenex HFA)
Pirbuterol (Maxair)
Quick Relief Beta
2
-agonists
Nebulizer SolutionsSlide55
Quick Relief
* 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)Slide56
Short-Acting Beta2-Agonists:Regularly scheduled use is not generally recommendedMay 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.Slide57
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 ConsiderationsSlide58
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 ConsiderationsSlide59
Transient narrowing of the airways associated with:Physical exertionCoughing, 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)
Special Considerations
Exercise Induced Asthma (EIA)
Exercise Induced Bronchospasm (EIB)Slide60
Occurrence:90% of asthmatics 40% of patients with allergic rhinitis22% of 1998 Olympic athletes9% of persons with EIB have no hx of asthma or allergies
10-50% of asthmatics on ICS still display EIB
Exercise Induced AsthmaSlide61
Management Strategies:Short-acting inhaled beta2-agonists used shortly before exercise last 2 to 3 hoursSalmeterol may prevent EIB for 10 to 12 hoursCromolyn if side effects a concernA lengthy warm-up period before exercise
An aerobic conditioning program
Long-term-control therapy, if appropriate
Avoid asthma triggers during exercise
Managing Exercise-Induced AsthmaSlide62
Over-The-Counter (OTC) Asthma Medicines:Always include OTC’s in medical historyOTC 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
Special ConsiderationsSlide63
Subcutaneous Allergy ImmunotherapySlide64
Subcutaneous Allergen Immunotherapy is considered for:
NAEPP. EPR-3, page 177.Slide65
Newer TherapyAnti-IgE Therapy – Omalizumab (Xolair)
Humanized IgG (5% murine)
Binds IgE regardless of specificity
Does not activate complement
Rarely has caused anaphylaxisSlide66
Indicated for adults and adolescents(>12) with severe persistent asthma inadequately controlled on high-dose ICS and LABASelected patients must have a positive skin test or in vitro reactivity to aeroallergens Dosed every 2-4 weeks; SQ dosingMay allow these patients to improve control, decrease dose of ICS and decrease reliance on oral corticosteroids
Xolair (Omalizumab)Slide67
Use of Alternative medicines may result in:allergic reactionsintensification of drug side effects
Users may not be aware of:
potency
contaminants
covert additivesRecommended that clinician ask patient about complementary and alternative medicine use (CAM)
Alternative Therapies
NAEPP. EPR-3, pages 240 - 244.
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).Slide68
According to the 2007 NAEPP EPR-3:
NAEPP. EPR-3, pages 240 - 242.Slide69
However, some people find these therapies helpful:Slide70
Potential for Allergic ResponsesDaisy family
Horse chestnut
Natural plant salicylates
Royal jelly
Alternative Medicines
Willow bark
Royal
Jelly
EchinaceaSlide71
Intensification of DrugsCNS stimulantsMa huang (ephedra)Ginseng
Yohimbe
Goldenseal
Gingko
Potentiate steroidsLicorice
Alternative Medicines
GinsengSlide72
Deactivation of DrugsDecreases theophylline levels St John’s wortDecreases prednisolone levels
xiao hu tang
sho-saiko-to
Alternative Medicines
St. John’s WortSlide73
Focus is on treating inflammationSeverity classification of the chronic disease determines therapyInhaled corticosteroids are the best therapy for treatment of persistent diseaseNew therapies on the horizon …. Updates on the guidelines are the best resources
Asthma Pharmacological TherapySlide74
Asthma Management Pharmacological Therapy: Case Studies
Presented by: Slide75
Case Study #1
Mild – Moderate Persistent
Inhaled Corticosteroids - Asthma education
Very LikelySlide76
Case Study #2
Not well controlled
Switch to Inhaled Corticosteroid
Assess adherence; evaluate for co morbidities; educate
Follow-up in 2-6 weeksSlide77
Case Study #3
Moderate Persistent
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
Write an action plan; Provide asthma self-management education; assess triggers; consider referral to an asthma specialist
Bring her back in 2-6 weeksSlide78
Case Study #4
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 importantSlide79
Case Study #5
Of course
Oral corticosteroids; evaluate for co-morbidities
Probably; need more family/personal historySlide80
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.
AcknowledgementsSlide81