Latest Guidelines for Asthma Management

Global Initiative for AsthmaBy: Dr. Mahmoud Taheri

Strategies for Asthma Management and Prevention

Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and

Prevention Program Implementation of Asthma

Guidelines in Health Systems

Definition of Asthma

A chronic inflammatory disorder of the airways Many cells and cellular elements play a role Chronic inflammation is associated with airway

hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing

Widespread, variable, and often reversible airflow limitation

Asthma Inflammation: Cells and Mediators

Factors that Exacerbate Asthma

Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs

Factors that Influence Asthma Development and Expression

Host Factors Genetic - Atopy - Airway

hyperresponsiveness Gender Obesity

Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet

Is it Asthma?

Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness

after exposure to airborne allergens or pollutants

Colds “go to the chest” or take more than 10 days to clear

Asthma Diagnosis

History and patterns of symptoms Measurements of lung function - Spirometry - Peak expiratory flow Measurement of airway responsiveness Measurements of allergic status to identify

risk factors

Typical Spirometric (FEV1) Tracings

1Time (sec)

2 3 4 5

FEV1

Volume

Normal Subject

Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)

Note: Each FEV1 curve represents the highest of three repeat measurements

Measuring Variability of Peak Expiratory Flow

Measuring Airway Responsiveness

Asthma Management and Prevention Program

Goals of Long-term Management

Achieve and maintain control of symptoms

Maintain normal activity levels, including exercise

Maintain pulmonary function as close to normal levels as possible

Prevent asthma exacerbations Avoid adverse effects from asthma

medications Prevent asthma mortality

Asthma Management and Prevention Program: Five Interrelated Components

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations5. Special Considerations

Asthma Management and Prevention Program

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.

.

Asthma Management and Prevention Program

Part 1: Educate Patients to Develop a Partnership

Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams

Clear communication between health care professionals and asthma patients is key to enhancing compliance

Asthma Management and Prevention Program

Component 1: Develop Patient/Doctor Partnership

Educate continually Include the family Provide information about asthma Provide training on self-management skills Emphasize a partnership among health

care providers, the patient, and the patient’s family

Asthma Management and Prevention Program

Component 1: Develop Patient/Doctor Partnership

Key factors to facilitate communication: Friendly demeanor Interactive dialogue Encouragement and praise Provide appropriate information Feedback and review

Asthma Management and Prevention Program

Factors Involved in Non-Adherence

Medication Usage Difficulties associated

with inhalers Complicated regimens Fears about, or actual

side effects Cost Distance to pharmacies

Non-Medication Factors Misunderstanding/lack of

information Inappropriate expectations Underestimation of severity Attitudes toward ill health Cultural factors Poor communication

Asthma Management and Prevention ProgramComponent 2: Identify and Reduce Exposure to Risk Factors

Measures to help reducing exposure to risk factors should be implemented wherever possible.

Asthma exacerbations are caused by a variety of risk factors – allergens, viral infections, pollutants and drugs.

Reducing exposure to some risk factors improves the control of asthma and reduces medications needs.

Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma

development

Asthma Management and Prevention ProgramComponent 2: Identify and Reduce Exposure to Risk Factors

Asthma Management and Prevention Program

Influenza Vaccination

Routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control

Asthma Management and Prevention Program

Component 3: Assess, Treat and Monitor Asthma

The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional

Global Strategy for Asthma Management and Prevention

Clinical Control of Asthma

The focus on asthma control isimportant because: the attainment of control

correlates with a better quality of life, and

reduction in health care use

Determine the initial level of control to implement treatment

(assess patient impairment) Maintain control once

treatment has been implemented

(assess patient risk)

Global Strategy for Asthma Management and Prevention

Clinical Control of Asthma

Levels of Asthma Control(Assess patient impairment)

Characteristic Controlled(All of the following)

Partly controlled(Any present in any week)

Uncontrolled

Daytime symptoms Twice or less per week

More than twice per week

3 or more features of partly controlled asthma present in any week

Limitations of activities None Any

Nocturnal symptoms / awakening None Any

Need for rescue / “reliever” treatment

Twice or less per week

More than twice per week

Lung function (PEF or FEV1)

Normal< 80% predicted or

personal best (if known) on any day

Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)

Assess Patient Risk Features that are associated with increased risk of adverse events in the future include:

Poor clinical control Frequent exacerbations in past year Ever admission to critical care for asthma Low FEV1, exposure to cigarette

smoke, high dose medications

*IMPORTANT*

Any exacerbation should prompt review of

maintenance treatment

Asthma Management and Prevention Program

Component 3: Assess, Treat and Monitor Asthma

Depending on level of asthma control, the patient is assigned to one of five treatment steps

Step 2 is the initial treatment for most patients. If the patient is severely uncontrolled, we start from step 3.

Our approach includes: - Assessing Asthma Control - Treating to Achieve Control - Monitoring to Maintain Control

Controller Medications Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists in

combination with inhaled glucocorticosteroids

Systemic glucocorticosteroids Theophylline Cromones Anti-IgE

Salbutamol (Albuterol)

Availability: Aerosol 90 mcg/inh. Brand Names: Ventolin Onset: 5-15 min Peak: 1 Hour Duration: 3-6 hrs.

Salmeterol

Availability: Aerosol 25 mcg/inh. Brand Names: Serevent Onset: 10-25 min Peak: 3-4 hrs. Duration: 12 hrs.

Beclomethasone

Availability: Aerosol 40 mcg/inh. Aerosol 80 mcg/inh. Brand Names: Becotide, Beclazone,

Qvar Onset: Within 24 hrs. Peak: 1-4 Weeks Duration: Unknown

Fluticasone

Availability: Aerosol 44 mcg/inh. Aerosol 110 mcg/inh. Aerosol 220 mcg/inh. Brand Names: Flovent Onset: Within 24 hrs. Peak: 1-4 Weeks Duration: Days after DC.

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

Beclomethasone 200-500 >500-1000 >1000

Budesonide 200-600 600-1000 >1000

Ciclesonide 80 – 160 >160-320 >320-1280

Flunisolide 500-1000 >1000-2000 >2000

Fluticasone 100-250 >250-500 >500

Mometasone furoate 200-400 > 400-800 >800-1200

Triamcinolone acetonide 400-1000 >1000-2000 >2000

Reliever Medications

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics Theophylline Short-acting oral β2-agonists

Component 4: Asthma Management and Prevention Program Allergen-specific Immunotherapy

Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis

The role of specific immunotherapy in asthma is limited

Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma

controlled

partly controlled

uncontrolled

exacerbation

LEVEL OF CONTROL

maintain and find lowest controlling step

consider stepping up to gain control

step up until controlled

treat as exacerbation

TREATMENT OF ACTION

TREATMENT STEPSREDUCE INCREASE

STEP1

STEP2

STEP3

STEP4

STEP5

RED

UC

EIN

CR

EASE

Shaded green - preferred controller options

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

TO STEP 4 TREATMENT, ADD EITHER

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

Step 1 – As-needed reliever medication Patients with occasional daytime symptoms of

short duration

A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)

When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)

Treating to Achieve Asthma Control

Shaded green - preferred controller options

TO STEP 4 TREATMENT, ADD EITHER

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

Step 2 – Reliever medication plus a single controller

A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)

Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids.

Treating to Achieve Asthma Control

Shaded green - preferred controller options

TO STEP 4 TREATMENT, ADD EITHER

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

Step 3 – Reliever medication plus one or two controllers

For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)

Inhaled long-acting β2-agonist must not be used as monotherapy

Treating to Achieve Asthma Control

Additional Step 3 Options for Adolescents and Adults Increase to medium-dose inhaled

glucocorticosteroid (Evidence A) Low-dose inhaled glucocorticosteroid

combined with leukotriene modifiers (Evidence A)

Low-dose sustained-release theophylline (Evidence B)

Treating to Achieve Asthma Control

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

Step 4 – Reliever medication plus two or more controllers

Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3

Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma

Treating to Achieve Asthma Control

Step 4 – Reliever medication plus two or more controllers

Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence A)

Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)

Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B)

Treating to Achieve Asthma Control

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

Treating to Achieve Asthma Control

Step 5 – Reliever medication plus additional controller options

Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)

Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)

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)

Treating to Maintain Asthma Control

Stepping down treatment when asthma is controlled

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 long-acting β2-agonist (Evidence D)

Treating to Maintain Asthma Control

Stepping up treatment in response to loss of control

Rapid-onset, short-acting or long-acting 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

Treating to Maintain Asthma Control

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 effective in maintaining a high level of asthma control and reduces exacerbations (Evidence A)

Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended (Evidence A)

Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness

Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)

Severe exacerbations are potentially life-threatening and treatment requires close supervision

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations

Primary therapies for exacerbations:• Repetitive administration of rapid-acting inhaled

β2-agonist• Early introduction of systemic

glucocorticosteroids• Oxygen supplementation

Closely monitor response to treatment with serialmeasures of lung function

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations

Asthma Management and Prevention Program

Special ConsiderationsSpecial considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma