Asthma Management Pharmacological Therapy

ASTHMA MANAGEMENT PHARMACOLOGICAL

THERAPY

Presented by: Hengameh Raissy, PharmD

Four Components of Asthma Management

• Assessment and Monitoring• Control of Factors Contributing to

Asthma Severity• Education for a Partnership in

Asthma Care• Pharmacological Therapy

NAEPP. EPR-3, page 1.

Asthma Classification Schemes

Stepwise Approach to Asthma Therapy

Asthma Medications and Delivery Devices

New/Complementary/Alternative

This lesson will cover:

• Asthma is a chronic inflammatory disorder of the airways

• A key principle of therapy is regulation of chronic airway inflammation

What 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 process

Pathophysiology of Asthma

INFLAMMATION

Airway Hyperresponsiveness

Airflow Limitation

Environmental Risk Factors Genetic Predisposition

SymptomsCough Wheeze Shortness of Breath

Adapted with permission from Stephen T. Holgate, MD, D. Sc.

bronchospasm

Precipitants

The Pharmacological Treatment of Asthma can focus on one or both aspects of the disease…

The Chronic disease:

• Intermittent• Mild Persistent• Moderate Persistent• Severe Persistent

The Acute (exacerbating) Disease:

• Mild • Moderate• Severe• Respiratory Failure

Asthma: The Chronic Disease

Classification of Severity

Stepwise Approach to

Therapy

Assessment of Control

The Risk of Asthma in a Wheezing Child 0-3 years: Modified Asthma Predictive Index

Major Criterion

• Parental history of asthma

• Physician-diagnosed atopic dermatitis

• Allergic sensitization to ≥1 aeroallergen

Minor Criterion

• Wheezing unrelated to colds

• Blood eosinophils ≥4%• Allergic sensitization to

milk, eggs, or peanuts

- 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 least

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.

Step 1Preferred:SABA PRN

Step 2Preferred:Low-dose

ICS

Alternative:Cromolyn

or Montelukast

Step 3Preferred:

Medium-dose ICS

Step 5Preferred:High-dose

ICS + either LABA or

Montelukast


ICS + either LABA or

Montelukast

OSC

Step 4Preferred:

Medium-dose ICS +

either LABA or

Montelukast

Initial Therapies / Stepwise Approach: Asthma Patients 0-4 Years of Age

ICS = inhaled corticosteroid; LABA = long-acting beta2-agonist; OSC = Oral Systemic Corticosteroids.; SABA = inhaled short-acting beta2-agonist.

Consider consult

Recommend consult


A

DD

DD

Intermittent Persistent

Each Step: Patient education, environmental control, management of co morbiditiesIf 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)

AssessControl

Assessing Control: 0 – 4 years

Components 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


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.


Persistent


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


2 days/wk >2 days/wkbut not daily Daily Several times

per day

Activity limits None Minor limitation

Some Limitation

Extremely limited

Lung FunctionFEV1

FEV1/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.


Step 2Preferred:Low-dose

ICS


LTRANedocromil

or theophylline

Step 3Preferred

Medium-dose ICS

OR

Low-dose ICS + either LABA, LTRA

or theophylline


ICS + LABA

Alternative: High dose

ICS + either LTRA or

theophylline


ICS + LABA + OSC

Alternative: High dose

ICS + either LTRA or

Theophylline +OSC

Step 4Preferred:

Medium-dose

ICS + LABA

Alternative:Medium-dose ICS +either LTRA

or theophylline

Initial Therapies / Stepwise Approach:Asthma Patient 5-11 Years of Age

PersistentIntermittent

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


A

BB

B

D

ICS = inhaled corticosteroid; LABA = long-acting beta2-agonist; LTRA= leukotriene receptor antagonist; OSC = Oral Systemic Corticosteroids; SABA = short-acting beta2-agonist.



at least 3 months)

Step Up If Needed


inhaler technique,


AssessControl

Asthma Control: 5 – 11 years



WellControlled

Not Well Controlled

Very PoorlyControlled

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



2 days/wk >2 days/wk Several times per day

Lung function• FEV1 or PF• FEV1/FVC

80% >80%

60 – 80% 75-80%

<60% <75%

Risk

Exacerbations requiring OSC 0-1/year ≥2/year

Reduction inlung growth Evaluation requires long-term follow-up



Classifying Asthma Severity: 12 and older


Persistent


Impairment

Normal FEV1/FVC:8-19yrs 85%20-39yrs 80%40-59yrs 75%60-80yrs 70%

Symptoms 2 days/wk >2 days/wkbut not daily Daily Throughout

the day

Nighttime awakenings 2x/month 3-4x/month >1x/wk but not

nightly Often 7x/week


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 FunctionFEV1

FEV1/FVC>80%

normal80%

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.



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 beta2-agonist; LABA = long-acting beta2-agonist; LTRA= leukotriene receptor antagonist.

PersistentIntermittent

Each Step: Patient education, environmental control, management of co morbidities

Steps 2-4: Consider subcutaneous allergen immunotherapy for patients with allergic asthma

Consider consultRecommend consult




at least 3 months)

Step Up If Needed


inhaler technique,


AssessControl

A

A/B/DB/D

BB


Step 2Preferred:

Low-dose ICS


LTRA or

theophylline

Step 3Preferred:

Medium-dose ICS

orLow-dose ICS

+ LABA

Alternative: Low dose ICS

+LTRA,

theophylline or zileuton

Step 5Preferred:High-dose ICS + LABA

And

Consider Omalizumab for patients who have allergies

Step 4Preferred:

Medium-dose ICS + LABA

Alternative: medium dose ICS + LTRA, theophylline or zileuton

Asthma Control: 12 and older



WellControlled

Not WellControlled

Very PoorlyControlled

Impairment

Symptoms 2 days/week >2 days/week Throughout the day

Nighttime awakenings 2x/month 1-3x/week >4x/week



2 days/week >2 days/week Several times per day

Lung function FEV1 or PF >80% FEV1 or PF = 60 -80% FEV1 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



• Severity assessment has been simplified and lung function measurement is emphasized

• Lower 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.

Signs and Symptoms

Initial FEV1 or PF

Clinical Course

MildDyspnea only with activity; RR in young

PF/FEV1 > 70% Care @ home Relief w/ SABA

ModerateDyspnea interferes/limits usual activity

PF/FEV1 = 40-69% Office or ED visit Response to SABA OCS

SevereDyspnea at rest; interferes w/ conversation; In infants use exam

PF/ FEV1 < 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 Flares

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)

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 Disease

Medications

Inhaled Medication:

• In general, inhaled therapy is favored over systemic (oral) therapy for asthma

• The medication is delivered on site and avoids most adverse side effects

Pharmacological Therapy


Metered-Dose

Inhaler (MDI)

Dry Powder Inhaler (DPI)

Spacer/Holding

Chamber

Spacer/Holding

Chamber and Face

Mask

Nebulizer

Inhaled Medication Delivery Devices

• Many MDIs used chlorofluorocarbons (CFCs) as propellants.

• CFCs were phased out globally in 2008 to protect the earth’s ozone layer

• Hydrofluroalkaline (HFA) inhalers are the non-CFC alternative

• DPIs (breath actuated Dry Powder Inhalers) are non-CFC compliant

Metered Dosed Inhalers

Transition to non-CFC containing inhalers:

Daily Long-Term Control:• Corticosteroids (inhaled and systemic)• Long-acting beta2-agonists (salmeterol,

formoterol) when in combination with ICS• Leukotriene modifiers (montelukast)• Leukotriene inhibitors (zileuton)• Mast cell stabilizers (cromolyn or nedocromil)• Methylxanthines (theophylline)

Overview of Asthma Medications

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 Control

• Benefit of daily use:– Reduced airway inflammation– Improved lung function – Reduced use of quick-relief medicine– Fewer symptoms and exacerbations

• In usual doses ICS do not provide short-term relief

• Must be used daily for full benefit

Inhaled Corticosteroids

Rat

e R

atio

for D

eath

from

Ast

h ma

No. of Canisters of Inhaled Corticosteroids per Yr.

2.5

2.0

1.5

1.0

0.5

0.01 2 3 4 5 6 7 8 9 10 11 12

Low-dose ICS and the Prevention ofDeath from Asthma

Suissa S et al. N Engl J Med. 2000;343:332-336.

Effects of Inhaled Steroids on Airway Inflammation

J 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 Membrane

Possible Dose-Dependent side effects:• Oral candidiasis (thrush)• Dysphonia• Reflex cough and bronchospasm• Slowed linear growth velocity• Decreases in bone mineral density• Dermal thinning and skin bruising• Ocular effects: glaucoma, cataracts


CAMP Trial and Follow-up Design

RoutineCare

Randomize

Treatment Trial Transition

5 visits 3 visits per year

2 visits

Study RxDiscontinued

2 - 4 months

4 – 6 years

4 months

Screeningand

Baseline

13 years

Follow-up

Enroll in follow-up study Refer back to PCP for Rx

per NAEPP guidelinesNedocromilBudesonidePlacebo

Enrollment in trial: Dec 1993 – Sept 19951,041 children age 5-13 years at randomizationMild to moderate persistent asthma

1-4 visits per year

Change in Bone Densityat End of CAMP Trial

0.17 0.180.17

0.0

0.1

0.2

0.3

0.4

0.5

g/cm

2

Budesonide vs. Placebo = - 0.01, P = 0.53Nedocromil vs. Placebo = - 0.01, P = 0.15

Budesonide Nedocromil Placebo (n = 304) (n = 306) (n = 410)

Mean Obtained Adjusted Adult Height

0

50

100

150

Total Females Males

Bud

Ned

Plbo

-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=0.98

ICS Metabolism

Reduce potential for adverse events by:• Rinsing mouth• Using lowest dose possible that results in

control• Use in combination with long-acting

beta2-agonists (LABA) or a leukotriene modifier if moderate/severe disease


Comparative Dosages:

HFA ≠ DPI ≠ MDI ≠ respules

• Preparations are not equivalent per puff or per microgram

• Comparative doses are estimated.– Few data directly compare preparations


Chemical Structure of Inhaled Corticosteroids

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/puff44 ug/puff

Fluticasone (Flovent HFA)


Drug Low Dose Medium 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 Adults

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 relief

• 28 week, randomized, double-blind, placebo-controlled; 164 patients; 12 - 65 yrs. old

• Persistent asthmatics controlled on Triamcinolone 400 mcg bid

Use of Salmeterol Alone to Treat Asthma

JAMA 2001;285:2583-93.

Treatment Failure Rate

Treatment arms:1. Placebo2. Change to Salmeterol3. Continue ICS

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. 2006

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 Control

Combination Therapy

• MDI• 100/5 mcg• 200/5 mcg

• Patients 12 and older

Dulera

Momestasone FuroateFormoterol Fumarate

Combination Therapy

• MDI• 80/4.5 mcg• 160/4.5 mcg

• Patients 12 and older

Symbicort

BudesonideFormoterol Fumarate

Advair®

DPI Doses:100/50* mcg250/50 mcg500/50 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 mcg115/21 mcg230/21 mcg

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….

Currently Approved Controller Therapy for Asthma in Children

FDA-Approved Ages (Years) for Use in Children0 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 DPI

Role of Leukotrienes in AsthmaMucus Transport

Airway Smooth MuscleInflammatory Cells(e.g. Mast Cells,

Eosinophils)

AirwayEpithelium

Sensory Nerves(C-Fibers)

LTD4Edema

BloodVessel

Increased Mucus

Secretion

Decreased Mucus Transport

EosinophilInflux

Epithelial Cell Damage Cationic Protein Release ,

Contraction & Proliferation

Adapted from Hay DWP et al. Trends Pharmacol Sci 1995;16:304-309

• 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)

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 Children

• Urgent control of Inflammation– Systemic 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 Medications

ProAir Proventil HFA Ventolin HFA

Albuterol HFA

Levalbuterol (Xopenex HFA)

Pirbuterol (Maxair)

Quick Relief Beta2-agonists

Neb

uliz

er S

olut

ions

Short-Acting Beta2-Agonistsalbuterol* (Proventil, Ventolin, ProAir), pirbuterol** (Maxair),

levalbuterol*** (Xopenex)

• Most effective medication for relief of acute bronchospasm (more so than anticholinergics)

• Effective as a pre exercise medication• More than one canister per month suggests inadequate

asthma control

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)

Short-Acting Beta2-Agonists:

• Regularly scheduled use is not generally recommended– May lower effectiveness and increase side effects– May increase airway hyper-responsiveness

• Using >2 canisters per month-risk factor for death


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 Considerations

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


Transient narrowing of the airways associated with:• Physical exertion• Coughing, 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)


Exercise Induced Asthma (EIA)Exercise Induced Bronchospasm (EIB)

Occurrence:• 90% of asthmatics • 40% of patients with allergic rhinitis• 22% of 1998 Olympic athletes• 9% of persons with EIB have no hx of asthma or

allergies• 10-50% of asthmatics on ICS still display EIB

Exercise Induced Asthma

Management Strategies:• Short-acting inhaled beta2-agonists used shortly

before exercise last 2 to 3 hours• Salmeterol may prevent EIB for 10 to 12 hours• Cromolyn if side effects a concern• A lengthy warm-up period before exercise • An aerobic conditioning program• Long-term-control therapy, if appropriate• Avoid asthma triggers during exercise

Managing Exercise-Induced Asthma

Over-The-Counter (OTC) Asthma Medicines:• Always include OTC’s in medical history• OTC 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


Subcutaneous Allergy Immunotherapy•Consists of small injections of relevant allergens in increasing concentrations over a 3-6 month build-up followed by maintenance injections every 2-4 weeks over 3-5 years•beneficial effects occur over months (not immediately)•Reports have concluded that over time it can prevent the development of new sensitivities to allergens•Controlled studies have demonstrated reduction in asthma symptoms caused by exposure to cat, dust mites, mold, ragweed, and grass•Sublingual therapy has yet to be proven as effective

Subcutaneous Allergy Immunotherapy

Subcutaneous Allergen Immunotherapy is considered for:

Patients with persistent asthma if evidence is clear of a relationship between symptoms and exposure to an allergen

Candidates for immunotherapy are generally > 5 years of age

Administration should occur in an office prepared to treat a systemic allergic reaction


Newer Therapy

Anti-IgE Therapy – Omalizumab (Xolair)

• Humanized IgG (5% murine)• Binds IgE regardless of specificity• Does not activate complement• Rarely has caused anaphylaxis

• Indicated for adults and adolescents(>12) with severe persistent asthma inadequately controlled on high-dose ICS and LABA

• Selected patients must have a positive skin test or in vitro reactivity to aeroallergens

• Dosed every 2-4 weeks; SQ dosing• May allow these patients to improve control,

decrease dose of ICS and decrease reliance on oral corticosteroids

Xolair (Omalizumab)

• Use of Alternative medicines may result in:– allergic reactions– intensification of drug side effects

• Users may not be aware of:– potency– contaminants– covert additives– Recommended 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).

According to the 2007 NAEPP EPR-3:

Insufficient evidence to recommend the following for asthma management:

Chiropractic therapy

Acupuncture

Hypnosis

Homeopathy and herbal medicine

Breathing techniques

Yoga

NAEPP. EPR-3, pages 240 - 242.

However, some people find these therapies helpful:

Acupuncture

• may relax and calm breathing

Biofeedback

• may help control involuntary physical responses

Hypnosis

• may allow more self discipline through suggestion

Massage, relaxation, art/music therapy, yoga

• may reduce anxiety and help to relax

Potential for Allergic Responses• Daisy family• Horse chestnut• Natural plant salicylates• Royal jelly

Alternative Medicines

Willow bark

Royal Jelly

Echinacea

Intensification of Drugs• CNS stimulants

– Ma huang (ephedra)– Ginseng– Yohimbe– Goldenseal– Gingko

• Potentiate steroids– Licorice


Ginseng

Deactivation of Drugs• Decreases theophylline levels

– St John’s wort• Decreases prednisolone levels

– xiao hu tang– sho-saiko-to


St. John’s Wort

• Focus is on treating inflammation• Severity classification of the chronic disease

determines therapy• Inhaled corticosteroids are the best therapy for

treatment of persistent disease• New therapies on the horizon …. Updates on the

guidelines are the best resources

Asthma Pharmacological Therapy

ASTHMA MANAGEMENT PHARMACOLOGICAL

THERAPY:

CASE STUDIES

Presented by:

19 mo old with nighttime cough and 3 spells in last 6 months treated with oral corticosteroids (OCS)

• He is thought to have intermittent asthma. What do you think?

• What is the best treatment?• His mom has asthma and he has milk allergy. Will

he have asthma when older?

Case Study #1

Mild – Moderate Persistent

Inhaled Corticosteroids - Asthma education

Very Likely

3 year old on montelukast who wakes up at night once per week with cough

• Is he controlled?• What should be done?

Case Study #2

Not well controlled

Switch to Inhaled CorticosteroidAssess adherence; evaluate for co morbidities; educateFollow-up in 2-6 weeks

6 year old with daily cough, FEV1=80%, FEV1/FVC=76%

• How severe is her asthma?

• What medications should be prescribed?

• Anything else?

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 weeks

15 year old who uses albuterol 3 times each basketball game/practice despite daily fluticasone

• What could the physician do next to help?

Case Study #4

Check pre and post spirometryPerform exercise challengeConsider more in depth studies and co morbidities

Consider asthma specialist consultation

You could try combination therapy but the work-up is most important

13 month old infant (3rd episode) with inspiratory and expiratory wheeze, RR=60, O2 Sat=90% after 1 hour

in the emergency department

• Is this asthma?

• He’s had 2 treatments, what next?

• Should he be in the hospital?

Case Study #5

Of course

Oral corticosteroids; evaluate for co-morbidities

Probably; need more family/personal history

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-CAsthma Education Specialist Maine Medical Center and MaineHealth, Portland, ME (207) 662-4515

Janice H. Howell, MD, FRCPC, FAAPFaculty Physician, Medical Education-Pediatrics, Orlando FL (321) 841-2121

Chris Garvey, FNP, MSN, MPA, FAACVPRManager 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.

Acknowledgements

We will breathe easier when the air in everyAmerican community is clean and healthy.

We will breathe easier when people are free from the addictivegrip of cigarettes and the debilitating effects of lung disease.

We will breathe easier when the air in our public spaces andworkplaces is clear of secondhand smoke.

We will breathe easier when children no longerbattle airborne poisons or fear an asthma attack.

Until then, we are fighting for air.

Asthma Management Pharmacological Therapy

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