ASTHMAASTHMA UPDATEUPDATEChad Fowler, M.D.Chad Fowler, M.D.

10/27/0410/27/04

Asthma: Why do we care?Asthma: Why do we care?It’s common: Affects 14-15 million It’s common: Affects 14-15 million persons in U.S.persons in U.S.

Most common chronic disease of Most common chronic disease of childhood: 4.8 million childrenchildhood: 4.8 million children

Hospitalizations and mortality are NOT Hospitalizations and mortality are NOT insignificantinsignificant

Prevalence, hospitalization rates, and Prevalence, hospitalization rates, and mortality rates have been on the risemortality rates have been on the rise

(CDC data ’82-’92)(CDC data ’82-’92)

What is Asthma?What is Asthma?

Chronic inflammatory disease of the Chronic inflammatory disease of the airwaysairwaysKey features include reversible Key features include reversible airway obstruction, airway airway obstruction, airway inflammation, and release of inflammation, and release of inflammatory mediators (bronchial inflammatory mediators (bronchial mast cells) in response to a Triggermast cells) in response to a Trigger

TriggersTriggers

Animal allergens Animal allergens (cat/dog/rodent)(cat/dog/rodent)

Pollen allergens Pollen allergens (trees/grasses/weeds)(trees/grasses/weeds)

Mold allergens Mold allergens (outdoor fungi/indoor (outdoor fungi/indoor fungi)fungi)

Cockroach allergenCockroach allergen

URI’sURI’s

House dust mitesHouse dust mites

Nonallergenic Nonallergenic airborne irritants: airborne irritants: Tobacco smoke, Tobacco smoke, wood-burning wood-burning stoves/fireplaces, stoves/fireplaces, perfumes, strong perfumes, strong odorsodors

Cold airCold air

ExerciseExercise

Clinical FeaturesClinical Features

WheezingWheezing

DyspneaDyspnea

Cough Cough

Chest tightnessChest tightness

Typically episodicTypically episodic

Sx’s exacerbated when exposed to Sx’s exacerbated when exposed to triggerstriggers

DiagnosisDiagnosisDemonstration of reversibility of airway Demonstration of reversibility of airway obstruction (15% increase FEV1 post B-obstruction (15% increase FEV1 post B-agonist)agonist)

If spirometry normal, challenge tests may If spirometry normal, challenge tests may be useful (histamine, methacholine)be useful (histamine, methacholine)

Personal or family hx of asthma, eczema, Personal or family hx of asthma, eczema, uticaria, rhinitis is helpfuluticaria, rhinitis is helpful

Disease course followed with Peak Disease course followed with Peak Expiratory Flow Rates or FEV1Expiratory Flow Rates or FEV1

DDx WheezingDDx WheezingAsthmaAsthmaCOPDCOPDGERDGERDForeign bodyForeign bodyPEPEILDILDCardiac asthmaCardiac asthmaLymphomaLymphoma

Infections Infections (pneumonia, (pneumonia, bronchitis, bronchitis, bronchiolitis, bronchiolitis, epiglotitis)epiglotitis)AnaphylaxisAnaphylaxisObstruction (tumor, Obstruction (tumor, hemorrhage, hemorrhage, edema)edema)

ClassificationClassification

Mild IntermittentMild Intermittent

Sx’s < 2 days/wkSx’s < 2 days/wk

< 2 nights/month< 2 nights/month

PEF/FEV1 > 80%PEF/FEV1 > 80%

PEF Variability < 20%PEF Variability < 20%

Mild PersistentMild Persistent

Sx’s > 2 days/week (<1x/day)Sx’s > 2 days/week (<1x/day)

> 2 nights/month> 2 nights/month

PEF/FEV1 > 80%PEF/FEV1 > 80%

PEF Variability 20-30%PEF Variability 20-30%

Moderate PersistentModerate Persistent

Sx’s dailySx’s daily

> 1 night/week> 1 night/week

PEF/FEV1 60-80%PEF/FEV1 60-80%

PEF Variability > 30%PEF Variability > 30%

Severe PersistentSevere Persistent

Sx’s continual daytimeSx’s continual daytime

frequent nighttimefrequent nighttime

PEF/FEV1 < 60%PEF/FEV1 < 60%

PEF Variability > 30%PEF Variability > 30%

TreatmentTreatmentGoals for ALL Asthma patients:Goals for ALL Asthma patients:

- Minimal/no chronic day/night sx’s- Minimal/no chronic day/night sx’s- Minimal/no exacerbations- Minimal/no exacerbations- No limitations on activities - No limitations on activities (work/school) (work/school)- PEF > 80% of personal best- PEF > 80% of personal best- Minimal use of rescue med (Albuterol)- Minimal use of rescue med (Albuterol)- Minimal/no adverse effects from - Minimal/no adverse effects from medications medications- Educate on self-management and - Educate on self-management and

controlling triggerscontrolling triggers

Rescue medication: AlbuterolRescue medication: AlbuterolMDI vs Neb MDI vs Neb

Controller medications:Controller medications:Inhaled corticosteroids (ICS)Inhaled corticosteroids (ICS)Leukotriene modifiersLeukotriene modifiersCromolyn/NedocromilCromolyn/NedocromilTheophyllineTheophylline

Rule of 2’s: If more than one of the Rule of 2’s: If more than one of the following, pt needs a controller medication: following, pt needs a controller medication: Sx’s >2x/week (day) Sx’s >2x/week (day)

Sx’s >2x/month (night)Sx’s >2x/month (night)>2 ER visits or hosp/yr>2 ER visits or hosp/yr

Mild IntermittentMild Intermittent

No daily medication (controller) No daily medication (controller) neededneeded

Rescue medication (Albuterol MDI vs Rescue medication (Albuterol MDI vs Neb)Neb)

Tx exacerbations: oral systemic Tx exacerbations: oral systemic corticosteroidscorticosteroids

Severe PersistentSevere PersistentHigh Dose Inhaled CorticosteroidsHigh Dose Inhaled Corticosteroids

AND AND

Long-acting beta2-agonistsLong-acting beta2-agonists

If needed Corticosteroid tablets/syrup If needed Corticosteroid tablets/syrup (always attempt to reduce systemic tx and (always attempt to reduce systemic tx and control with high dose ICS)control with high dose ICS)

ReferRefer

Comparative Daily Doses of Inhaled Comparative Daily Doses of Inhaled Corticosteroids (ICS) Corticosteroids (ICS)

New New Recommendations (NAEPP)Recommendations (NAEPP)

Mild Persistent: Low-dose ICS Mild Persistent: Low-dose ICS preferred tx adults, children > 5yo, preferred tx adults, children > 5yo, and preschool children. and preschool children.

Cromolyn/Nedocromil now alternative Cromolyn/Nedocromil now alternative to low-dose ICS in adults and children to low-dose ICS in adults and children >5 yo.>5 yo.Cromolyn is also alternative to low-Cromolyn is also alternative to low-dose ICS in preschool childrendose ICS in preschool children

CAMP (Childhood Asthma CAMP (Childhood Asthma Management Program) StudyManagement Program) Study

Children 5-12yoChildren 5-12yo

Budesonide vs NedocromilBudesonide vs Nedocromil

Budesonide provided greater Budesonide provided greater reduction in Sx’s and Albuterol use, reduction in Sx’s and Albuterol use, lower hospitalization rates and lower hospitalization rates and urgent care visits, less need for urgent care visits, less need for additional meds/prednisone.additional meds/prednisone.

Moderate Persistent: Adults and Moderate Persistent: Adults and children >5yo - low-medium dose ICS children >5yo - low-medium dose ICS + LABA (Salmeterol)+ LABA (Salmeterol)

Preschool children - low-dose ICS + Preschool children - low-dose ICS + LABA LABA

LABAs are not recommended for use LABAs are not recommended for use without an ICSwithout an ICS

Controller Medications: Dosing in KidsController Medications: Dosing in Kids

ICS: Fluticasone (Flovent) down to 4yoICS: Fluticasone (Flovent) down to 4yo

Budesonide nebulized inhalation Budesonide nebulized inhalation suspension (Pulmocort suspension (Pulmocort

Respules) Respules) down to 12 mo of age down to 12 mo of age

LABA: Formoterol (Loradil) down to 5yoLABA: Formoterol (Loradil) down to 5yo

Salmeterol (Serevent Diskus) down Salmeterol (Serevent Diskus) down to 4yoto 4yo

Cromolyn sodium nebulizer solution down to Cromolyn sodium nebulizer solution down to 2yo2yo

Leukotriene modifier: Montelukast Leukotriene modifier: Montelukast (Singulair)(Singulair)

- Oral granule formation down to 1yo- Oral granule formation down to 1yo

chewable tablets 2-5yochewable tablets 2-5yo

Zafirlukast (Accolate) approved for Zafirlukast (Accolate) approved for children 5 years and older children 5 years and older

Theophylline approved for any ageTheophylline approved for any age

Safety of ICSSafety of ICS

Long-term use (labeled doses) is safe in Long-term use (labeled doses) is safe in children (growth, bone mineral density, children (growth, bone mineral density, adrenal function). Should always step adrenal function). Should always step down to lowest effective dose. Review down to lowest effective dose. Review every 1-6 months.every 1-6 months.

Low-medium dose ICS are not associated Low-medium dose ICS are not associated with development of cataracts/glaucoma. with development of cataracts/glaucoma. High cumulative lifetime doses may High cumulative lifetime doses may slightly increase prevalence of cataracts in slightly increase prevalence of cataracts in adults and elderly.adults and elderly.

We have come a long way We have come a long way with the treatment of Asthma with the treatment of Asthma

since since the 1940’s….the 1940’s….

                                                                                                                

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In SummaryIn SummaryClassify Asthma earlyClassify Asthma earlyTreatment guided by classification/sx’s Treatment guided by classification/sx’s (don’t forget to reassess)(don’t forget to reassess)Persistent Asthma = need for controller Persistent Asthma = need for controller medication (rule of 2’s)medication (rule of 2’s)ICS preferred treatment of all ages with ICS preferred treatment of all ages with persistent asthma (Cromoly/nedocromil persistent asthma (Cromoly/nedocromil alternatives) alternatives) LABA use with ICSs for moderate/severe LABA use with ICSs for moderate/severe persistent asthma (not to be used as sole persistent asthma (not to be used as sole controller agent)controller agent)