Bronchial asthma

Classification and guideline treatment

Prepared by:

Reem Ahmed Abd el Moneim

PharmD 4

Bronchial asthma

Source: Peter J. Barnes, Source: Peter J. Barnes, MDMD

Classification

According to etiology:1-Allergic or extrinsic asthma 2-Non-allergic or intrinsic asthma 3-Mixed forms

According to degree of severity:

Grade 1: Intermittent Grade 2: Persistent, mild Grade 3: Persistent, moderate Grade 4: Persistent, severe

SymptomsNocturnal symptoms

FEV1/PEFR

Stage 1

intermittent

<1 time a week

<2 times a month

>80% predicted

Stage 2

Mild-persistant

>1 time a week but >1 time a day

>2 times a month

>80% predicted,variability 20-30%

Stage 3

Moderate-persistant

daily >1 time a week

60-80%predicted,

variability <30%

Stage 4

Severe-persistant

continousfrequent<60%predicted,

variability <30%

According to level of asthma control:

CharacteristicControlled

(All of the following)Partly controlled

(Any present in any week)Uncontrolled

Daytime symptomsNone (2 or less /

week)More than

twice / week

3 or more features of

partly controlled

asthma present in any

week

Limitations of activities

NoneAny

Nocturnal symptoms / awakening

NoneAny

Need for rescue / “reliever” treatment

None (2 or less / week)

More than twice / week

Lung function (PEF or FEV1)

Normal <80% predicted or

personal best (if known) on any day

ExacerbationNone One or more / year 1 in any week

Asthma Management and prevention

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

Reliever MedicationsReliever Medications

Rapid-acting inhaled β2-agonists

Short-acting oral β2-agonists

Systemic glucocorticosteroids

Theophylline

Anticholinergics

Rapid-acting inhaled β2-agonists

Short-acting oral β2-agonists

Systemic glucocorticosteroids

Theophylline

Anticholinergics

Controller MedicationsController Medications

Inhaled glucocorticosteroids Systemic glucocorticosteroids Long-acting inhaled β2-agonists Long-acting oral β2-agonists Theophylline Cromones Anti-IgE Leukotriene modifiers

Inhaled glucocorticosteroids Systemic glucocorticosteroids Long-acting inhaled β2-agonists Long-acting oral β2-agonists Theophylline Cromones Anti-IgE Leukotriene modifiers

StageDaily controller medication

Other treatment option

MildLow dose ICSSustained release theophylline

ModerateModerate dose ICS+inhaled long acting β 2 agonist or leukotriene inhibitor

-Moderate dose ICS+either sustained release theophylline or long acting β 2 agonist or leukotriene inhibitor.

-High dose ICS

SevereHigh dose ICS+inhaled long acting β 2 agonist or leukotriene inhibitor

Oral glucocorticoid

Anti-IgE(omlizumab)

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

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

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

For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)

Treating to Achieve Asthma Control

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

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)

Leukotriene-Inhibiting Drugs

Leukotriene inhibitors are either leukotriene receptor antagonists or leukotriene synthesis inhibitors, which act by blocking 5-lipoxygenase activity. The leukotriene receptor antagonists include zafirlukast (Accolate) and montelukast (Singulair); zileuton (Zyflo) is the only leukotriene synthesis inhibitor.

Clinical recommendation

-Leukotriene inhibitors are effective in the treatment of asthma but are less effective than inhaled corticosteroids (evidence A)

-Leukotriene inhibitors added to inhaled corticosteroids are less effective than long-acting beta agonists added to inhaled corticosteroids in the treatment of asthma (evidence A)

-Leukotriene inhibitors are alternative treatments in exercise-induced asthma and can be of benefit for children when oral therapy is preferred over inhalers (evidence B)

-Leukotriene inhibitors are effective in the treatment of allergic rhinitis but are less effective than intranasal corticosteroids (evidence A)

DrugAge and recommended oral dose

Therapeutic issues

Montelukast (Singulair)

Adults: 10 mg before bed

Children six to 14 years: 5 mg before bed

Children two to five years: 4 mg before bed

Renal adjustments: none

Hepatic adjustments: in mild to moderate disease

Zafirlukast (Accolate)

)Ventair(

Patients older than 11 years: 20 mg twice daily

Children seven to 11 years: 10 mg twice daily

Renal adjustments: none

Hepatic adjustments: not defined

Monitor hepatic enzymes every two to three months

Administration with meals decreases bioavailability; take at least one hour before meals or two hours after

Inhibits metabolism of warfarin (Coumadin), increasing prothrombin time

Zileuton (Zyflo)Patients older than 12 years: 600 mg four times daily

Can inhibit metabolism of warfarin, theophylline, and propranolol (Inderal)

Monitor hepatic enzymes every two to three months

Anti-IgE treatment:Omalizumab(Xolair®)

Omalizumab blocks the receptors on the surfaces of the mast cells and basophils to which antibodies attach, thereby preventing antibodies from attaching to the cells. As a result, the cells do not release their chemicals, and the allergic reaction and inflammation are prevented.

DOSING:

Omalizumab is injected under the skin. The recommended dose is 150-375 mg every 2 to 4 weeks. The dose and frequency is based on body weight and levels of serum IgE, a type of antibody. Doses greater than 150 mg should be divided and administered at different sites so that no more than 150 mg is administered at each injection site.

SIDE EFFECTS

Headaches, viral infections, upper respiratory tract infections and injection-site reactions such as pain, redness, swelling, itching and bruising.

Use of omalizumab may also lead to serious, life-threatening allergic reactions (anaphylaxis) .

Signs and symptoms of anaphylaxis

-Wheezing, shortness of breath, cough, chest tightness, or trouble breathing.

-Low blood pressure, dizziness, fainting, rapid or weak heartbeat, anxiety.

-Flushing, itching or feeling warm.

-Swelling of the throat or tongue, throat tightness, hoarse voice, or trouble

swallowing.

It is recommended that patients be observed for these reactions for at least two hours after injection of omalizumab; however, these reactions can occur up to 24 hours or longer after the injections. 

Cancer occurs more frequently in patients who take omalizumab .

Non pharmacological treatment:

-Reduce exposure to indoor allergens

-Avoid tobacco smoke

-Avoid vehicle emission

-Identify irritants in the workplace

-Explore role of infections on asthma development, especially in children and young infants

Influenza VaccinationInfluenza Vaccination

Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised

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