Asthma

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Our current understanding of the pathophysiology of asthma and the availability of potent,
effective therapies mean that asthma can be well controlled. However, to achieve this goal,
optimal therapy must be prescribed and the patient must be taught how and when to use it.
Pharmacists, as part of the health care team, help improve the pharmacologic management of
asthma by teaching patients about their medications, how to use them, and the importance of
using them as prescribed. Alerting physicians to suspected problems, such as under using anti-
inflammatory therapy or overusing inhaled bronchodilators, will provide an opportunity for the
physician to consider changes in a patient's management plan when appropriate. Acting in these
educational and information-sharing roles, pharmacists contribute to improving the control of
asthma and enabling patients to live full, active, and productive lives.Y

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Asthma is a chronic, episodic disease of the airways, and it is best viewed as a syndrome. In 1997, the National
Heart, Lung, and Blood Institute (NHLBI) included the following features as integral to the definition of asthma
, recurrent episodes of respiratory symptoms; variable airflow obstruction that is often reversible, either
spontaneously or with treatment; presence of airway hyper reactivity; and, importantly, chronic airway inflammation
in which many cells and cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes,
macrophages, neutrophils, and epithelial cells. All of these features need not be present in any given asthmatic
patient. Although the absolute "minimum criteria" to establish a diagnosis of asthma is not known or widely agreed
upon, the presence of airway hyper reactivity is a common finding in patients with current symptoms and active
asthma.

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Asthma is a chronic disease characterized by recurrent attacks of breathlessness and wheezing,

which vary in severity and frequency from person to person. Symptoms may occur several times
in a day or week in affected individuals, and for some people become worse during physical
activity or at night. During an asthma attack, the lining of the bronchial tubes swell, causing the
airways to narrow and reducing the flow of air into and out of the lungs. Recurrent asthma
symptoms frequently cause sleeplessness, daytime fatigue, reduced activity levels and school and
work absenteeism. Asthma has a relatively low fatality rate compared to other chronic diseases.Î

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Asthma was not generally considered to be a fatal illness and this was the teaching in medical schools well into the
present century. It was not until the rise in deaths from asthma in the 1960s that attitudes began to change.

The increasing death rate during the 1980s has been particularly alarming. As shown in the following figure.

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Office Visits ED Visits Hospitalizations
Age Increase from Increase from Increase from

1994 1995 1994
(years) 1980 (%) 1992* (%) 1980 (%)
0-4 1,024,000 98 248,000 -14 97,000 73
5-14 2,004,000 23 322,000 11 67,000 20
15-34 1,876,000 65 566,000 29 78,000 15
35-64 3,982,000 164 630,000 75 139,000 9
>65 1,488,000 119 101,000 13 85,000 8
Total 10,374,000 90 1,867,000 27 466,000 21
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The effect asthma has on an individual's quality of life and the extent to which it may restrict daily activities is often
overlooked. Yet, it is an important part of understanding this condition and the benefits that effective treatment can
bring. Results from a 1998 survey conducted by the American Lung Association (ALA) highlight these quality-of-
life issues.

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The complete causes of asthma are unknown. Heredity does seem to play a role, as do allergens and environmental
factors. According to the latest Expert Panel Report (EPR) in 1997 from the National Heart, Lung, and Blood
Institute's National Asthma Education and Prevention Program, "Atopy, the genetic predisposition for the
development of an IgE-mediated response to common aeroallergens, is the strongest identifiable predisposing factor
for developing asthma."*

There are two categories of asthma: allergic or extrinsic and idiosyncratic or intrinsic. Allergic asthma is a result of
an antigen\antibody reaction on mast cells in the respiratory tract. This reaction causes the release of inflammatory
mediators from mast cells, which elicit the clinical response associated with an asthma attack. Idiosyncratic asthma
is a result of neurological imbalances in the autonomic nervous system (ANS) in which the alpha and beta-
adrenergic as well as the cholinergic sites of the ANS are not properly coordinated. Onset of asthma between the
ages of 5 to 15 years usually indicates asthma with an allergic basis.*

Studies suggest a genetic basis for airway hyper responsiveness, including linkage to chromosomes 5q and 11q.
However, asthma clearly does not result from a single genetic abnormality, but is rather a complex multigenic
disease with a strong environmental contribution. For example, allergic potential to inhalant allergens (dust mites,
mold spores, cat dander, etc) more commonly is found in asthmatic children as well as asthmatic adults whose
asthma began in childhood, compared with adult-onset asthmatics.*
Exposure to environmental allergens can trigger asthma symptoms. Among the most common allergens are
microscopic droppings of dust mites and cockroaches, airborne pollens and molds, plants and plant proteins,
enzymes, and pet dander (minute scales of hair, feathers, or skin). Exposure to a variety of occupational irritants
(e.g., vapors, dust, gases, fumes, tobacco smoke, air pollution) also can worsen or cause asthma!
pertain medications may trigger asthma symptoms. These include beta-blockers, used to treat high blood pressure,
heart disease, and glaucoma (in eye drops). About 5% to 20% of adults with asthma have attacks triggered by
sensitivities or allergies to medications such as aspirin, ibuprofen, indomethacin, and naproxen. Others react to
sulfites (chemicals commonly used to preserve foods such as tuna, salads, dried apples and raisins, and beverages
such as lemon juice, grape juice, and wine).
Other factors that may contribute to asthma or worsen symptoms include sinus infections, gastro esophageal reflux
disease (GERD), pregnancy, menstruation, and even the time of day. Asthma also can be induced by exercise or
cold air.
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Respiratory syncytial virus (RSV), rhinovirus, influenza,parainfluenza, Mycoplasma pneumonia

Airborne pollens (grass, trees, weeds), house-dust mites, animal danders, cockroaches, fungal
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pold air, fog, ozone, sulfur dioxide, nitrogen dioxide, tobacco smoke, wood smoke.
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Bakers (flour dust); farmers (hay mold); spice and enzyme workers; printers (Arabic gum);
phemical workers (azo dyes, anthraquinone, polyvinyl chloride); plastic, rubber and wood
workers; (Formaldehyde, western cedar, dimethylethanolamine, anhydrides)

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Airway inflammation is the primary problem in asthma. An initial event in asthma appears to be the release of
inflammatory mediators (e.g., histamine, tryptase, leukotrienes and prostaglandins) triggered by exposure to
allergens, irritants, cold air or exercise. The mediators are released from bronchial mast cells, alveolar macrophages,
T lymphocytes and epithelial cells. Some mediators directly cause acute bronchoconstriction, termed the "early-
phase asthmatic response." The inflammatory mediators also direct the activation of eosinophils and neutrophils, and
their migration to the airways, where they cause injury. This so-called "late-phase asthmatic response" results in
epithelial damage, airway edema, mucus hyper secretion and hyper responsiveness of bronchial smooth
muscle è
Varying airflow obstruction leads to recurrent episodes of wheezing, breathlessness, chest
tightness and cough.(

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cells interact in a complex manner and release multiple inflammatory mediators that act on
various target cells in the airways to produce the characteristic pathophysiology of asthma.

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PEF = peak expiratory flow; FEV1 = forced expiratory volume in one second;
FVp = forced vital capacity; FEV1/FVp% = FEV1 as percentage of FVp.
*--The initial classification is based on the presence of certain clinical features before treatment.
The presence of one of the features of severity is sufficient to place a patient in that category. A
patient should be assigned to the most severe grade in which any feature occurs. The
characteristics noted in this classification are general and may overlap because asthma is highly
variable. Furthermore, a patient's classification may change over time.

Mild Intermittent Asthma
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The level of asthma severity will determine the types of medicine required to get asthma under control.X

Another type of classification commonly seen is (
1. phronic asthma
2. Acute severe asthma
3. Allergic asthma
4. Exercise induced asthma
5. Nocturnal asthma

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A diagnosis of asthma usually is based on the patient's symptoms, medical history, a physical examination, and
laboratory tests that measure pulmonary (lung) function. Doctors typically look for signs that the patient's airflow is
obstructed and that the obstruction is at least partially reversible. Factors that trigger symptoms may be evident, such
as exercise, cold air, and exposure to an allergen; however, the precipitating factors may not be clearly identified.
Evidence of reversible airway obstruction is often detected in the physical examination or by physiologic testing.
Physiologic testing generally is recommended to confirm the diagnosis. During an asthma attack, wheezing can be
heard by listening to the chest with a stethoscope. The airway obstruction is considered reversible if the wheezing
disappears in response to treatment, or when the suspected triggering factor is removed or resolved.
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The most reliable way to determine reversible airway obstruction is with , a test that measures the amount
of air entering and leaving the lungs. This simple test can be performed in the physician's office.
Spirometry uses a measuring device called a that is connected by a flexible tube to a disposable
cardboard mouthpiece. The patient exhales and inhales deeply, then seals his or her lips around the mouthpiece and
blows as forcefully and for as long as possible until all the air is exhaled from the lungs.
Ideally, the patient should exhale for at least 6 seconds. The spirometer measures the amount of air exhaled and the
length of time it took to exhale it. The amount of air exhaled in the first second, expressed as "FEV1," is measured
and compared to the total amount exhaled. If the amount exhaled in 1 second is disproportionately low to the total
exhaled, the patient has an obstruction. To test for reversibility, the patient then inhales a bronchodilator (i.e., a drug
that widens the airways in the lungs) and the spirometry is repeated. If the values of the test performed after
administration of the bronchodilator are significantly better than the prebronchodilator values, the obstruction is
considered reversible.
Sometimes a patient with asthma does not demonstrate reversibility after the inhalation of a bronchodilator. In this
case, the patient may be treated for a few weeks with anti-inflammatory medications and then returns for another
spirometry test. If the post treatment spirometry results are better than the initial results, the obstruction is
considered reversible.

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Because asthma symptoms vary, it is not unusual for a patient with chronic asthma to have normal spirometry. In
such cases, %*#2,)3 monitoring may be used to demonstrate reversible airway obstruction.
A peak flow meter is a portable device that can be carried by the patient. It consists of a small tube with a gauge that
measures the maximum force with which one can blow air through the tube.
The patient performs the peak flow meter test twice a day for about 2 weeks and records the results for review in a
follow up appointment. The first test should be performed after waking in the morning, before taking bronchodilator
medications. The patient should perform the peak expiratory flow maneuver 3 times and record the highest
measurement. The second test should be done in the afternoon or early evening after taking a bronchodilator. Peak
flows vary during the day and the early morning peak is lower than the evening peak. A variability greater than 20%
indicates a reversible airway obstruction.

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Bronchial provocation, also known as bronchoprovocation and bronchial challenge, identifies and characterizes
hyperresponsive airways by having the patient inhale an aerosolized chemical, called a broncho-spastic agonist that
triggers a hyperresponsive reaction. The chemicals most often used are histamine and methacholine.
Patients perform spirometry without inhaling the agent and then inhale increasingly higher doses of the agent. After
each incremental dose inhalation, spirometry is performed. Patients who demonstrate a reduction in FEV1 of 20%
with a low dose of methacholine or histamine have nonspecific hyperresponsiveness. Although some patients
without asthma demonstrate hyperresponsiveness, most patients with a positive reaction have asthma.
The other common bronchoprovocation test is the exercise challenge test, which is used primarily with patients
whose asthma is triggered by exercise. The patient performs spirometry and then exercises, usually on a treadmill or
exercise cycle. The exercise test should resemble as closely as possible the conditions under which the symptoms
are usually triggered. After the patient exercises, spirometry is repeated. This may be done several times,
immediately after exercise and periodically, until there is a drop in the FEV1 greater than 20% or until 30 minutes
have elapsed.
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People with asthma have symptoms when the airways are narrowed (bronchospasm), swollen (inflamed), or filled
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The symptoms might also vary from one asthma episode to the next, being mild during one asthma episode and
severe during another.

Some people with asthma might have extended symptom-free periods, interrupted by periodic asthma episodes,
while others have some symptoms every day. In addition, some people with asthma might only have symptoms
during exercise, or when they are exposed to allergens or viral respiratory tract infections.

Mild asthma episodes are generally more common. Usually, the airways open up within a few minutes to a few
hours. Severe episodes are less common, but last longer and require immediate medical help. It is important to
recognize and treat even mild symptoms to help you prevent severe episodes and keep asthma in better control.Î

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Early warning signs are changes that happen just before or at the very beginning of an asthma episode. These
changes start before the well-known symptoms of asthma and are the earliest signs that a person's asthma is
worsening.

In general, these signs are not severe enough to stop a person from going about his or her daily activities. By
recognizing these signs, one can stop an asthma episode or prevent one from getting worse. Early warning signs
include:
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If early warning signs and symptoms are not recognized and treated, the asthma episode can progress and symptoms
might worsen. As symptoms worsen, one might have more difficulty performing daily activities and sleeping.
Symptoms of worsening asthma include:
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When asthma symptoms become severe, the patient will be unable to perform regular activities. If one has late,
severe symptoms, follow the "Red Zone" or emergency instructions in the Asthma Action Plan immediately. These
symptoms occur in life-threatening asthma episodes and the patient needs medical help right away. Late, severe
symptoms include:
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Those with asthma are at increased risk of developing problems associated with acid reflux, including the
development of gastroesophogeal reflux disease. Avoiding acid reflux can be aided by avoiding food or drink for

several hours prior to bedtime and sleeping with the head slightly elevated.

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A classification of asthma drugs based on current knowledge of their mode of action is represented in Table No 7.
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Anti-inflammatory treatment is recommended for all patients with asthma, except those that are
classified as mild intermittent asthma. Inhaled corticosteroids are the most widely studied and
recommended drugs in this class. Other drugs like sodium cromoglycate and nedocromil sodium
have weak selective anti-inflammatory effects and are of limited clinical value in adult asthma.

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Systemic absorption of inhaled corticosteroids arises from oropharyngeal and gastrointestinal

absorption and to a lesser extent from drug deposited in the lungs. This may be reduced by the
use of a spacer device combined with mouth washing after inhalation. The former increases the
fraction delivered to the lung. Both measures reduce the incidence of dysphonia and
oropharyngeal candidiasis.
Dry powder formulations result in similar or greater drug delivery to that of MDIs.
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Patients with poor asthma control should be assessed for the following:
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corticosteroids. This is supported by several studies which have shown that combining low dose steroids with
salmeterol or formoterol provides better asthma control compared than doubling the dose of inhaled corticosteroids.
LABAs are not suitable for acute relief of asthma exacerbations although formoterol has an acute onset of
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education should be staged over several visits. The use of nurse educators and other specially
trained healthcare professionals is cost-effective in this regard.
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pulmonologist are not available. The guidelines for referral are presented in Table No 10

YYY< YY**Y' YYY' +
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The method of assessment presented conforms to international assessment criteria.

The following points should be noted:

· The assessment of severity is outlined in Fig No 7., which is used to
assign a child to a particular treatment group

· The assessment of severity refers to a child's symptoms between acute attacks. The
assessment and management of the acute attack are dealt with in a separate document.

· Asthma presents as a spectrum of severity rather than in discrete severity groups.

Practitioners should attempt to grade each patient accurately but must regard this only as a
starting point.

· If unsure of grading, place the child on therapy appropriate to the severity group, which is
judged to be the most likely, and monitor control by means of a diary card (for symptoms
and/or PEF). Reassess after 4 weeks.

· One or more features may be present to assign a grade of severity; a patient must be
assigned to the most severe grade in which any feature occurs.

· Asthma severity can vary with time. Regular reassessment is necessary with a view to
stepping therapy up or down.

· The PEF is assessed at times other than during acute exacerbations. The predicted or the
best PEF, whichever is higher, should be utilised.

· In practice about 70% of childhood asthmatics will fall into the intermittent or
mild persistent', 25% into the 'moderate persistent' and 5% into the 'severe persistent'
categories{

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pockroach allergy is widespread. They may be a cause of ongoing airway inflammation and
sensitivity to cockroaches is a risk factor for more severe asthma. Obsessive cleaning, "bait
stations" and/or boric acid indoors can reduce cockroach numbers.

Asthmatics known to be allergic to dogs or cats should avoid contact with them. pat allergens
are notoriously difficult to eliminate and may persist for several months after the cat has been
removed from the home.

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treated with proper plumbing, damp proofing, mould repellent paint and Lysol sprays.

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exposure to mouldy places, e.g. farms, forests, compost heaps or parks, particularly in autumn,
winter and in spring.åmay be implicated in perennial asthma.

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Exercise induced asthma can be prevented by the use of a short-acting u2 agonist. LABA are
preferred for children who engage in repetitive exercise because of their prolonged duration of
action. Leukotriene antagonists are also an option for preventive treatment of exercise induced
asthma.

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These may be divided into additives, e.g. Preservatives and allergens. phildren with asthma
should avoid exposure to cooldrinks containing sulphur dioxide (SO2) and sodium benzoate.
Food allergens are a rare cause of asthma as an isolated manifestation. Milk allergy may play a
role in the child below the age of 2 years, especially with concomitant eczema.
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aa and a have weak anti-inflammatory effects. They are mainly of value in young
atopic patients with mild asthma. Their disadvantages include higher cost, frequent dosing interval and poor
efficacy in comparison with inhaled corticosteroids. Monitoring of symptoms and lung function is recommended
and inhaled corticosteroids should be substituted if control is inadequate after 6-12 weeks treatment. promones
may be tried in asthmatics with a persistent cough despite optimal treatment with corticosteroids. They are also
effective for the prevention of exercise induced asthma. Their main advantage is a good safety profile.
p. pONTROLLERS
These are agents that have prolonged bronchodilatory action, but weak anti-inflammatory effects. They include
the long-acting ß2 agonists and the slow release xanthines (theophyllines). Leukotriene antagonists may be also
classified as controllers.

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for mild persistent asthma in certain situations,(e.g. If inhaled corticosteroids unavailable or
patients prefer oral medication).
ñ Leukotriene receptor antagonists
Leukotriene receptor antagonists inhibit the effect of the cysteinyl leukotrienes, products of arachidonic acid
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inflammatory effects. LRAs have a role in moderate and severe persistent asthma as a steroid-sparing agent. The
role of these agents as monotherapy in mild persistent asthma still needs to be determined. A trial of treatment is
acceptable in this situation (maximum duration for 30 days). If asthma is not controlled on LRAs, switch to
inhaled steroids. phurg-Strauss syndrome, a form of systemic vasculitis, in association with the administration of
leukotriene antagonists in adults has been reported. To date, there are no reports of this condition in children.
OTHER DRUGS
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if children refuse to use spacers.

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devices and breath-actuated devices can be used successfully. Nebulisers should only be used in this age group in
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inefficiency of the delivery systems. Oral ß2 gonists and short acting theophyllines are not
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have recently been approved (by the FDA in the USA) for use in children aged 2 - 5 years.

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bioavailability and clinical outcomes with various doses.
Adapted from National Asthma Education and Prevention Program (National Heart, Lung, and Blood Institute)
Second Expert Panel on the Management of Asthma. Expert panel report 2: guidelines for the diagnosis and
management of asthma. Bethesda, Md.: National Institutes of Health, 1997; publication no. 97-4051.

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Step 1: mild
intermittent No daily medication needed
asthma
One daily medication:
Anti-inflammatory drug
Y Low-dose inhaled corticosteroid or cromolyn (Intal) or nedocromil (Tilade)
Y phildren usually begin with a trial of cromolyn or nedocromil
Step 2: mild
Y
persistent asthma Zafirlukast (Accolate) or zileuton (Zyflo) may also be considered in patients
12 years or older

Sustained-release theophylline to serum concentration of 5 to 15 µg

per mL is an alternative but not preferred therapy
One daily medication:
Medium-dose inhaled corticosteroid

Step 3: moderate
Two daily medications:
persistent asthma
Low- to medium-dose inhaled corticosteroid and long-acting
bronchodilator, especially for nighttime symptoms (either salmeterol
[Serevent], sustained-release theophylline or long-acting beta2 agonist
tablets)
Daily medications:
High-dose inhaled corticosteroid

Step 4: severe Long-acting bronchodilator (salmeterol, sustained-release
persistent asthma theophylline or long-acting beta2 agonist tablets)

Oral corticosteroid in a dosage of 2 mg per kg per day with the daily

dose generally not exceeding 60 mg

RL PHARMAI I AHMA MAAG M Y

Whether they work in community pharmacies, hospitals, or clinics, pharmacists are in a pivotal
position to contribute to the overall management of asthma. Every year, pharmacists fill more
than7 million prescriptions for asthma medications, which remain the principal treatment for the
disease. Pharmacists have many other opportunities to assisting he management of asthma.Y
Pharmacists can educate patients by providing information on the types and purposes of asthma
medications and by demonstrating how to use inhaled medications and peak flow meters. They
can reinforce and clarify the instructions contained in a patient's individual asthma management
plan. In addition, pharmacists can refer patients who use over-the-counter medications to
physicians for medical care Pharmacists can be valuable source of important information for
other members of the health care team. They can monitor medication use and refill intervals and
use this information to alert prescribers and help identify patients with poorly controlled asthma.
Pharmacists also can share information about asthma medications and the National Asthma
Education and Prevention Program guidelines on the diagnosis and management of asthma with
members of the health care team.Y

,
, Y

1. Educate patients about asthma medications.Y

2. Instruct patients about the proper techniques for inhaling medications.Y
3. Monitor medication use and refill intervals to help Identify patients with poorly
controlled asthma. Y
4. Encourage patients purchasing OTp asthma inhalers or tablets to seek medical care.Y
5. Help patients use peak flow meters appropriately.Y
6. Help patients discharged from the hospital understand their asthma management plan.Y

p'-,-,1&p'//Y

There are numerous areas where pharmacists can contribute to improving health outcomes in
patients with asthma.Y

Pharmacists can:Y

!)
$
!Y

Pharmacists can help patients understand that, with appropriate therapy, most patients can lead
normal, productive, and physically active lives. Pharmacist's can educate patients about the two
broad categories of asthma medications:Y

Medications used to prevent and/or decrease the frequency of symptoms. Y

Preventive medication should be taken on a regular basis even when the patient is free of
symptoms. This type of long-term medication includes inhaled anti-inflammatory agents such
ascorticosteroids, cromolyn, and nedocromil,which are preferred therapy. It may include
extended-release formulations of theophylline. Also included as long-term medication are
extended-release oral and long-acting inhaledbeta2-agonists, which are added to inhaled
corticosteroidswhen the recommended doses of inhaled corticosteroids are not sufficient to
control chronic symptoms, especially nighttime symptoms. Preventive long-term medication also
may include, for severe asthma, alternate day oralcorticosteroid therapy. In addition, the use of a
short- or long-acting inhaled beta2-agonists or cromolyn beforeexercise to prevent exercise-
induced bronchospasm falls into the "prevention" category. Y

Medications taken to relieve asthma symptoms.Y

Medications in this category are designed to relieve symptoms and generally are prescribed to be
taken only as needed (PRN). This therapy includes primarily short-acting inhaled beta2-agonists
(albuterol, bitolterol, pirbuterol,or terbutaline). In addition, a short course of oralcorticosteroids
for patients who are not fully responsive to inhaled bronchodilators may be used to treat acute
exacerbations of asthma.Y

An effective asthma management plan should ensure that the patient is given written and verbal
instructions that describe when and how a medication should be taken, how much to take, how to
evaluate the response to therapy, when to seek medical care, and what to do when the desired
effect isn't achieved or side effects are encountered. Pharmacists can reinforce these instructions
by reminding patients, for example, to contact their physician when acute symptoms are not
relieved by using their short-acting beta2-agonists inhaler as directed or when their peak
expiratory flow rate (PEFR) drops below a predetermined value.Y

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,p
Y

Any one of the following criteria may indicate the need for medication adjustment, improved
medication administration technique, or patient education concerning asthma and its
management:Y

ñY Adverse effects from medications.Y
ñY Waking up at night from symptoms of asthma more than twice a month.Y
ñY Increased use of inhaled, short-acting beta2-agonistsY
(E.g., more than three to four times in 1 day).Y
ñY Long-term overuse of inhaled, short-acting beta2-agonists (e.g., refilling the prescription more
often than one canister/month or more than one canister/2 months of a short-acting agent when it
is used in addition to a long-acting agent).Y
ñY Overuse or misuse of inhaled long-acting beta2-agonists.Y
ñY No adherence to anti-inflammatory medications (e.g., refilling the prescription less than half as
often as would be required if the directions on the prescription were followed).Y
ñY Failure to achieve quick and sustained response (i.e., beginning within 10 to 20 minutes and
lasting longer than 3 to 4 hours) to short-acting beta2-agonists during an acute asthma episode
(as measured by a decrease in symptoms or an increase in peak expiratory flow rate).Y
ñY Poor tolerance to physical activity (i.e., the patient experiences symptoms of exercise-induced
asthma).Y
ñY Missing school or work because of asthma symptoms. Y
ñY An emergency department visit or hospitalization for asthma.Y

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Y

Inhaled medications are preferred over oral therapies. However, a major limitation in their
effectiveness is the patient's ability to use the device appropriately. Studies suggest that members
of the health care team (e.g., physicians, nurses, and pharmacists) may not adequately instruct
patients on how to use a metered-dose inhaler (MDI). Improper MDI technique can be one cause
of a poor response to therapy. Pharmacists can play an important role on the health care team by
teaching patients with asthma about proper medication technique. Other devices, such as dry
powder inhalers, breath-actuated inhalers, and nebulize, are also available, and they require
different techniques for administration. A placebo inhaler, which can be obtained from
pharmaceutical manufacturers, and instructional videos, may be useful in demonstrating properY
technique.Y

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!Y

During symptomatic periods, selective short-acting inhaledbeta2-agonists may be sufficient to

relieve asthma symptoms. When asthma is stable, it is preferable to use these agents on an as-
needed basis. Overuse and over reliance on short-acting inhaled beta2-agonists can be signs that
asthma is poorly controlled. During an exacerbation, patients may increase the dose and/or
frequency of use, which may lead toa delay in seeking appropriate medical care.Y

Pharmacists may find indications of chronic overuse of medical history and the frequency of
refills. Overuse can be defined as using more than one canister per month of short- or long-acting
beta2-agonists or more than one canister of a short-acting beta2-agonists in 2 months when used
in conjunction with a long-acting agent. Pharmacists should also monitor for overuse of a long-
acting beta2-agonists (e.g., salmeterol). In general, these agents should not be used more than
twice a day and are not appropriate to relieve acute symptoms. Y

If overuse is noted, pharmacists should alert the physician, who can assess the need for
reevaluation of the patient and consider whether the patient needs to initiate or intensifyAnti-
inflammatory therapy. Before contacting the physician, pharmacists should have the patient
demonstrate his or herMDI technique. Poor technique may be one of the causes of Overuse of an
MDI. The physician will find this information useful in making a decision on how to respond to
the situation. Physicians also may want to evaluate recent trends in peak flow meter readings.Y

Physicians will consider several factors when deciding whether to initiate or increase anti-
inflammatory therapy. In general, a short course of oral corticosteroids may be indicated if the
excessive use of an MDI is short term; due to an acute, severe episode; or the result of an isolated
exacerbation caused by a common cold or other upper respiratory tract infections. The initiation
or dose increase of an inhaled anti-inflammatory agent (corticosteroids, cromolyn, or
nedocromil) as long-term therapy may be indicated if the patient relies on short-acting inhaled
beta2-agonists daily to relieve symptoms, has frequent fluctuations in the peak expiratory flow
rate, or has other signs of poorly controlled asthmaY

Patients on preventive therapy for asthma also should be monitored for signs of no adherence to
anti-inflammatory therapy. In some cases, patients do not adhere toanti-inflammatory therapy
because they do not understand the purpose of or perceive any immediate benefit from this
Therapy. Some patients may be discouraged about following their prescribed regimen because
they fear adverse reactions longer than indicated by the directions for use on the Prescription
may indicate no adherence. For example, if an inhaled anti-inflammatory agent contains 100
puffs and the directions are to take 2 puffs twice a day, a patient refilling the prescription once
every 60 days is underusingthe medication. In this example, the canister should be depleted in 25
days (100 puffs divided by 4 puffs per day =25 days).Y

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Asthma is one of the very few potentially fatal diseases for which OTp products are available for
self-treatment. Use ofOTp inhalers may lead to a delay in seeking appropriate medical care.
Pharmacists should refer anyone using an OTp product for respiratory symptoms to a physician
for diagnosis, regular monitoring, and proper treatment. The physician can then determine the
need for other therapies, such as an inhaled anti-inflammatory agent to preventY

Over-the-counter inhalers contain epinephrine, which is anon selective, weak, and extremely
short-actingbronchodilator. Thus, if physicians determine that the PRNuse of an inhaled
bronchodilator is indicated, they can that will provide greater efficacy and a longer duration of
pombination of ephedrine and theophylline. Generally, bronchodilators are less effective and
cause more side effects when administered by the oral route; and combinations of theophylline
and ephedrine have the potential to cause synergistic toxicity.Y

X!1
%# !Y

It is recommended that clinicians consider peak expiratory flow rate monitoring for patients over
5 years of age with moderate or severe asthma. Regular home monitoring may detect decreased
lung function and signs of an impending asthma episode before it become more severe. The
PEFR is the greatest flow velocity that can be obtained during a forced expiration starting with
fully inflated lungs. It provides a simple, quantitative, and reproducible measure of airway
obstruction with a relatively inexpensive device that is available without a prescription.Y

Measuring PEFR in a patient with asthma is analogous to measuring blood pressure with
sphygmomanometer or blood glucose to guide insulin dosage. The PEFR is used by the
Physician to assess the severity of asthma as a basis for adding medication, monitoring response
to chronic therapy, and detecting deterioration in lung function before symptoms develop. The
physician may consider more aggressive therapy if the patient's highest value is less than 80
percent of predicted value and/or daily variability is more than 20Y

Pharmacists should discuss the following items with patients:Y

Y The intended purpose of a peak flow meter Y

(2) How to use it and record the values. The patient's physician should develop an individualized
plan for the use of the peak flow meter. The plan should include a threshold value and
instructions on what the patient should do if the PEFR drops below this value (e.g., increase
medication, call the physician, or seek emergency medical care).Y

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Every patient being discharged from the hospital for the treatment of acute asthma should receive
and understand an individualized asthma management plan. An asthma management plan should
include specific written instructions for patients and families. Hospital pharmacists can discuss
such a plan with a patient before discharge, reinforcing and clarifying instructions that have been
designed to prevent subsequent hospitalizations or emergency department visits. Pharmacists
also can review the patient's inhaler and peak flow meter technique and provide instruction, if
needed. Y

;
,

XY

Written guidelines should include the following points:Y

ñY Specific instructions about use of medications, including dose, frequency of administration,

guidelines for changing dose or adding medications if appropriate, and adverse effects to report
to the clinician.Y
ñY The importance of long-term preventive medications.Y
ñY How to monitor body signs or symptoms and/or PEFR to detect increasing airflow obstruction as
early as possible; early signs of airflow obstruction vary according to the individual and should
be identified for each patient.Y
ñY priteria for initiating or modifying treatment: a drop in PEFR or early signs or symptoms.Y
ñY List of steps to take in managing an acute asthma episode i.e., remove the precipitating trigger,
give medication, avoid strenuous physical activity, and keep patient and family calmY
ñY Specific criteria for seeking emergency medical care, including a pattern of declining PEFR;
failure of medications at home to control worsening symptoms; difficulty in breathing (wheeze
may be absent), walking, or talking; intercostal retractions; blue fingernails or lips.Y
ñY Observable signs that long-term therapy is less than optimal, such as asthma symptoms that
cause sleep interruption, consistently low or highly variable PEFR,and/or too frequent use of
short-acting inhaled beta2-agonists. Such signs should be promptly discussed with the clinician.Y

pp 3

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Asthma

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Asthma

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Asthma is a chronic disease characterized by recurrent attacks of breathlessness and wheezing,

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Age Increase from Increase from Increase from

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Respiratory syncytial virus (RSV), rhinovirus, influenza,parainfluenza, Mycoplasma pneumonia

Anxiety, stress, laughter.

Particularly in cold, dry climate

Aspirin, NSAIDS (pyclooxygenase inhibitors), sulfites, benzalkonium chloride, Beta-blockers

Î!,    . According to the current view, several inflammatory

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Mild Persistent Asthma 

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Moderate Persistent Asthma 

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evere Persistent Asthma 

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Another type of classification commonly seen is (

2. Acute severe asthma

4. Exercise induced asthma

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pough (worse at night)

Symptoms occurring or worsening at night, awakening the patient

Airflow obstruction at least partially reversible

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