STEPWISE APPROACH

IN LONGTERM
MANAGEMENT OF
ASTHMA IN CHILDREN
 Inflammation in asthma
Inflamasi akut

Steroid
response

Chronic inflammation

Structural changes

Time

Barnes PJ
Target of long-term asthma treatment

Normal daily life good control of 1. Symptom

activity symptoms control

Minimize risk of
Minimize
exacerbation &
medication side
2. Risk
fixed airway
effect Reduction
limitation
Steps of asthma diagnosis

Made within 6 weeks,

can be less than 6 weeks
if clinical information
is strongly confirmed.

Made after 6 weeks,

experiencing initial
longterm treatment
Tabel 4.2. Kriteria penentuan derajat asma
Classification
Klasifikasi of Asthma
kekerapan dibuat pada kunjungan-kunjungan awal dan Severity
dibuat berdasarkan
(PNAA 2015)
anamnesis:

Derajat asma Uraian kekerapan gejala asma

Intermiten Episode gejala asma <6x/tahun atau jarak antar gejala ≥6 minggu
Persisten ringan Episode gejala asma >1x/bulan, <1x/minggu
Persisten sedang Episode gejala asma >1x/minggu, namun tidak setiap hari
Persisten berat Episode gejala asma terjadi hampir tiap hari
When to initiate controllers
administration
Asthma differential diagnosis is ruled out

Non pharmacology management (triggers avoidance) is already done

Asthma comorbid factors such as allergic rhinitis,

rhinosinusitis or GER have already been managed

Asthma frequency classification is persistent asthma (mild,

moderate, severe)
Stepwise approach to control
symptoms and reduce risk of
asthma attack in children > 5
years
STEPS IN LONG TERM TREATMENT OF ASTHMA
FOR CHILDREN > 5 YEARS

Keterangan gambar: ICS (inhaled corticosteroids, steroid

inhalasi); LTRA (Leukotriene Receptor Antagonist);
SABA (short acting beta agonist, agonis β2 kerja pendek);
LABA (long acting beta agonist, agonis β2 kerja panjang)
 Stepwise approach to control
symptoms and reduce risk of asthma
attack in children < 5 years
PNAA 2015 : Diagnostic Spectrum &
Criteria of Asthma in children < 5 years old ( Asma Balita )
!!
Gejala (batuk,
wheezing,sulit bernapas)
≤10 hari, selama IRA
2-3 episode/thn
Gejala (batuk, Gejala (batuk, wheezing,
wheezing,sulit bernapas) susah bernapas ) > 10 hari,
selama IRA
>10 hari, selama IRA >3 episode/thn, atau
>3 episode/thn, atau episode berat dan/atau
episode berat dan/atau perburukan malam hari
perburukan malam hari !
! !

Tidak ada gejala!di antara Di antara episode anak Di antara episode anak
episode mungkin batuk, wheezing batuk, wheezing atau sulit
atau sulit bernapas bernapas saat bermain
atau tertawa!

Riwayat alergi pada Riwayat alergi pada

Riwayat alergi pada
keluarga (-) keluarga (+)
keluarga (-)
' '
MUNGKIN'BUKAN'ASMA' MUNGKIN''ASMA' SANGAT MUNGKIN ASMA'
! !
!

Keterangan: Skema di atas menggambarkan bahwa asma pada balita merupakan suatu
spektrum yang dinamis, semakin ke kanan pola gejala yang ditemui, maka makin kuat
dugaan ke arah asma, dan seorang pasien dapat berubah posisinya seiring waktu.
!

Gambar 9.1. Skema kemungkinan asma pada balita (Modifikasi GINA 2015)
Steps in longterm treatment
CHIDREN < 5 years
Controllers therapy steps
• Initial step in long term management is to define asthma
1 frequency classification

• If a step in therapy has lasted for 6-8 weeks and asthma

2 still uncontrolled, then step up therapy

• If a step in therapy has lasted for 8-12 weeks and

3 asthma is well controlled, then step down therapy

• Stage change in management must considers triggers

4 avoidance and comorbid diseases management

• At step 4, if asthma still uncontrolled, add omalizumab

5 to therapy
 Steps in asthma
long term management

6-8
weeks

8-12
weeks
Level of asthma control

• to evaluate the management

• as a base for step up or step down of the therapy
1. Papadopoulus NG, Arakawa H, Carlsen KH, Custovic A, Gern J, Lemanske R et al. International consensus on (ICON) pediatric asthma. Allergy 2012.
2.The Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention 2014. Available from: www.ginasthma.org
4. Hamasaki Y, Kohno Y, Ebisawa M, Kondo N, Nishima S, Nishimuta T et al. Japanese Guideline for Childhood Asthma 2014. Allergol Inter 2014; 63:335-56.
Assessment of symptom control
Partially
In the past 6 Well-
controlled Uncontrolled
weeks controlled
(Min. one)
Daytime asthma None
> 2 x/week
symptoms (< 2 x/week) 3-4
Activity limitation None Yes conditions
Night waking None Yes of partly
None controlled
Reliever needed > 2 x/week
(< 2 x/week)
How often should asthma be reviewed ?

§ First time after controller • Symptoms

started: 2 wks – 1 mo • Exacerbations
§ Then every 1-3 months • Side-effects
à then every 3-12 mo • Patient
§ After an exacerbation: satisfaction
within 1 week • Lung function

GINA 2015
 Step up asthma treatment

GINA 2015
 Omalizumab or oral corticosteroid

6-8 weeks
High dose Mod dose High dose Mod dose
ICS ICS ICS + LTRA ICS + TSR
+ LABA
6-8 weeks
Mod dose Low dose Low dose Low dose
ICS ICS ICS + LTRA ICS + TSR
+ LABA
6-8 weeks
Low dose ICS OR LTRA
 Stepping down asthma treatment

GINA 2015, Box 3-7

 High dose ICS Mod dose ICS
+ LABA
> 3 months
Reduce ICS dose by 50% and continue second controller

Moderate dose ICS Low dose ICS + LABA

> 3 months
Reduce ICS dose by 50% Reduce ICS/LABA to once daily

Low dose ICS Once daily ICS/LABA

> 3 months
STOP only if: no symptoms
Once daily dosing for 6–12 months, and
patient has no risk factors
 Inhaled corticosteroid (ICS)
• Drug of choice

• The most effective

 ICS in asthma

At a cellular level, ICS reduce the number of inflammatory cells in

the airways, including eosinophils, T lympho-cytes, mast cells, and
dendritic cells.
LTRA

52
Controller drug
Inhaled cortico-steroid, dosages
Inhaled corticosteroid: how high can you go?
Dose - response curve for ICS

90% max

Clinical effect

Clinical
Benefit
Adverse effect

0 50 100 200 400 600 800 1000

Daily dose of inhaled steroid (FP ug)
Pedersen et al. Allergy. 1997;52:1-34.
Step up
Drug Design, Development and Therapy
Paediatric Respiratory Reviews 16 (2015) 97–100 Dovepress
open access to scientific and medical research

Open Access Full Text Article REVIEW

Clinical effectivenessContents
andlistssafety of montelukast
available at ScienceDirect

in asthma. What are the conclusions from clinical

Paediatric Respiratory Reviews
trials and meta-analyses?
Montelukast has a place in:
Drug Design, Development and Therapy 2014:8 839–850
• Children with mild persistent asthma who do not
Kam Lun Ellis Hon 1 Abstract: Asthma is a common childhood atopic disease associated with chronicity and
Ting Fan Leung 1 impaired quality of life. As there is no cure for this disease, treatment relies on avoidance of

response
Mini-Sympoisum:
Alexander KC Leung 2
1
Department of Paediatrics,
to low
Childhood asthma: dose The fuss ICS and the future
triggers such as food and aeroallergens, the use of inhaled bronchodilators/corticosteroids and
antiallergic or immunomodulating therapies. Inhaled corticosteroids (ICSs) and bronchodilators

the treatment
•Montelukast of young asthma:children where we with viral-triggered
The Chinese University of Hong have been the mainstay. However, in Asia, myths and fallacies regarding Western medicine and
Kong, Prince of Wales Hospital,
Shatin, Hong Kong; 2 Department
of Pediatrics, The University
in paediatric are now and what still
corticosteroids are prevalent and lead to nonadherence to treatment. Also, use of traditional
and proprietary herbal medicines is popular. In the past decades, a novel class of nonsteroidal

wheezing diseases or exercise-induced asthma

immunomodulating montelukasts has become available. This article reviews the evidence for the
of Calgary, Calgary, AB, Canada
§
needs to be done? effectiveness and clinical efficacy of these medications. A number of randomized and controlled
trials have been performed over the years. The majority of studies confirm the usefulness of

•Andrew childrenBush * whose parents are steroid-phobic and if ICS

montelukast as monotherapy and add-on therapy to ICS in mild to moderate childhood asthma
across all age groups. ICSs are generally superior to montelukasts for asthma management.
However, montelukast has a place in the treatment of young children with viral-triggered

Professoris unacceptable. wheezing diseases, exercise-induced asthma, and in children whose parents are steroid-phobic
of Paediatrics and Head of Section (Paediatrics), Imperial College, Professor of Paediatric Respirology, National Heart and Lung Institute, Consultant
and find ICS unacceptable.
Keywords: cysteinyl leukotriene receptor antagonist, inhaled corticosteroid, randomized control
Paediatric Chest Physician, Royal Brompton Harefield NHS Foundation Trust
trial, meta analysis Paediatric Respiratory Reviews 16 (2015) 97–100

Introduction
EDUCATIONAL AIMS Asthma is a common, complicated chronic disorder of the airways and is characterized
by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsive-
ness, and underlying inflammation. The Canadian Asthma Consensus guidelines
The reader will come to appreciate that:
suggest that asthma should be considered in individuals who present clinically with
recurrent symptoms of breathlessness, chest tightness, wheezing or cough, and signs
Anti-leukotriene therapy in asthma

Wanzel SE. Middleton’s Allergy, 8th edition

Adherence Is a Key Determinant of the
Effectiveness of Drug Therapy

Oral vs. Dosing Side

inhaled frequency effects

Cost

Effectiveness = Efficacy + Adherence

Patient
“Does it work?” “Can it work?” education
(e.g., controlled
clinical data)
Inhalation Onset of
technique action

Adapted from Simon et al J Clin Epidemiol 1995;48:363–373; Sacristán JA et al Clin Ther 1997;19:1510–1517; Kemp JP, Kemp JA Am Fam
Physician 2001;63:1341–1348, 1353–1354; Kelloway JS et al Arch Intern Med 1994;154:1349–1352; Bender BG, Bender SE Immunol Allergy Clin
North Am 2005;25:107–130; Rand CS Eur Respir Rev 1998;8:270–274.
Principals in evaluation of
long term asthma management

• Asthma control has to be monitored regularly depends on

patient’s condition, asthma severity, or other comorbid
diseases that accompany asthma

• In general, a patient is monitored every month and

achievement of improvements after 3 months

• Besides type of drugs, dose, route of administration, and

compliance, asthma patient need to be monitored for
triggers avoidance and any comorbid diseases that
accompany asthma

• Steroid dose reduction is considered every 8-12 weeks, as

much as 25 – 50%
 General principles of the treatment

• Establish a patient-doctor partnership

1

• Environmental management ] AVOIDANCE

2

• Provide asthma medication

3

• Control based management

4
 General Principle of Asthma Management

The Cycle of Asthma

The goal of long-term asthma Management
management:
§ Achieving asthma control • Diagnosis
• Control symptoms & risk
§ Minimizing the risk of exacerbations factors (including pulmonary
function)
§ Improve airway limitation • Inhalation & compliance
techniques
§ Minimizing side effects • Symptoms • Patient choice
• Exacerbation
• Side effects
• Patient Satisfaction
§ Control-based asthma management: • Lung function

treatment is adjusted in a continuous Asthma medicine

cycle of assessment, treatment, and Non-pharmacological strategy

Modifiable risk factor treatment
review of responses. Review of
responses is carried out every 3 months.

Global Initiative for asthma. Global strategy for asthma management and
35 prevention, 2018. Available from: www.ginasthma.org
 Control Based Approach

ALL CHILDREN
• Assess symptom control, future risk, comorbidities
• Self-management: education, inhaler skills, written asthma action plan, adherence
• Regular review: assess response, adverse events, establish minimal effective treatment
• (Where relevant): environmental control for smoke, allergens, indoor/outdoor air pollution

KEY ISSUES

GINA 2016
GINA 2016, Box 6-5 (4/8)
 Communication, information, and education for children
Communication, information, and education for family
Communication, information, and education for schools

IMPORTANT

National Heart, Lung, and Blood Institute. National asthma education and prevention program expert panel report 3: guidelines
for the diagnosis and management of asthma full report 2007.
Asthma Action Plan (AAP) (1)
Asthma Action Plan (AAP) (2)
Conclusions
we can control
chronic inflammation
drug that can control