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ASTHMA MANAGEMENT:

STEPWISE APPROACH
Olesia Zigah (Mrs.)
MSc Pharm.

23/01/2004

Definition of Asthma

Asthma is a chronic inflammatory disorder


of the airways in which many cells and
cellular elements play a role

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Mechanisms Underlying the


Definition of Asthma
Risk Factors
(for development of asthma)

INFLAMMATION
Airway
Hyperresponsiveness

Risk Factors
(for exacerbations)
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Airflow Obstruction

Symptoms

Control of Asthma
Goals of Pharmacotherapy

Minimal (ideally no) chronic symptoms

Minimal (infrequent) exacerbations

No emergency visits

Minimal (ideally no) need for as needed use of


2-agonist

No limitations on activities, including exercise

PEF circadian variation of less than 20 percent

(Near) normal PEF

Minimal (or no) adverse effects from medicine


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Classification of Severity
CLASSIFY SEVERITY

Clinical Features Before Treatment


Symptoms
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent

Continuous
Limited physical
activity
Daily
Attacks affect activity
> 1 time a week
but < 1 time a day

Nocturnal
Symptoms
Frequent

> 1 time week

> 2 times a month

FEV1 or PEF
60% predicted
Variability > 30%
60 - 80% predicted
Variability > 30%
80% predicted

Variability 20 - 30%

< 1 time a week


STEP 1
Intermittent

Asymptomatic
and normal PEF
between attacks

2 times a month

80% predicted
Variability < 20%

The presence of one feature of severity is sufficient to place patient in that category.

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Pharmacologic Therapy
Controller Medications:
Inhaled

glucocorticosteroids
Systemic glucocorticosteroids
Cromones
Methylxanthines
Long-acting inhaled -agonists
2
Long-acting

oral 2-agonists

Leukotriene

modifiers

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Anti-IgE

Pharmacologic Therapy
Reliever Medications:
Rapid-acting
Systemic

inhaled 2-agonists

glucocorticosteroids

Anticholinergics
Methylxanthines
Short-acting

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oral 2-agonists

Establish Medication Plans for LongTerm Asthma Management in Infants


and Children

Childhood and adult asthma share the


same underlying mechanisms.
However, because of processes of
growth and development, effects of
asthma treatments in children differ
from those in adults.
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Establish Medication Plans for LongTerm Asthma Management in Infants


and Children

Many asthma medications (e.g.


glucocorticosteroids, 2- agonists,
theophylline) are metabolized faster in
children than in adults, and younger
children tend to metabolize medications
faster than older children
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Establish Medication Plans for LongTerm Asthma Management in Infants


and Children

Long-term treatment with inhaled


glucocorticosteroids has not been shown to
be associated with any increase in
osteoporosis or bone fracture
Studies including a total of over 3,500
children treated for periods of 1 13 years
have found no sustained adverse effect of
inhaled glucocorticosteroids on growth
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Establish Medication Plans for LongTerm Asthma Management in Infants


and Children

Rapid-acting inhaled 2- agonists are


the most effective reliever therapy for
children
These medications are the most
effective bronchodilators available and
are the treatment of choice for acute
asthma symptoms
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Stepwise Approach to Asthma Therapy: Children

Step 1: Intermittent Asthma


Daily Controller
Medications
None required

Reliever
Medications
Rapid-acting inhaled 2-agonist
for symptoms (but < once a week)
Rapid-acting inhaled 2-agonist,
cromone, or leukotriene modifier
before exercise or exposure to
allergen

Continuously review medication technique, compliance and environmental control


Review treatment every three months.
Step up if control is not achieved; step down if control is sustained for at least 3 months
Preferred treatments are in bold print

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Stepwise Approach to Asthma Therapy: Children

Step 2: Mild Persistent Asthma


Daily Controller
Medications

Reliever
Medications

Low-dose inhaled
glucocorticosteroid

Rapid-acting inhaled 2-agonist


for symptoms (but < 3-4 times/day)

Other options:
sustained-release theophylline, or
Cromone, or
leukotriene modifier (for patients
12 of age)

Other options:
inhaled anticholinergic, or
short-acting oral 2-agonist, or
short-acting theophylline

Continuously review medication technique, compliance and environmental control.


Review treatment every three months
Step up if control is not achieved; Step down if control is sustained for at least 3 months
Preferred treatments are in bold print

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Stepwise Approach to Asthma Therapy: Children

Step 3: Moderate Persistent Asthma


Daily Controller
Medications
Low- to medium-dose inhaled glucocorticosteroid, plus long-acting inhaled 2-agonist
Other options:
Medium-dose inhaled glucocorticosteroid plus
sustained-release theophylline, or
High-dose inhaled glucocorticosteroid, or
Medium-dose inhaled glucocorticosteroid plus
leukotriene modifier

Reliever
Medications
Rapid-acting inhaled
2-agonist for symptoms
(but < 3 - 4 times/day)
Other options:
inhaled anticholinergic or
short-acting oral
2-agonist or
short-acting theophylline

Continuously review medication technique, compliance and environmental control.


Review treatment every three months.
Step up if control is not achieved; Step down if control is sustained for at least 3 months.
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Preferred treatments are in bold print.

Stepwise Approach to Asthma Therapy: Children

Step 4: Severe Persistent Asthma


Daily Controller
Medications
High-dose inhaled glucocorticosteroid,
plus long-acting inhaled 2agonist
plus one or more of the following, if
needed:

sustained-release theophylline, or
leukotriene modifier or
oral glucocorticosteroid

Reliever
Medications
Rapid-acting inhaled
2-agonist for symptoms
(but < 3-4 times/day)
Other options:
inhaled anticholinergic or
short-acting oral
2-agonist or
short-acting theophylline

Continuously review medication technique, compliance and environmental control.


Review treatment every three months.
Step up if control is not achieved; Step down if control is sustained for at least 3 months.
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Preferred treatments are in bold print.

Estimated Comparative Daily Dosages


for Inhaled Glucocorticosteroids
Drug

Low Daily Dose


( g)
Child

Medium Daily Dose


( g)
Child

High Daily Dose ( g)


Child

BeclomethasoneCFC

100-250

250-500

> 500

BeclomethasoneHFA

50-200

200-400

> 400

Budesonide-DPI

100-200

200- 600

> 600

250-500

500-1000

>1000

Flunisolde

500 -750

750-1250

> 1250

Fluticasone

100-200

200- 400

> 400

Triamcinolone
acetonide

400-800

800-1200

> 1200

Budesonide-Neb

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Step down
Review treatment every 3 month; a
gradual stepwise reduction in
treatment may be possible.
Step up
If control is not maintained consider
step up. First, review patients
medication technique, adherence,
and environmental control.
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Notes

The stepwise approach is intended to


assist, not replaced, the clinical
decision making.
Classify severity: assign patient to
most severe step in which any
feature occurs.
Gain control as quickly as possible
(a course of short systemic
corticosteroids may be required)
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Quick Relief Medications

Bronchodilator as needed for symptoms.


Intensity of treatment will depend upon
severity of exacerbations.
- Preferred treatment: Short-acting inhaled
beta2-agonists by nebulizer or face mask
and space/holding chamber.
- Alternative treatment: Oral beta2agonist.

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Summary

Asthma can be effectively controlled,


although it cannot be cured
Effective asthma management programs
include education, objective measures of
lung function, environmental control, and
pharmacologic therapy
A stepwise approach to pharmacologic
therapy is recommended. The aim is to
accomplish the goals of therapy with the
least possible medication
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Anything more than mild, occasional


asthma is more effectively controlled
by suppressing inflammation than by
only treating acute bronchospasm
The availability of varying forms of
treatment, cultural preferences, and
differing health care systems need to
be considered
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