Hiew Jing Yee

Tay Kai Ching

Tiffany Ng
Overview of Asthma
● Definition: Obstructive  respiratory disorder with genetic and environmental origins
○ Increased sensitivity/responsiveness to certain stimuli

Shortness
of breath

Coughing
Symptoms

Wheezing

Chest
tightness

(Asthma and Allergy Foundation of America, n.d.)

1. Moodle Monash. 2018. Pathophysiology, diagnosis, assessment of asthma. https://lms.monash.edu/mod/book/view.php?id=4846500&chapterid=341884

2. https://community.aafa.org/blog/what-happens-in-your-airways-when-you-have-asthma
 Role of Pharmacist

Role of Pharmacist

Education &
Follow-up
Counselling

Medications
Disease overview & (treatment) & Asthma control
how to identify Side effects
Inhaler Technique & status, adherence etc.
triggers and Importance of
recognise symptoms Medication
Adherence
1. Respiratory medication therapy adherence clinic protocol: Asthma/COPD (Adult & pediatric) 2nd edition. 2015.
http://jknj.jknj.moh.gov.my/farmasi/garispanduan2/[2015]%20Book.%20Protocol%20Respiratory_2.6_FA.pdf
(GINA, 2019.)
Case Presentation
 Patient
Info
Name: Ms P.M.

Age: 30

Allergy: NKDA

Social History: Non-smoker, non-alcoholic.

Diagnosed with asthma since 2015

Asthma Assessment
 Asthma Control Status Timeline
Date Asthma Control Status Treatment Regimen

21/3/2018 N/A Start MDI Salbutamol 100 mcg 2 puffs

PRN

9/1/2019 Uncontrolled Start MDI Budesonide 200 mcg 2 puffs

BD
+ MDI Salbutamol 100 mcg 2 puffs
PRN

20/3/2019 Uncontrolled- Same drug regimen as above

2° to non-compliance to
MDI BUdesonide

19/6/2019 Controlled Same drug regimen as above

24/7/2019 Controlled Same drug regimen as above

23/10/2019 Partly Controlled - Same drug regimen as above

2° to cold/URTI

22/1/2020 Partly Controlled Current medications:

(Latest) MDI Budesonide 200 mcg 2 puffs TDS
Pharmaceutical Care Issues (PCIs)
 PCI

PCI Pharmacist’s Outcome

recommendation

1 Patient’s asthma symptoms were not To start Only MDI

well controlled. MDI Salbutamol 2 MDI Salbutamol Salbutamol
puffs PRN was started. 2 puffs PRN 2 puffs PRN
and was started.
MDI Budesonide
1 puff PRN
 Rationale

Based on GINA
(2011.), as-needed
salbutamol is
recommended as the
only treatment for
Step 1 Asthma.
 Rationale

Low-dose ICS and

SABA PRN is
recommended as Step 1
asthma management
according to GINA
(2019).
 Role of Inhaled
Corticosteroids

ICS suppresses airway

inflammation,
reduces airway hyper-
responsiveness and
hence, able to control
asthma symptoms.
WHY is GINA no longer recommending SABA-only
treatment for Step 1 Asthma?
Hence, ICS-containing
regimen should be initiated
starting Step 1 Asthma

>50 years ago: However, management.

Asthma Disease of AIRWAY INFLAMMATION

BRONCHO- is found in most patients.
CONSTRICTION *even those with intermittent or
infrequent symptoms

“Although SABA provides quick relief of symptoms, SABA-only treatment is

associated with increased risk of exacerbations and lower lung function.
 Rational
e
SABA → bronchodilation ● SABA’S function: bronchodilation,
(by relaxing the airway not able to treat the underlying
smooth muscles) inflammation
● SABA-only treatment can’t
suppress airway inflammation
and hence, asthma progresses.
Inflammation- ● SABA reliever monotherapy
induced can increase risk of asthma-
Bronchoconstriction
related death due to under-
treatment of inflammation 1,2.
● Therefore, low-dose ICS has
been added to the Step 1
Low-dose ICS →
Asthma Management on top of
reduce airway inflammation
SABA.
1. Suissa S et al. Am J Respir Crit Care Med 1994;149:604-10
2. Suissa S et al. N Engl J Med 2000;343:332-6
 PCI

PCI Pharmacist’s Outcome

recommendation

2 Patient’s symptoms remained not To start with Medium-dose

well controlled, doctor prescribed low-dose ICS ICS MDI
MDI Budesonide 2 puffs BD MDI Budesonide Budesonide
(medium dose). 1 puff BD. 2 puffs BD
was prescribed.
 Rationale
Based on British Thoracic Society (BTS) starting dose of inhaled corticosteroids will usually be low dose
symptomatic asthma.

Low dose Medium dose High dose

Hence, low dose
ICS budesonide
would be 200 mcg
1 puff BD.
 PCI

PCI Pharmacist’s Outcome

recommendation

3 Patient was started To counsel patient on ICS’s Patient was

with side effects and ways to
MDI Budesonide (ICS). minimize/prevent the
side effects.
counselled on the
side effects and
ways to
minimize/prevent
the side effects
ICS’s Side Effects and its Prevention
Side effects (local):
1. Sore throat
2. Oral candidiasis
3. Hoarse voice
4. Dysphonia

Prevention/Ways to minimize side effects:

5. Rinse mouth after use and spit out the rinse and/or brush
teeth after use.
6. Use of spacer device able to reduce oropharyngeal
deposition of drug particles.

1. British guideline on the management of asthma. (2019.) British Thoracic Society. Retrieved from
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/
 PCI
PCI Pharmacist’s Outcome
recommendation

4 Patient’s asthma To change MDI Budesonide Dr remains

symptoms remained to low-dose ICS-LABA. MDI Budesonide
not well-controlled. 2 puffs TDS.
The dose frequency of 2 options:
MDI Budesonide was - Symbicort Turbuhaler
increased from 160/4.5 mcg 1puff
BD to TDS. BD
- Seretide Accuhaler
50/250 mcg 1 puff BD
 Rationale
● Based on GINA 2019, low-
dose ICS-LABA is
recommended as preferred
controller in Step 3.
● Daily high dose ICS may
expose patient to greater risk
of side effects 1.
● Not much benefits for ICS
dosage frequency of more than
BD 2
-> concentration-dependent 3
● Plus, TDS dosing might cause
adherence issue.

1. Clinical Practice Guidelines (CPG): Asthma; 2017. Available from http://www.acadmed.org.my/index.cfm?menuid=67

2. Scottish Intercollegiate Guidelines Network (SIGN). Pharmacological management of asthma. Evidence table 4.4c: inhaled corticosteroid vs leukotriene receptor antagonists. Scottish
Intercollegiate Guidelines Network; 2002. Available from http://www.sign.ac.uk/guidelines/published/support/guideline63/table4.4c.html: [Accessed. 10 Jul 2014].
3. Donnelly, R. & Paul Seale, J. Clin Pharmacokinet (2001) 40: 427. https://doi-org.ezproxy.lib.monash.edu.au/10.2165/00003088-200140060-00004
Symbicort or
Seretide?
 Rationale - Symbicort
(Budesonide/Formoterol)
● Symbicort reduces more in severe
exacerbations compared to Seretide 1
● Fast onset of action and 24-hour symptom
control 1,2
● Lesser overall steroid load -> less side
effects 3

❏ High cost
❏ Requires sharp, forceful inhalation to get
full dose

Symbicort Turbuhaler. Photo by Health Department Federal Territories of Kuala

Lumpur & Putrajaya

1. Kuna P et al. Int J Clin Pract 2007;61:725-736

2. Palmqvist M et al. Pulm Pharmacol Ther. 2001;14(1):29-34
3. Vogelmeier et al. Eur Respir J 2005;26:819-818
 Rationale - Seretide Accuhaler
(Fluticasone/Salmeterol)
● Dose counter improves
adherence
● Inhalation easier for patient
with lower inspiratory
capacity
● Ease of use
● Higher lung deposition than
pMDI
● Cheaper cost

1. Moore A, Stone S. Meeting the needs of patients with COPD: patients’ preference for the Diskus inhaler compared with the Handihaler. Int J Clin Pract Vol 58, pp 444-450, 2004.
2. Seretide Accuhaler Malaysia Prescribing Information Ver Number IPI19MAL revised on 5 Sep 2017.
3. Tarsin WY, Pearson SB, Assi KH, Chrystyn H. Emitted dose estimates from Seretide Diskus and Symbicort Turbuhaler following inhalations by severe asthmatics. Int J Pharmaceutics Vol 316, pp
131-137, 2006.
4. Ashurst IC, Prime D, Haywood PA. Development of a dry powder inhaler device containing a combination of salmeterol and fluticasone.
5. Nurulhayati Abd Jamal. n.d. https://drive.google.com/file/d/1G1fYNzHOGQroVmPsKnSG8O2v_gcRj2U8/view
 Lower Cost
@RM20.12
(KKBJ, 2020)

Our group recommends

Seretide
Adherence issue Strong and
- dose counter forceful
available inhalation not
- ease to track needed
Summary (GINA,
2019)
 High-
dose ICS- 1. SYMBICORT 4 PUFFS BD
LABA

ICS-LABA 1.SYMBICORT 2 PUFF BD @

or SERETIDE ACC 1 PUFF BD
High-dose OR
ICS @ 2. BUDESONIDE 4 PUFFS BD @
add LAMA
FLUTICASONE 4 PUFF BD @ ADD TIOTROPIUM

ICS-LABA
or
1.SYMBICORT 1 PUFF BD RELIEVER:
Medium- OR Salbutamol
dose ICS 2. BUDESONIDE 2 PUFFS BD @ FLIXOTIDE 2 PUFF BD 2 puffs PRN
(Maximum 8
Puffs/day)
Low-dose
ICS @ ICS-
1. BUDESONIDE 1 PUFF BD @ SYMBICORT 1 PUFF PRN
LABA
or OR
Low- dose 2. BUDESONIDE 1 PUFF PRN WHENEVER SALBUTAMOL IS USE
ICS

ICS-LABA 1.
SYMBICORT 1 PUFF PRN
or
Low-dose
OR
ICS 2. BUDESONIDE 1 PUFF PRN WHENEVER SALBUTAMOL IS USE
Take-Home Messages
1. Before stepping up treatment, check patient’s adherence and
inhaler technique.
2. Ensure understanding of a good inhaler technique is on par with
Handling Inhaler Devices Practical Guide.
3. If the patient is steroid-naive and ICS is prescribed, make sure it is
started from low dose.

1. Handling Inhaler Devices Practical Guide:

https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/handling-inhaler-devices-practi
cal-guide-pharmacists-2011.pdf
Why is low-dose ICS+LABA added on SABA-monotherapy at step 1 asthma
management?

1. Over-reliance of SABA + under-use of ICS

WHY?
- Some people not aware about ICS’s indication and benefits
- Some people have misperception about ICS (steroid=bad)
- Some people only use SABA(reliever) when the asthma symptoms exacerbate, as
they might think that the inhaler is meant for symptoms exacerbation only (like
coughing)

CONSEQUENCE:
- Progression of asthma (aka airways obstruction or narrowing) → poorly controlled
asthma → symptoms happen more frequent → increase medication need (dose &
frequency)
Budesonide 200mcg kenapa tak boleh TDS since
not exceeding total daily dose?

PK half-life, duration of action: 24 hours

Adherence issue
 Seretide (Fluticasone/Salmeterol)
Pros Cons

Cheaper cost

Dose counter available

Seretide Accuhaler. Photo by Health Department Federal Territories of Kuala

Lumpur & Putrajaya
 Rationale - Symbicort
(Budesonide/Formoterol) Pros Cons

Symbicort reduces more in Requires sharp, forceful

severe exacerbations inhalation in order to get
compared to Seretide 1 full dose

Has fast onset of action and High cost

24-hour symptom control 1,2

Lesser overall steroid load,

hence less side effects 3.

Symbicort Turbuhaler. Photo by Health Department Federal Territories of Kuala

Lumpur & Putrajaya

1. Kuna P et al. Int J Clin Pract 2007;61:725-736

2. Palmqvist M et al. Pulm Pharmacol Ther. 2001;14(1):29-34
3. Vogelmeier et al. Eur Respir J 2005;26:819-818
(CPG Management of Asthma in Adults, 2017.)
 Rationale - Importance of using ICS and SABA
together

● Patient was not compliant to

preventer, hence had been using
Salbutamol reliever for >2x/week for
exacerbations.

● Over-reliance on SABA reliever and

under-use of ICS can increase risk of
asthma-related death due to under-
treatment of inflammation 3,4.

1. Image by VanSpanckeren K. Outline of American Literature. Accessed from http://ufdimages.uflib.ufl.edu/AA/00/01/16/97/00001/Outline_US_Lit.pdf

2. Bergeron C et al. Can Respir J 2010;17(4):e85-e94
3. Suissa S et al. Am J Respir Crit Care Med 1994;149:604-10
4. Suissa S et al. N Engl J Med 2000;343:332-6
 Asthma Control Status
Daytime symptoms ≤2x/week >2x/week? ≥3 features of
partly controlled
None Any asthma present
Limitation of
in any week
activities

Nocturnal None Any

symptoms/awakeni
ng

%PEFR= Normal <80% expected

PEFR/expected PEF x
100

Exacerbations None ≥ 1x/year Once a week

Status of Asthma (all of 1 or 2 of above UNCONTROLLE

Control above) PARTLY D
CONTROLLE CONTROLLED
Conclusion on initiating asthma pharmacotherapy

17 STARTING ASTHMA TREATMENTFor the best outcomes, ICS-containing treatment should be initiated as soon as
possible after the diagnosis of asthma is made, because:

• Patients with even mild asthma can have severe exacerbations

• Low dose ICS markedly reduces asthma hospitalizations and death• Low dose ICS is very effective in preventing severe
exacerbations, reducing symptoms, improving lung function, and preventing exercise-induced bronchoconstriction, even in
patients with mild asthma

• Early treatment with low dose ICS leads to better lung function than if symptoms have been present for more than 2–4 years

• Patients not taking ICS who experience a severe exacerbation have lower long-term lung function than those who have started
ICS

• In occupational asthma, early removal from exposure and early treatment increase the probability of recovery