asthma management and education initiative

ASTHMA MANAGEMENTASTHMA MANAGEMENT and and

EDUCATION INITIATIVEEDUCATION INITIATIVE

JOB CORPS

2005 National Health and Wellness Conference

Orlando, Florida

June 7, 2005

Gary Strokosch, MD

Region V Medical Consultant

Guidelines for the Diagnosis Guidelines for the Diagnosis and Management of Asthmaand Management of Asthma----------------------------------------------------------------------------Update on Selected Topics Update on Selected Topics

- 2002 -- 2002 -Expert Panel Report (EPR) – Update 2002National Asthma Education and Prevention

Program (NAEPP)NIH Publication No. 02-5074June 2003

PREVIOUS REPORTSPREVIOUS REPORTS

1997 Guidelines for the Diagnosis and Management of Asthma (EPR-2)

1991 National Asthma Education and Prevention Program’s (NAEPP) first report

AVAILABLE NAEPP AVAILABLE NAEPP PUBLICATIONSPUBLICATIONS

http://www.nhlbi.gov.nhlbi/nhlbi.htm

(National Heart, Lung and Blood Institute)

OBJECTIVEOBJECTIVE

To give participants the tools to develop up-to-date individual management plans

for JC students with asthma

SCOPE OF ASTHMA - ISCOPE OF ASTHMA - I

11 million people reported having an asthma attack in 2000

More than 5% of all children under 19 report asthma attacks in 2000

In 2003 14.7% of teens 12-17 years of age have had asthma diagnosed

SCOPE OF ASTHMA - IISCOPE OF ASTHMA - II

1999: 2 million ER visits1999: 478,000 hospitalizations for asthma1999: 4426 deaths from asthmaMortality is 3 times higher in Black males

than white malesMortality is 2 ½ times higher in Black

females than while females

2002 UPDATE OUTLINE2002 UPDATE OUTLINE

Overview of asthmaMedication Updates

– Steroids Efficacy & Safety– Combination Therapy– Antibiotics

Monitoring Issues– Written Plans for Management– Peak Flow Vs. Symptom Monitoring

Management

DEFINITIONDEFINITION

Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role.

----------------------note----------------------

The ability to synthesize IgE antibody to environmental allergens (i.e., atopy) remains a major risk factor in asthma pathogenesis.

NATURAL HISTORY OF NATURAL HISTORY OF PERSISTENT ASTHMAPERSISTENT ASTHMA

The majority of children who wheeze before 3 years of age do not experience any more symptoms after 6 years of age.

A smaller group of children wheezing before 3 years of age go on to have persistent asthma.

A predictive index identified the following risk factors for developing persistent asthma

PREDICTIVE INDEXPREDICTIVE INDEXMajor and Minor Risk FactorsMajor and Minor Risk Factors Physician diagnosis of atopic dermatitis/eczema

- OR - Parental history of asthma

--------- OR --------- Two out of three of the following asthma-

associated phenotypes:– Peripheral blood eosinophilia (>4%)– Wheezing apart from colds– Physician-diagnosed allergic rhinitis

BIRTH COHORTBIRTH COHORTFOLLOWED FOR 13 YEARSFOLLOWED FOR 13 YEARS

76% of those diagnosed with asthma after 6 years of age had a positive predictive index

97% of those without a diagnosis of asthma after 6 years of age had a negative predictive index

(Castro-Rodriguez, et.al. 2000)

SPIROMETRYSPIROMETRY

Recommends tests be done:Recommends tests be done:

At the time of the initial assessmentAfter treatment is initiated and symptoms

and PEF have stabilizedAt least every 1-2 years

SYMPTOM CLASSIFICATIONSYMPTOM CLASSIFICATION

Severe Persistent

Moderate Persistent

Mild Persistent

Mild Intermittent


Severe Persistent– Day: continual– Night: frequent

Moderate Persistent– Day: daily– Night: >1/week

Mild Persistent– Day: >2/week (<1/day) [3-6/week]– Night: >2/month

Mild Intermittent– Day: 2/week– Night: 2/month

TARGET OF THERAPY - ITARGET OF THERAPY - I

1) Acute symptoms of asthma usually arise from BRONCHOSPASM and require and respond to bronchodilator therapy.

TARGET OF THERAPY - IITARGET OF THERAPY - II

2) Acute and chronic INFLAMMATION affects the airway caliber and airflow and also causes bronchial hyper responsiveness, resulting in susceptibility to bronchospasm. Therapy is with anti inflammatory drugs but may require weeks to achieve a successful response.

TARGET OF THERAPY - IIITARGET OF THERAPY - III

3) Some patients experience persistent airflow limitations and this REMODELING has NO current therapy.

INFLAMMATIONINFLAMMATION

This inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and cough, particularly at night and in the early morning.

INFLAMMATION - IINFLAMMATION - I

Airway inflammation in asthma is found in patients with mild, moderate and severe disease.

INFLAMMATION – IIINFLAMMATION – II

Mild / Moderate Persistent Mild / Moderate Persistent AsthmaAsthma

Inflammation of airway by inflammatory cells such as activated lymphocytes & eosinophils

Denudation of the epitheliumDeposition of collagen in the subbasement

membrane areaMast cell degranulation

INFLAMMATION – IIIINFLAMMATION – III

Severe Persistent & Deaths from Severe Persistent & Deaths from AsthmaAsthma

Occlusion of bronchial lumen by mucousHyperplasia & hypertrophy of bronchial

smooth muscleGoblet cell hyperplasia

IgE PATHOGENESISIgE PATHOGENESIS

1. IgE antibodies are synthesized to environmental allergens (atopy)

2. Synthesized IgE binds to mast cells and basophils via high-affinity IgE receptors

3. These cells are signaled to release preformed and newly generated mediators, including histamine & cysteinyl leukotrienes to rapidly contract airway smooth muscle

4. Mast cells also produce a variety of cytokines (pro-inflammatory proteins) including interleukin (IL 1,2,3,4 &5), granulocyte-macrophage colony-stimulating factor, interferon and tumor necrosis factor-α

ATOPYATOPY

Atopy is the genetic susceptibility to produce IgE ABs directed toward common environmental allergens, including house-dust mites, animal proteins, and fungi.

With the production of IgE ABs, mast cells and possibly other airway cells (e.g., lymphocytes) are sensitized and become activated when they encounter specific antigens.

Atopy has been found in 30 to 50% of the general population, therefore frequently found in the absence of asthma.

Atopy is one of the strongest predisposing factors in the development of asthma.

EOSINOPHIL PATHOGENESISEOSINOPHIL PATHOGENESIS1. Infiltration seen in all acute inflammation &

many patients with chronic persistent asthma2. The granules are the source of inflammatory

mediators– Injure airway epithelium– Enhance bronchial responsiveness– Affect acetylcholine release

3. Release cysteinyl leukotrienes to contract airway smooth muscle

4. Eosinophils are produced & released from bone marrow via IL-5, migrate to airway via a number of factors

EOSINOPHIL PATHOGENESISEOSINOPHIL PATHOGENESIS

Although its role in pathophysiology is less clear, it is affected by anti-inflammatory therapy.

ASTHMA MEDICATIONSASTHMA MEDICATIONS

1. Beta2-Agonists

2. Corticosteroids

3. Leukotriene Modifiers

4. Methyl Xanthines

5. Cromolyn and Nedocromil

6. Anticholinergics


1. Beta2-Agonists Injected Short-acting inhaled Long-acting inhaled

2. Corticosteroids Inhaled Systemic (oral)

3. Leukotriene Modifiers4. Methyl Xanthines5. Cromolyn and Nedocromil6. Anticholinergics

COMBINATIONCOMBINATIONASTHMA MEDICATIONSASTHMA MEDICATIONS

1. Beta2-Agonists Long-acting inhaled

2. Corticosteroids Inhaled

3. 4. 5. 6.

ADVAIRADVAIR100/50, 250/50 & 500/50100/50, 250/50 & 500/50

Fluticasone DPI 100/250/500 mcg

Salmererol DPI 50 mcg


1. Beta2-Agonists Injected Short-acting inhaled Long-acting inhaled

2. Corticosteroids Inhaled Systemic (oral)

3. Leukotriene Modifiers4. Methyl Xanthines5. Cromolyn and Nedocromil6. Anticholinergics


1. Beta2-Agonists Short-acting inhaled

2.

3. 4. 5. 6. Anticholinergics

COMBIVENTCOMBIVENT

For Use In COPDFor Use In COPD

Ipratropium 18 mcg/puff MDIAlbuterol 90 mcg/puff MDI

Ipratropium 0.5 mg/3ml Nebulizer SolutionAlbuterol 2.5 mg/3ml Nebulizer Solution

CORTICOSTEROID CORTICOSTEROID EFFICACYEFFICACY

Does chronic use of inhaled Does chronic use of inhaled corticosteroids improve long-term corticosteroids improve long-term outcomes with mild or moderate outcomes with mild or moderate

persistent asthma, in comparison persistent asthma, in comparison to the following treatment?to the following treatment?

PRN beta2-agonists?Long-acting beta2-agonists?Theophylline?Cromolyn/Nedocromil?Combinations of above drugs?

RESULTRESULT

Inhaled corticosteroids improve long-term outcomes with mild or moderate persistent asthma, compared to previously outlined

treatments.

RECOMMENDATIONRECOMMENDATION

Inhaled corticosteroids are the preferred treatment for initiating therapy for persistent asthma.

CORTICOSTEROID CORTICOSTEROID SAFETYSAFETY

What are the long term What are the long term adverse effects of chronic adverse effects of chronic inhaled corticosteroid use inhaled corticosteroid use

on the following outcomes?on the following outcomes?

Vertical Growth?Bone Mineral Density?Ocular Toxicity (posterior subcapsular

cataract and glaucoma)?Suppression of adrenal/pituitary axis?

RESULTRESULT

The use of corticosteroids at recommended doses does not have long-term, clinically

significant, or irreversible effects on any of the outcomes reviewed.

LINEAR GROWTHLINEAR GROWTH

Growth reduction my occur from inadequate control of any chronic disease.

Although low/medium doses may have the potential of decreased growth velocity, the effects are small, nonprogressive and may be reversible.

When high doses are needed, the use of adjunctive therapy should be initiated in order to reduce the steroid dose.

Children and adolescents taking steroids by any route should be monitored for growth interference.

BONE MINERAL DENSITYBONE MINERAL DENSITY

A small, dose-dependent reduction in BMD may be associated with inhaled corticosteroid use in patients older than 18 years of age, but the clinical significance of these findings is not clear.

CATARACTS / GLAUCOMACATARACTS / GLAUCOMA

In children, no significant effects are seen with low-to-medium doses. However, high (>2000 mg) cumulative lifetime doses of inhaled corticosteroids may increase slightly the prevalence of cataracts in two studies of adult and elderly patients.

HPA AXIS FUNCTIONHPA AXIS FUNCTION

Available evidence indicates that, on average, children may experience only clinically insignificant, if any, effects of low-to-medium dose of inhaled corticosteroids. Rare individuals may be more susceptible to their effects even at conventional doses.

OVERALLOVERALLRECOMMENDATIONRECOMMENDATION

Inhaled corticosteroids are the preferred treatment for initiating therapy for persistent asthma.

COMBINATION THERAPY:COMBINATION THERAPY:

ADDITION OF OTHER LONG-ADDITION OF OTHER LONG-TERM-CONTROL TERM-CONTROL

MEDICATIONS TO INHALED MEDICATIONS TO INHALED CORTICOSTEROIDSCORTICOSTEROIDS

QUESTIONQUESTION

In patients with moderate persistent asthma who are receiving inhaled corticosteroids, does addition of another long-term-control agent improve outcomes?

ANSWERANSWER

Strong evidence consistently indicates that long-acting inhaled beta2-agonists added to low-to-medium inhaled corticosteroids improve outcomes.

Adding a leukotriene modifier or theophylline to inhaled corticosteroids also improves outcomes, but the evidence is not as substantial.

RECOMMENDATIONRECOMMENDATION

The preferred treatment for adults and children older than 5 years of age is the addition of long-acting inhaled beta2-agonists to low-to-medium doses of inhaled corticosteroids (not as a substitute).

““JUST DOUBLE THE DOSE”JUST DOUBLE THE DOSE”

Studies of adults in which the dose of inhaled corticosteroids was at least doubled consistently demonstrate improved outcomes when their asthma was not controlled with low-to-medium-doses of inhaled steroids, but these results are consistently less effective than adding a long-acting inhaled beta2-agonist.

USE OF ANTIBIOTICS TO USE OF ANTIBIOTICS TO TREAT ASTHMA TREAT ASTHMA

EXACERBATIONSEXACERBATIONS

DOES ROUTINELY ADDING DOES ROUTINELY ADDING ANTIBIOTICS TO ANTIBIOTICS TO

STANDARD CARE STANDARD CARE IMPROVE THE OUTCOMES IMPROVE THE OUTCOMES

OF TREATMENT FOR OF TREATMENT FOR ACUTE EXACERBATION OF ACUTE EXACERBATION OF

ASTHMA?ASTHMA?

NOTES ON COMORBID NOTES ON COMORBID INFECTIONINFECTION

Most asthma exacerbations are associated with infection by a respiratory virus, especially rhinovirus.

Only a small percentage of exacerbations are associated with infection by an atypical bacterium, like Mycoplasma pneumoniae or Chlamydia pneumoniae.

It is widely believed that coincident bacterial sinusitis contributes to asthma exacerbations.

Airway obstruction due to mucus plugging possibly predisposes patients to bacterial infection of non-draining regions of the lungs.

Viral and bacterial infections are both associated with neutrophilic inflammation of the upper and lower airways.

MORE NOTES ON MORE NOTES ON COMORBID INFECTIONCOMORBID INFECTION

Low-grade fever may accompany viral respiratory infections.

Sputum discoloration (from PMNs) may accompany viral respiratory infections.

Sputum of patients with uncomplicated asthma exacerbations commonly contains high numbers of PMNs.

UNCHANGED UNCHANGED RECOMMENDATIONRECOMMENDATION

(Same as EPR-2)(Same as EPR-2)

Therefore, antibiotics are not recommended for the treatment of acute asthma exacerbations except as needed for comorbid conditions – e.g., for the patients with fever and purulent sputum, evidence of pneumonia, or suspected bacterial sinusitis.

WRITTEN ACTION PLANS WRITTEN ACTION PLANS COMPARED TO MEDICAL COMPARED TO MEDICAL

MANAGEMENT ALONEMANAGEMENT ALONE

QUESTIONQUESTION

Compared to medical management alone, does the use of a written asthma action plan improve outcomes?

SUMMARY ANSWER TO SUMMARY ANSWER TO THE QUESTIONTHE QUESTION

Data are insufficient to support or refute the benefits of using written asthma action plans compared to medical management alone.

UNCHANGED UNCHANGED RECOMMENDATIONRECOMMENDATION

(Same as EPR-2)(Same as EPR-2)

Use of written action plans as part of an overall effort to educate patients in self-management is recommended, especially for patients with moderate or severe persistent asthma and patients with a history of severe exacerbations.

WRITTEN ACTION PLANS WRITTEN ACTION PLANS SHOULD:SHOULD:

Enhance clinician-patient communication Meet the medical needs of the student Have a format that facilitates the student’s understanding

and ability to take appropriate action Be explicit Be an algorithm of procedures to take Contain steps to take if treatment is ineffective or an

emergency arises Contain contact information for securing urgent care Be periodically reviewed and revised as needed

PEAK FLOW-BASEDPEAK FLOW-BASED COMPARED TOCOMPARED TO

SYMPTOM-BASEDSYMPTOM-BASED WRITTEN ACTION PLANSWRITTEN ACTION PLANS

QUESTIONQUESTION

Compared to a written action plan based on symptoms, does use of a written action plan based on peak flow monitoring improve outcomes?

SUMMARY ANSWER TO SUMMARY ANSWER TO THE QUESTIONTHE QUESTION

Evidence neither supports nor refutes the benefits of written action plans based on peak flow monitoring compared to symptom-based plans in improving health care utilization, symptoms, or lung function.

However, patient preferences and circumstances may warrant choosing peak flow monitoring.

PEAK FLOW MONITORINGPEAK FLOW MONITORINGTRADITIONAL RECOMMENDATIONSTRADITIONAL RECOMMENDATIONS

Peak flow monitoring can be used for short-term monitoring, managing exacerbations, and daily long-term monitoring.

When used in these ways, the patient’s measured personal best is the most appropriate reference value.

Daily long-term monitoring should be limited to moderate and severe persistent asthma.

MANAGEMENTMANAGEMENT


Severe Persistent– Day: continual– Night: frequent

Moderate Persistent– Day: daily– Night: >1/week

Mild Persistent– Day: >2/week (<1/day) [3-6/week]– Night: >2/month

Mild Intermittent– Day: 2/week– Night: 2/month


Severe Persistent Step 4– Day: continual– Night: frequent

Moderate Persistent Step 3– Day: daily– Night: >1/week

Mild Persistent Step 2– Day: >2/week (<1/day) [3-6/week]– Night: >2/month

Mild Intermittent Step 1– Day: 2/week– Night: 2/month


Severe Persistent Step 4 PEF/FEV1 <60%– Day: continual– Night: frequent

Moderate Persistent Step 3 PEF/FEV1 60-80%– Day: daily– Night: >1/week

Mild Persistent Step 2 PEF/FEV1 >80%– Day: >2/week (<1/day) [3-6/week]– Night: >2/month

Mild Intermittent Step 1 PEF/FEV1 >80%– Day: 2/week– Night: 2/month


Severe Persistent Step 4 PEF/FEV1 <60%– Day: continual Variability >30%– Night: frequent

Moderate Persistent Step 3 PEF/FEV1 60-80%– Day: daily Variability >30%– Night: >1/week

Mild Persistent Step 2 PEF/FEV1 >80%– Day: >2/week (<1/day) [3-6/week] Variability 20-30%– Night: >2/month

Mild Intermittent Step 1 PEF/FEV1 >80%– Day: 2/week Variability <20%– Night: 2/month

DAILY MEDICATIONSDAILY MEDICATIONSPreferred Treatment:Preferred Treatment:

Step 4– High-dose inhaled corticosteroids, AND– Long-acting beta2-agonists

Step 3– Low-to-medium dose inhaled corticosteroids, AND– Long-acting beta2-agonists

Step 2– Low-dose inhaled corticosteroids

Step 1– No daily medication needed

QUICK RELIEFQUICK RELIEFTREATMENTTREATMENT

Short-acting bronchodilator inhalerNebulizer treatment with bronchodilatorCourse of systemic corticosteroids

NOTES ON TREATMENTNOTES ON TREATMENT

Classify patients to their most severe stepGain control ASAP, then step down to the least

medication needed for controlMinimize use of short acting inhaled beta2-agonist

Provide education on self-management and controlling environment

Refer to asthma specialist if it is difficult to control asthma or if step 3 or 4 is required

STEPPINGSTEPPING

STEP DOWN: Review treatment every 1 to 6 months; a gradual stepwise reduction in treatment may be possible.

STEP UP: If control is not maintained, consider step up. First, review patient medication technique, adherence and environmental control.

2004 PERRY 2004 PERRY POINTFIVE ASTHMA MEDICATIONSFIVE ASTHMA MEDICATIONS

www.jobcorpshealth.comwww.jobcorpshealth.com

Albuterol inhalation aerosol (albuterol)Fluticasone propionate oral inhaler (Flovent)Triamcinolone acetonide inhalation aerosol

(Azmacort)Salmeterol xinafoate oral inhaler (Serevent)Montelukast sodium tablets, 10 mg (Singulair)

2004 PERRY POINT2004 PERRY POINTTWO ORAL STEROIDSTWO ORAL STEROIDS

Prednisone tablets, 20 mg (prednisone)

Dexamethasone tablets, 4 mg (Decadron)

PROPELLENTSPROPELLENTS

CFC: chlorofluorocarbons– Safe to inhale but damaging to the earth’s

ozone layer– MDIs with CFC are being phased out

HFA: hydrofluoroalkane– Safe for the environment and the patient– Delivers nearly twice as much medication to

the patient

SEVERAL WEBPAGESSEVERAL WEBPAGESREGARDING ASTHMAREGARDING ASTHMA

www.chestnet.org– American College of Physicians

www.whatsasthma.org (many links)– Neomedicus and Merck

www.lungusa.org– American Lung Association

PERSONAL COMMENTSPERSONAL COMMENTS

ORAL CORTICOSTEROIDSORAL CORTICOSTEROIDS

Only prednisone needed for PO useOnce per day about equivalent to BIDMay stop med abruptly after ~5 daysUsed almost exclusively for quick relief, not for

supplementing (long term) inhaled steroids or long acting beta2-agonists in step 4

INHALED STEROIDSINHALED STEROIDSCOMMON PRACTICESCOMMON PRACTICES

Beclomethasone (Beclovent) not in common use in some medical centers

Budesonide (Pulmicort) ~20% absorbed, but used mostly in nebulizer for children

Flunisolide (Aerobid) not used muchFluticasone (Flovent) ~1% absorbed,

commonly used & available in 3 strengthsTriamcinolone acetonide (Azmacort) not in

common use in some medical centers

LONG ACTINGLONG ACTINGBETABETA22-AGONISTS-AGONISTS

Salmeterol (Serevent) off market (CFC)Fixed dose of salmeterol now only available

in combination with 3 strengths of fluticasone as Advair (100/50, 250/50 & 500/50)

Formoterol (Foradil) available

FORMOTEROLFORMOTEROL

Available as ForadilIt is both short acting and long acting12 mcg of Foradil is equivalent to 50 mcg

of salmeterol (Serevent)Provided as 12 mcg capsules to be used in

aerolizer (not PO) every 12 hours

CROMOLYN & NEDOCROMILCROMOLYN & NEDOCROMIL

Cromolyn is available as IntalNedocromil is available as Tilade

Not commonly used

LEUKOTRIENE MODIFIERSLEUKOTRIENE MODIFIERS

Used as adjunctive therapy for asthmaOral treatment availableSimultaneously treats allergic rhinits

LEUKOTRIENE MODIFIERSLEUKOTRIENE MODIFIERS

Leukotriene Receptor Antagonists (LTRAs)– Montelukast is available as Singulair prescribed as one 10 mg

tablet per day– Zafirlukast is available as Accolate prescribed as 20 mg tablet

BID

5-Lipoxygenase Inhibitors– Zileuton is available as Zyflo prescribed as 600 mg QID

METHYLXANTHINESMETHYLXANTHINES

Theophylline used very little now and requires blood level monitoring

QUICK RELIEFQUICK RELIEF

Albuterol inhaler commonly used Pirbuterol (Maxair) is also useful and also available as

an Autohaler, a breath activated inhaler, easier and more reliable to use

Albuterol nebulizer solution is available, usually given as 2.5 mg/3ml (0.083%) for teens and young adults

Ipratropium (anticholinergic) (Atrovent) useful for beta2 receptor resistance to albuterol

Anticholinergic + albuterol generally used for COPD Injectable beta2-agonists too short acting

SUGGESTED MINIMAL STOCKSUGGESTED MINIMAL STOCK

Albuterol inhalerAlbuterol nebulizer solution 2.5 mg/3ccPrednisone 20 mg tabsAdvair (fluticasone + salmeterol) DPI in

100/50 & 250/50 dosesFlovent (fluticasone) MDI 44,110 & 220

mcg/puff OR DPI 50, 100 & 250 mcg/puff

TWO POSSIBLE ADDITIONSTWO POSSIBLE ADDITIONS

Quick Relief: Pirbuterol (Maxair) is also useful and also available as an Autohaler, a breath activated inhaler, easier and more reliable to use

Quick Relief and Long Acting Beta2-Agonists: Formoterol (Foradil) can be given BID in place of Serevent

COMMENTS ABOUTCOMMENTS ABOUTPEAK FLOW METERSPEAK FLOW METERS

Comparable to careful monitoring of signs and symptoms in managing asthma

Inexpensive / disposable mouthpiecesCan be used with “personal best” or

predicted average PEF (liters per minute)Daily use reserved for most severe patients,

but adherence drops off quicklyVery subject to effort, in contrast to FEV1

OTHERSOTHERS

Pulse oximetry – most useful in emergency rooms

Spirometry – useful to detect degree of obstruction and if it can clear with bronchodilators and or steroids

Asthma specialists – useful for step 3 and/or step 4 patients or difficulty with management

asthma management and education initiative

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