ASTHMA

Fatima H. ElsamaniBsc. Msc.UOFKfatimaelsamani2013@gmail

Definition DiagnosisClassifications of asthma severity and

controlTreatment goalTreatment guidelineManaging exacerbations and controlAsthma in pregnancy

Asthma is a chronic inflammatory disorder of the airways causing recurrent episodes of wheezing, breathlessness, cough, and chest tightness, particularly at night or early in the morning

reversible spontaneously or with treatment.

Diagnosis1. Episodic symptoms of airflow obstruction are

present.

2. Airway obstruction is reversible (FEV1 improves by 12% or more after SABAs).

3. Alternative diagnoses are excluded.

Classification of Asthma Severity and Control

Assessing Asthma Control in Adults

Treatment Goals

1. Minimal or no chronic symptoms day or night .2. Minimal or no exacerbations .3. No limitations on activities; no school/work missed4. Maintain (near) normal pulmonary function.5. Minimal use of SABAs .6. Minimal or no adverse effects from medications .

Asthma Treatment Guidelines

Pharmacologic Therapy for Asthma

Pharmacologic Agents • Steroid Inhalers.• Anti-cholinergics.• β2 Agonists – Short Acting (SABA) – Long Acting (LABA)• Combination Inhalers. • Methylxanthine• Leukotriene Modifiers• Monoclonal Antibodies

Inhaled Corticosteroids (ICS) • First line for persistent asthma; immediate benefit is not seen.

• Use HOLDING CHAMBERS only if needed; holding chambers are only for MDIs – cannot be used for DPIs; holding chambers with a mask can be used for young Children.

• RINSE MOUTH with water after inhalations.

• Use steroid inhaler as SCHEDULED, not as needed.

• Consider calcium and vitamin D supplements in adults, particularly in premenopausal women .

Dry Powder Inhaler (DPI) Vs. Metered Dose Inhaler

Is a handheld device thatdelivers medication in the formof Dry Powder to the lungs asyou inhale through it. It doesn'tcontain propellants or otherIngredients.

Is a handheld device that Delivers a specific amount ofmedication in aerosol form,rather than as a pill or capsule.The MDI consists of apressurized canister inside aplastic case, with a mouthpieceattached.

DPI: MDI:

ICS – Adverse Effects

Inhaled •Oral candidiasis

•Hoarseness •May slow bone

growth in children but similar adult height

Systemic •Cushing effects

•Growth retardation •Osteoporosis •Hypertension

•Cataracts •Glucose intolerance

•Skin thinning •Myopathy

•Euphoria •Depression

Anticholinergics Ipratropium• MDI 18 mcg/puff (HFA)• Also available as a solution for nebulisation • 2 – 4 Puffs TID – QID (up to 12 puffs / 24 hours)• Used for COPD• Duration 2 -8 hours Tiotropium• DPI 18 mcg • 1 capsule per day• Used for COPD• Duration > 24 hours • Long Acting, not for rapid relief

Adverse Effects: Headache – Flushed Skin – Blurred Vision –Tachycardia – Palpitation

β2 -Agonists

LABA• Not for acute symptoms.• Should NOT be used as monotherapy for asthma

SABA• Used for acute bronchospasm. • Regular use indicates poor control.

Adverse Effects• Tremor• Tachycardia• Electrolyte effects rare

Adverse Effects• Tremor• Tachycardia• Hypokalemia• Hypomagnesaemia• Hyperglycemia• Tachyphylaxis

SABA

LABA

The U.S. Food and Drug Administration (FDA) issued a safety announcement June 2010 because of safety concerns with LABAs:

• Use of a LABA alone without a long-term asthma control drug, is contraindicated.

• LABAs should not be used in patients whose asthma is adequately controlled on low- or medium-dose ICSs.

• LABAs should only be used as additional therapy for patients who are currently taking, but are not adequately controlled on, a long-term asthma control agent, such as an ICS.

• Once asthma control is achieved and maintained, patients should be assessed at regular intervals and step down (e.g., discontinue the LABA), if possible, and the patient should continue to be treated with a long-term asthma control agent, such as an ICS.

• Pediatric and adolescent patients who require a LABA and an ICS should use a combination product to ensure adherence with both medications.

Combination therapy

Combination Inhalers

LABA + ICSFluticasone – Salmeterol Budesonide – FormoterolMometasone – Formoterol

SABA + Anticholinergicsalbutamol Plus ipratropium

(MDI)

Primarily used for COPDCombination solution for

nebulization is also available

Used for management of Chronic Asthma

Monoclonal Antibodies

Omalizumab• Dose: 150–375 mg SC every 2–4 weeks• Adverse Events: Injection site reactions, Urticaria, Thrombocytopenia (transient), Anaphylaxis (rare), Malignancy• Helpful in moderate to severe persistent allergy related asthma• Use in ≥ 12 years old• Half-life: 26 days• Second-line therapy / Very expensive

Methylxanthine (Theophylline)

• Liquids, capsules, sustained-release capsules (many dosage strengths)

• Dose: 10 mg/kg/day – BID–TID Max: 800 mg/day

• Achieve concentrations of 5–15 mcg/mL

• Beneficial for night symptoms - Not for acute relief

• Many drug interactions.

Methylxanthine Adverse Events

At high levels:Nausea – Vomiting - CNS stimulation – Headache – Tachycardia – SVT – Seizures - Hematemesis – Hyperglycemia – Hypokalemia

At usual levels:Insomnia - GI upset - Increased hyperactivity in some children - Difficult urination in BPH

Leukotriene modifiers

Montelukast 5 – 10 mg / day• Oral 10-mg tablet / Chewable 4- and 5-mg tablets• Oral granules 4-mg/packet• FDA-approved for use in ≥ 1 year old; used in 6 months and older• Drug interactions: Phenobarbital • Churg-Strauss syndrome

Zafirlukast 20 mg BID• 10-mg tablet / 20-mg tablet / For ≥ 5 years old• Drug interactions: Warfarin, erythromycin, theophylline• take1 hour before or 2 hours after meals

Zileuton 1200 mg BID• 600-mg CR tablet• Only for those 12 years and older• Drug interactions: Warfarin and theophylline

Adverse effects

• Hepatotoxicity . Monitor LFTs (baseline, every month × 3 months , every 2–3 months for 1 year for montelukast and zafirlukast .

• Headache

• GI upset

• Risk of neuropsychiatric events (behavior and mood changes: aggression, agitation, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior, Tremor)

Managing Exacerbations: Initial – ED or Hospital

Classifying Severity of Asthma Exacerbations in the Urgent or Emergency Care Setting

Mild-moderate exacerbation (FEV1 of 40% or more)

a. Oxygen to achieve Sao 2 of 90% or moreb. An inhaled SABA up to three doses in the first hour

i. Adult dose: salbutamol MDI 4–8 puffs every 20 minutes for up to 4 hours; then every 1–4 hours as needed or by nebulizer 2.5–5 mg every 20 minutes for three doses; then 2.5–10 mg every 1–4 hours as neededii. Pediatric dose (12 years or younger): salbutamol MDI 4–8 puffs every 20 minutes for three doses; then every 1–4 hours as needed; use holding chamber (add mask if younger than 4 years) or by nebulizer 0.15 mg/kg (minimal dose 2.5 mg) every 20 minutes for three doses; then 0.15–0.3 mg/kg up to 10 mg every 1–4 hours as needed

c. OCS if no response immediately or if patient recently took OCS

Severe exacerbation (FEV1 less than 40%)

a. Oxygen to achieve Sao2 of 90% or moreb. High-dose inhaled SABA plus ipratropium by MDI plus valved holding chamber or nebulizer every 20 minutes or continuously for 1 hourc. Oral corticosteroids

i. Adult dose: Prednisone 40–80 mg/day in one or two divided doses until peak expiratory flow reaches 70% of predictedii. Pediatric dose (12 years or younger): 1–2 mg/kg in two divided doses (maximum 60 mg/day) until peak expiratory flow is 70% of predicted

d. Consider adjunctive therapies (intravenous magnesium or heliox) if still unresponsive .

Impending or actual respiratory arrest

a. Intubation and mechanical ventilation with oxygen 100%

b. Nebulized SABA plus ipratropium

c. Intravenous corticosteroids

d. Consider adjunctive therapies (intravenous magnesium or heliox) if patient is still unresponsive to therapy.

e. Admit to intensive care.

Treatments that are NOT recommended in emergency care or hospital: Methylxanthines, antibiotics (unless needed for comorbid conditions), aggressive hydration, chest physical therapy, mucolytics, or sedation.

Exercise-induced bronchospasma. Presents with cough, shortness of breath, chest pain or

tightness, wheezing, or endurance problems during exercise

b. Diagnosis is made by an exercise challenge, in which a 15% decrease in FEV1 or peak expiratory flow is seen before and after exercise, measured at 5-minute intervals for 20–30 minutes.

c. Prevention and treatment :

i. Long-term control therapy, if appropriate (initiate or step-up)ii. Pretreatment with a SABA before exercise .iii. Leukotriene modifiers (LTMs) can attenuate symptoms in 50% of patients.

Asthma in Pregnancy

o Asthma may worsen, improve, or stay the same during pregnancy.

o Asthma may increase the risk of perinatal mortality, hyperemesis, vaginal hemorrhage, preeclampsia, complicated labor, neonatal mortality, prematurity, and low-birth-weight infants, especially if uncontrolled.

oRisks are relatively small and are not shown in all studies.

Medications:a. Preferred controller: Budesonide ICS (only category B ICS);

however, if well controlled on otherICS before pregnancy, it may be continued

b. Preferred rescue: salbutamol

c. LABAs are category C; less clinical experience. Use during pregnancy is reasonable if necessary for asthma control. Salmeterol is preferred LABA because of more experience with salmeterol.

d. LTM modifiers have limited data; most data are with montelukast (category B), and the data for montelukast are reassuring. Considered alternative therapy

e. Prednisone is category C; potential adverse effects in pregnancy are cleft palate, preeclampsia, gestational diabetes, low birth weight, prematurity. However, few studies were of patients with asthma, and women might have been exposed to longer-term prednisone use. Prednisone should be used, if necessary, for acute exacerbations in pregnancy.

Vaccines Adults with asthma (19–64 years of age) should receive:

1. The 23-valent pneumococcal polysaccharide vaccine (Pneumovax) once; then a one-time revaccination with pneumococcal vaccine at age 65 if 5 years or more after the first vaccination

2. Influenza vaccine every fall/winter

Patient Case

A 20-year-old woman who attends the university presents to the clinic today because of coughing and trouble breathing, about twice per week, which has been occurring for about 1 year. Her symptoms do not limit her activity, and she denies any nighttime symptoms. Spirometry is done today, and her FEV1 is 85% of predicted. She is taking no medications. Which best classifies her asthma?

A. Intermittent.B. Mild persistent.C. Moderate persistent.D. Severe persistent.

Which medication is the best option for the patient from previous case , in addition to salbutamol MDI 1 or 2 puffs before exercise?

A. salbutamol MDI 1 or 2 puffs four times/day as needed.B. Montelukast 10 mg/day.C. Omalizumab 150 mg subcutaneously every 4 weeks.D. Mometasone MDI 220 mcg/puff 1 puff/day.

Your recommendation has slightly improved her symptoms. However, she has now begun coughing at night once weekly. Which is the most appropriate treatment?

A. Budesonide/formoterol MDI 80/4.5 2 puffs two times/day.B. Montelukast 10 mg/day.C. Salmeterol MDI 2 puffs two times/day.D. Fluticasone 110 mcg/puff 1 puff two times/day

QUESTIONS ?