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How do we assess severity in asthma patients?
- Can only assess severity in pt not previously on asthma tx
- Rule of 2s - if pt meets any of these criteria, then we go to Step 2 to initiate tx. If they are way worse, then we'd go to Step 3 and consider a short course of systemic oral corticosteroids
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What are the Rule of 2s criteria for Mild asthma severity (persistent)?
- Sx > 2 d/wk, but not daily
- Nighttime awakenings 1-2 x/month (3-4 x/mo in > 12 y.o.)
- SABA use for sx control > 2 d/wk
- Exacerbations 2+ in 6 mo for 0-4 y.o.; in 1 year for 5+
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If a pt's asthma symptoms are less than the rule of 2s, what treatment is recommended?
the asthma severity would be considered intermittent and initiating treatment should begin at Step 1
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On what basis do we adjust treatment in asthma?
based on control
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What are the criteria for the Rule of 2s to classify asthma as "not well controlled'? What is the recommended action for treatment?
- symptoms > 2 d/wk
- nighttime awakenings 2+ x per month (4 for adults)
- some limitation of normal activity
- SABA use > 2 d/wk
- exacerbations requiring steroids 2-3/yr
Step up one step and reevaluate in 2-6 weeks
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General treatment approach for asthma
- All pts need SABA
- Next add ICS
- Then add LABA or LTRA
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What are the Steps for Managing Asthma?
- Step 1 - intermittent asthma - only SABA
- for all following steps, SABA remains as part of tx
- Step 2 - persistent asthma - daily meds - add low-dose ICS (alt in > 5yo, add LTRA, cromolyn, theophylline)
- Step 3 - persistent asthma - daily meds - go to medium dose ICS (> 5 yo prefer low dose ICS + LABA, LTRA, or theophylline)
- Step 4 - persistent asthma - daily meds - medium-dose ICS + LTRA or LABA (the LABA is preferred) (alt for > 5 yo is ICS + LTRA, theophylline or zileuton)
- Step 5 - persistent asthma - daily meds - high-dose ICS + LTRA or LABA (LABA preferred) (for > 12 yo consider omalizumab)
- Step 6 - persistent asthma - daily meds - high-dose ICS + LTRA or LABA + oral corticosteroid (consider omalizumab for > 12 yo)
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When would stepping down asthma treatment be appropriate?
if the pt has had good control for 3 months
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Name SABAs for asthma the MOA and the device for each
- MOA: beta agonist - bronchodilation
- Albuterol (neb - AccuNeb; MDI - ProAir, Proventil, Ventolin HFA)
- Levalbuterol (neb and HFA - xopenex)
- Pirbuterol (MDI - Maxair)
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Name ICSs for asthma the MOA and the device for each
- MOA - decrease inflammation
- First agent added when SABA not enough
- Ciclesonide (MDI - Alvesco HFA)
- Mometasone (DPI - Asmanex)
- Fluticasone (DPI or MDI - Flovent)
- Budesonide (DPI or neb - Pulmicort)
- Beclomethasone (MDI - QVAR HFA)
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Name LABAs for asthma the MOA and the device for each
- MOA - beta agonist - bronchodilation
- Never use without ICS in asthma!
- Add when SABA + ICS not effective
- Salmeterol (DPI - Serevent)
- Formoterol (DPI - Foradil)
- Fluticasone/salmeterol (DPI or MDI - Advair)
- Budesonide/formoterol (MDI - Symbicort HFA)
- Mometasone/formoterol (MDI - Dulera HFA)
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Name LTRAs for asthma the MOA and the device for each
- MOA: prevents airway edema and contraction
- Can consider adding on in place of LABA when SABA + ICS is not effective
- Montelukast (Singulair)
- Zafirlukast (Accolate)
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What is the MOA and place in therapy for theophylline in asthma?
- MOA: bronchodilation and suppression of airway stimuli
- Can add to ICS in Steps 2-4
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What is the MOA and place in therapy for omalizumab (Xolair) in asthma?
- MOA: mab that inhibits IgE binding to mast cells and basophils
- Can add on in Steps 5 & 6 (high dose ICS + LABA +/- oral steroids)
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How do we decide when to use nebs, MDIs, orals, spacers, etc?
- Kids < 4, use nebs with face mask
- MDIs are more portable than nebs
- If PO is desired, can use LTRA, theophylline
- Use spacers with MDIs (except pirbuterol and beclomethasone)
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How can we assess medication adherence and implement strategies to remove barriers and improve outcomes in asthma pts?
- Ask pt how often they use SABA, how they are taking maintenance meds, how often they have exacerbations, etc
- Change betw nebs and HFA based on pt preference
- Educate pt on how to properly use inhalers, peak flow meter, when to seek medical attention
- Evaluate triggers and co-morbid conditions
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How does new research on tiotropium, levalbuterol, ICS add-on therapy for children, and omalizumab affect the 2007 asthma guidelines?
- Tiotropium - anticholinergic - more effective sx control over increasing the ICS dose (is not inferior to Advair (fluticasone/salmeterol))
- Levalbuterol and albuterol have identical efficacy and SEs
- Adding LABA to ICS is more likely to have "best response" than adding LTRA or increasing the ICS dose
- Omalizumab decreases the # of sx days/2 weeks and decreases exacerbations
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Appropriate therapy for asthma exacerbations at home
- SABA - more frequent use - up to 2 treatments of 2-6 puffs 20 minutes apart
- PO steroids if on hand
- if good response, PEF > 80%, contact Dr. for f/u instructions, continue SABA q 3-4 h for 24-48 h
- if incomplete response, PEF 50-79%, add oral systemic corticosteroid, continue SABA, contact Dr. today
- if poor response, PEF < 50%, add oral systemic corticosteroid, repeat SABA immediately, if severe distress and nonresponsive to tx, call Dr. and go to ER - consider calling 911
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Appropriate therapy for asthma exacerbations in hospital
- High-dose SABA + ipratropium q 20 minutes or continuously for 1 hr
- supplemental oxygen - intubate if necessary
- PO steroids
- if impending or actual resp arrest consider adjunct therapies: Mg Sulfate IV, Heliox, Ketamine
- If PEF is < 69% after 4 h, admit to ward or ICU
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Appropriate therapy upon discharge for asthma exacerbation
- SABA
- ICS
- rest of PO steroid course
- follow up in 1-4 weeks
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