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
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+
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
On what basis do we adjust treatment in asthma?
based on control
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
General treatment approach for asthma
- All pts need SABA
- Next add ICS
- Then add LABA or LTRA
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)
When would stepping down asthma treatment be appropriate?
if the pt has had good control for 3 months
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)
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)
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)
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)
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
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)
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)
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
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
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
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
Appropriate therapy upon discharge for asthma exacerbation
- rest of PO steroid course
- follow up in 1-4 weeks