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The Effect of Inhaled Corticoster

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					     2007 NHLBI
   Guidelines for the
Diagnosis & Management
      of Asthma
   Expert Panel Report-3



      ASTHMA
    MEDICATIONS

  Mary Bouthiette RN, AE-C
Lynn Feenan RN, MSN, AE-C
      November 2008
 The 4 Components of Asthma Management
(Essential for Effective Asthma Management)

 Component 1: Measures of Asthma Assessment and Monitoring



 Component 2: Education for a Partnership in Asthma Care



 Component 3: Control of Environmental Factors and Comorbid
  Conditions That Affect Asthma

 Component 4:   MEDICATIONS
         The Goals of Asthma Therapy:
              (Asthma Control)                          EPR-3, p284

    Reducing impairment
      prevent chronic and troublesome symptoms
      prevent frequent use of inhaled SABA for symptoms
      maintain (near) “normal” pulmonary function
      maintain normal activity levels
      meet patients’ and families’ satisfaction with care



    Reducing risk
      prevent recurrent exacerbations of asthma (ED/inpatient)
      prevent progressive loss of lung function
      provide optimal pharmacotherapy



NAEPP Draft Report, ERP 2007
                                                        EPR-3, Page 78
     Monitoring Asthma Control
Ask the patient
   Has your asthma awakened you at night or early morning?
   Have you needed more rescue inhaler than usual?
   Have you needed urgent care for asthma? (office, ED, etc)
   Are you participating in your usual or desired activities?
   What are your triggers? (and how can we manage them?)

Actions to consider
   Assess whether medications are being taken as prescribed
   Assess whether inhalation technique is correct
   Assess spirometry and compare to previous measurements
   Adjust medications, as needed to achieve best control with
    the lowest dose needed to maintain control
   Environmental mitigation strategy

NAEPP Draft Report, ERP 2007
STEPWISE APPROACH FOR MANAGING ASTHMA IN
CHILDREN 0 - 4 YEARS OF AGE EPR-3, p291-296

                                          Persistent Asthma: Daily Medication
 Intermittent
                            Consult with asthma specialist if step 3 or higher care is required
   Asthma
                                             Consider consultation at step 2

Quick-Relief Medication for All Patients
   SABA as needed for symptoms. Intensity of                                                              Step up if
   treatment depends on severity of symptoms: up to 3                                      Step 6         needed (check
   treatments at 20-minute intervals as needed. Short                                      Preferred:     adherence,
   course of systemic oral corticosteroids may be                                        High dose ICS    environmental
   needed.                                                                 Step 5                         control )
• Use of beta2-agonist >2 days a week for symptom                          Preferred:
   control (not prevention of EIB) indicates inadequate                  High dose ICS       AND
   control and the need to step up treatment.
                                                            Step 4                        either LTRA
                                                                                           Or LABA         Assess
                                                           Preferred:        AND
                                              Step 3                                                       Control
                                                          Medium-dose
                                            Preferred:        ICS                            AND
                          Step 2           Medium-dose                    either LTRA                     Step down
                       Preferred:              ICS                         Or LABA                        if possible
                      Low-dose ICS                            AND                             Oral
                                                                                         Corticosteroid   (asthma well
     Step 1            Alternative:                        either LTRA                                    controlled
    Preferred:                                              Or LABA                                       for 3
                          LTRA
    SABA prn                                                                                              months)
                        Cromolyn



    Patient Education and Environmental Control at Each Step
STEPWISE APPROACH FOR MANAGING ASTHMA IN
CHILDREN 5-11 YEARS OF AGE   EPR-3, p296-304

                                          Persistent Asthma: Daily Medication
 Intermittent
                            Consult with asthma specialist if step 4 or higher care is required
   Asthma
                                             Consider consultation at step 3

Quick-Relief Medication for All Patients
   SABA as needed for symptoms. Intensity of                                                                  Step up if
                                                                                               Step 6
   treatment depends on severity of symptoms: up to 3                                                         needed (check
   treatments at 20-minute intervals as needed. Short                                                         adherence,
   course of systemic oral corticosteroids may be
                                                                                               Preferred:
                                                                                                              environmental
   needed.                                                                                   High-dose ICS
                                                                             Step 5          + LABA + oral
                                                                                                              control and
• Use of beta2-agonist >2 days a week for symptom                                                             comorbidities)
                                                                             Preferred:      Corticosteroid
   control (not prevention of EIB) indicates inadequate
                                                                           High dose ICS
   control and the need to step up treatment.               Step 4                            Alternative:
                                                                              + LABA         High-dose ICS
                                                                            Alternative:    +either LTRA or    Assess
                                              Step 3                      High-dose ICS+     Theophylline      Control
                                      Preferred :          Preferred:       either LTRA
                                                          Medium-dose                            + oral
                                    Low-dose ICS+                         or Theophylline                      Step down
                        Step 2       either LABA,          ICS+LABA                          corticosteroid
                       Preferred:      LTRA, or
                                                                                                               if possible
                      Low-dose ICS Theophylline            Alternative:
                                                                                                               (asthma well
                       Alternative:                       Medium-dose
     Step 1               LTRA                             ICS+either
                                                                                                               controlled
    Preferred:          Cromolyn
                                          OR                                                                   for 3
                                                            LTRA, or
    SABA prn                         Medium-dose                                                               months)
                      Theophylline                        Theophylline
                                          ICS


    Patient Education and Environmental Control at Each Step
STEPWISE APPROACH FOR MANAGING ASTHMA IN
YOUTHS > 12 YEARS AND ADULTS  EPR-3, p333-343

                                          Persistent Asthma: Daily Medication
 Intermittent
                            Consult with asthma specialist if step 4 or higher care is required
   Asthma
                                             Consider consultation at step 3

Quick-Relief Medication for All Patients
   SABA as needed for symptoms. Intensity of                                                               Step up if
   treatment depends on severity of symptoms: up to 3                                                      needed (check
   treatments at 20-minute intervals as needed. Short                                       Step 6         adherence,
   course of systemic oral corticosteroids may be                                                          environmental
   needed.                                                                                  Preferred:     control and
• Use of beta2-agonist >2 days a week for symptom
   control (not prevention of EIB) indicates inadequate
                                                                             Step 5       High-dose ICS    comorbidities)
                                                                            Preferred:    + LABA + oral
   control and the need to step up treatment.               Step 4        High dose ICS   Corticosteroid
                                                                             + LABA                         Assess
                                                           Preferred:
                                              Step 3      Medium-dose                                       Control
                                            Preferred:                                        AND
                                                           ICS+LABA
                          Step 2           Low-dose ICS                       AND
                                                                                                            Step down
                       Preferred:        OR                Alternative:                     Consider
                                                                             Consider    Olamizumab for     if possible
                      Low-dose ICS Medium-dose            Medium-dose
                       Alternative:     ICS+                              Olamizumab for  patients with     (asthma well
                                                           ICS+either
     Step 1               LTRA      either LABA,              LTRA,        patients with    allergies       controlled
    Preferred:          Cromolyn       LTRA,              Theophylline       allergies                      for 3
    SABA prn          Theophylline  Theophylline           Or Zileutin                                      months)
                                     Or Zileutin


    Patient Education and Environmental Control at Each Step
                                                             EPR-3, Page 330


     Recommended Action for Treatment
      Based on Assessment of Control
            Well                  Not Well              Very Poorly
        Controlled                Controlled            Controlled
   Maintain current step    Step up 1 step and     Consider short course
                            reevaluate in 2-6      of oral corticosteroids
                            weeks
   Consider step down if    For side effects,      Step up 1-2 steps and
   well controlled for at   consider alternative   reevaluate in 2 weeks
   least 3 months           treatment options
                                                   For side effects,
                                                   consider alternative
                                                   treatment options
  Before stepping up check adherence and environmental control
NAEPP Draft Report, ERP 2007
            Treatment Strategies

 Gain Control!!!
   Aggressive, intensive initial therapy to
    suppress airway inflammation and gain prompt
    control
 Maintain Control
   Frequent follow-up, clinically and
    physiologically
   Therapeutic modifications depending on
    severity and clinical course
   “Step down” long-term control medications to
    maintain control with minimal side effects
             Asthma Medications

 Used to prevent and control asthma symptoms.

 Improve quality of life

 Reduce the frequency and severity of
  exacerbations
 Reverse airway obstruction
            Asthma Medications:
             2 General Classes

 LONG-TERM CONTROL MEDICATIONS are taken
  daily to achieve and maintain control of persistent
  asthma.


 QUICK-RELIEF MEDICATIONS are taken to treat
  acute symptoms and exacerbations
     Long-Term Control Medications

 Inhaled Corticosteroids

 Cromolyn sodium and Nedocromil

 Immunomodulators

 Leukotriene Modifiers

 LABAs (Salmeterol and Formoterol)

 Methylxanthines
           Inhaled Corticosteroids

 ICSs are the preferred long-term therapy in
  children of all ages and adults
 ICSs are well tolerated and safe at the
  recommended dosages (Evidence A)
 ICSs improve asthma control more effectively
  than leukotriene receptor antagonists
 ICSs reduce impairment and risk of exacerbations
            Inhaled Corticosteroids

   To reduce the potential for adverse effects, the
    following measures are recommended:


      - spacers/valved holding chambers
      - rinsing mouth after inhalation
      - using the lowest dose of ICS that maintains
       asthma control
           Inhaled Corticosteroids

 Benefit of daily use:



   - fewer symptoms and exacerbations
   - < use of quick-relief medicine
   - improved lung function
   - reduced airway inflammation
                 Available
          Inhaled Corticosteroids

 Beclomethasone HFA (QVAR)

 Budesonide DPI (Pulmicort)

 Budesonide Inhaled (Pulmicort Respules)

 Flunisolide CFC & HFA (Aerobid)

 Fluticasone HFA & DPI (Flovent)

 Mometasone DPI (Asmanex)

 Triamcinolone (Azmacort)
            Beclomethasone HFA

 Brand name is QVAR
 Available in 40 or 80 mcg per puff
 Medium daily dose for child 5-11 years of age is
  160-320 mcg
 Medium daily dose for > 12 years of age and
  adults is 240-480 mcg
 Must use with appropriate spacer
 Rinse mouth after dose
                Budesonide DPI

 Brand name is Pulmicort Flexhaler

 Available in 90 and 180 mcg per inhalation

 Flexhaler contains LACTOSE with some taste

 Built in counter

 Medium daily dosage for child 5-11 years of age

  is 400-800 mcg
 Budesonide Inhalation Suspension for
             Nebulization

 Brand name is Pulmicort Respules

 Available in 0.25mg, 0.50mg, 1.0mg/2ml
  suspension for nebulizer/compressor
 Not recommended to mix with albuterol

 Use in jet nebulizer with appropriate fitting mask

 No blow-by!
                    Flunisolide

 Brand name is Aerobid or Aerobid M

 Available in MDI 250 mcg per puff

 Available in HFA 80 mcg per puff

 Must be used with appropriate spacer

 Rinse out mouth
                   Fluticasone

 Brand name is Flovent HFA MDI

 Available in 44, 110, 220 mcg/puff

 Medium daily dosage for child 0-11 years of age is
  >176-352 mcg
 4 test sprays away from the face shaking well for
  5 seconds before each spray
 Use with appropriate spacer

 Rinse mouth out after use
               Mometasone DPI

 Brand name is Asmanex Twisthaler

 Available in 200 mcg per inhalation

 Approved for youths 12 years of age and adults

 Medium daily dosage is 400 mcg

 Very fine powder you may not taste, smell or feel

 Dose counter

 No priming
                Triamcinolone

 Brand name is Azmacort

 Available in 75 mcg/puff

 Device has a built in spacer and mouthpiece

 Rinse out mouth after use

 Medium daily dose for children 5-11 years of age
  is 600-900 mcg
 2 test sprays away from face
                    Cromolyn

 Brand name is Intal (non-steroidal)

 MDI 1mg/puff

 Nebulizer 20mg ampule

 Safety is primary advantage

 Disadvantage is TID-QID dosing

 Used as alternative but not preferred
                   Nedocromil

 Brand name is Tilade (non-steroidal)

 MDI 1.75 mg/puff

 Safety is primary advantage

 Disadvantage is TID-QID dosing

 Used as alternative but not preferred
               Immunomodulators:
                  Omalizumab

 Brand name is Xolair

 Anti-IgE injection therapy for year round allergic asthma

 Approved for 12 years of age and older who have moderate
  to severe persistent allergic asthma
 Dosage according to pre-treatment serum IgE and body
  weight
 Anaphylaxis can happen

 Epipen must be prescribed
            Leukotriene Receptor
            Antagonists (LTRAs)

 LTRAs are alternative, but not preferred, therapy
  for the treatment of patients who require step 2
  care for mild persistent asthma
 LTRAs can be used as adjunctive therapy with ICS

 For youths 12 years of age and adults, LTRAs are
  NOT preferred adjunctive therapy compared to
  addition of LABAs
              Available LTRAs

 Montelukast-Brand name is Singulair



 Zafirlukast-Brand name is Accolate



 Zieuton-Brand name is Zyflo
  Dosing Regimen in Adults & Children

 Brand name is Singulair

 Administered once daily at bedtime

 4mg chewable tablets qhs (1-5 years of age)

 5mg chewable tablets qhs (6-14 years of age)

 10mg tablet qhs (12 years of age and adults)
  Inhaled Long-Acting Beta 2 Agonists

 Should NOT be used for acute symptom relief or
  exacerbations
 Use ONLY with ICSs

 LABA is the preferred therapy to combine with
  ICSs in youths 12 years of age and adults
                   Salmeterol

 Brand name is Serevent

 DPI 50 mcg blister

 Not appropriate for monotherapy

 Use only with ICS’s

 Not to be used as a rescue medication
                  Formoterol

 Brand name is Foradil which is a capsule

 DPI 12 mcg/single use capsule

 Not appropriate for monotherapy

 Use only with ICSs

 Should NOT be used for acute symptom relief or
  exacerbations
           Combined Medication

 Budesonide/Formoterol



 Fluticasone/Salmeterol
           Budesonide/Formoterol
                 HFA MDI

 Brand name is Symbicort

 Available in 80 mcg/4.5 mcg

 Available in 160 mcg/4.5 mcg

 Usual dosage is 2 puffs bid…dose depends on
  level of severity and control
 2 test sprays, shaking well before each spray
             Fluticasone/Salmeterol

 Brand name is Advair

 DPI 100, 250 or 500 mcg/50 mcg

 HFA MDI 45, 115, 230 mcg/21 mcg

 Usual dosages of DPI for 5-11 years of age and 12 years of
  age and adults is 1 inhalation bid
 Usual dosages of HFA for 5-11 years of age and 12 years of
  age and adults
 4 test sprays away from the face shaking well for 5 seconds
  before each spray
                Methylxanthines

 Brand name is Theophylline

 Available in liquid, sustained-release tablets and
  capsules
 Routine serum theophylline level monitoring is
  essential
 Various factors such as diet, food, age, smoking
  and other medications can affect serum
  concentrations
          Quick-Relief Medications

 Anticholinergics



 Inhaled Short-Acting Beta 2 Agonists



 Systemic corticosteroids
               Anticholinergics

 Provides additive benefit to SABAs in acute
  asthma episodes
 Does not block EIB

 Evidence is lacking for added benefits in long
  term control asthma therapy
 Alternative to patients with intolerance to SABAs
               Ipratropium HFA

 Brand name is Atrovent

 MDI has 200 puffs per canister at 17 mcg per puff

 HFA does not contain soy as did the older product

 2 test sprays away from the face

 Nebulizer solutions is 0.25 mg/ml

 Usual dosage for 12 years of age and adults is

  2-3 puffs q 6hr OR 0.25mg q 6hr
         Ipratropium with Albuterol

 Brand name is Combivent



 Available in CFC, MDI and Nebulizer solution



 Release 3 test sprays away from the face
  Inhaled Short Acting Beta 2 Agonists

 Treatment of choice for relief of acute symptoms
  and prevention of EIB
 May double usual dose for exacerbations

 Albuterol, levalbuterol and pirbuterol are
  bronchodilators that relax smooth muscle
 > use of SABA > 2 days per week for symptom
  relief (not prevention of EIB) generally indicates
  inadequate asthma control
             Albuterol CFC & HFA

 Brand name is Proventil or Ventolin

 Also available in inhalation solution for use in
  nebulizer/compressor
 Used for quick relief of asthma symptoms

 Also used for prevention of EIB

 Both CFC & HFA available in 90 mcg per puff and
  200 puffs per canister
 4 test sprays
          Pirbuterol CFC Autohaler

 Brand name is Maxair

 Breath actuated device

 200 mcg/puff, 400 puffs per canister

 No need for spacer

 Children < 4 years of age may not generate
  sufficient inspiratory flow rate to activate
  autohaler
               Levalbuterol HFA

 Brand name is Xopenex

 Available in 45 mcg per puff with 200 puffs per
  canister that requires 4 test sprays
 Also available in Nebulizer solution at 0.31 mg,
  0.63 mg and 1.25 mg/3ml unit dose vials AND 1.25
  mg/0.5ml
          Systemic Corticosteroids

 Short courses or “bursts” of oral systemic
  corticosteroids are effective for establishing
  control when initiating therapy or during a period
  of gradual deterioration
 Dosage is 2 mg per kg per day

 Long term oral systemic corticosteroids are used
  for severe persistent asthma
        OTC Medications in Asthma

 Always include OTC’s in medical history

 OTC products such as ASA may provoke asthma

 OTC short acting bronchodilators are NOT a
  substitute for prescription medications
       Complementary & Alternative
               Medicine

 Ask patients about all the medications and
  interventions they are using
 Evidence is insufficient to recommend or not
  recommend most CAMs or treatments for asthma
 Patients who use herbal treatments for asthma
  should be cautioned about the potential for
  harmful ingredients and for interactions with
  recommended asthma medications
Delivery Devices for Inhaled Medications

 Metered-dose inhaler (MDI)

 Breath-actuated MDI

 Dry powder inhaler (DPI)

 Spacer or valved holding chamber (VHC)

 Nebulizers/Compressors
                 Remember To:

 Educate patients and families how to use inhalers
  and devices
 Give and have patients return demonstration

 Ask patients to demonstrate technique at every
  visit
 Different devices require different inhalation
  techniques
      Asthma Education Resources

 www.nhlbi.nih.gov

 www.breathenh.org

 www.asthmanow.net

 www.asthmaeducators.org

 www.aafa.org

 www.aaaai.org

				
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