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Asthma Reference: National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute. National Institutes of Health; April 1997. National Institute of Health Publication No. 97-4051. Asthma Statistics 14.6 million Americans have asthma The centers for disease control and prevention reported a 61% increase in asthma rate between 1982 and 1994 American lung association reports 5,600 people die annually in the US from asthma Total estimated cost of asthma in 1993 was 12.6 billion in direct and indirect expenditures Missing the Mark: U.S. Not Meeting Asthma Goals Asthma in America reveals that the united states is not meeting the goals for asthma management established last year by the national heart, lung, and blood institute (NHLBI).* A point-by-point comparison: *According to the NHLBI’s Practical Guide for the Diagnosis and Management of Asthma: “The goals of asthma therapy provide the criteria that the clinician and patient will use to evaluate the patient’s response to therapy.” Reference: DATA on file National Goals Of Asthma Therapy No sleep disruption No missed school or work No (or minimal) need for ER visits / hospitalizations Maintain normal activity levels Have normal or near normal lung function “Asthma In America” Survey Findings According to the NHLBI’s practical guide for the diagnosis and management of asthma: “the goals of asthma therapy provide the criteria that the clinician and patient will use to evaluate the patient’s response to therapy.” Reference: DATA on file. 30% of asthma patients awakened by breathing problems at least once a week. 49% of children with asthma - and 25% of adults with asthma - missed school or work because of asthma in past year. 32% of children with asthma went to emergency room for asthma attacks in past year. 41% of all people with asthma sought urgent care from the ER, clinic or hospital last year. “Asthma In America” Survey Findings - Continued 48% of patients limited in sports / recreation. 36% limited in normal physical exertion. 25% limited in their social activities. Only 35% of patients report having had a lung- function test in past year. Only 28% have peak flow meters to monitor their airflow; 9% report using one at least a week. Asthma: Overview Definition Histopathology (what happens at the tissue level Etiology/triggers (what causes asthma) Pathogenesis (what does asthma do) Treatment options Pharmacist role What is Asthma? DEFINITION OF ASTHMA: “Asthma is a chronic inflammatory disorder of the airways…associated with variable airflow limitation [bronchoconstriction] and increased airway responsiveness.” (1997 NIH Guidelines) Reference: National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute. National Institutes of Health; April 1997. National Institute of Health publication No. 97-4051. Asthma: Definition Chronic inflammatory disorder of the airways Characterized by wheezing, coughing, chest tightness, difficult breathing/breathlessness Bronchial hypersensitivity to stimuli Airflow obstruction is reversible, either spontaneously or with treatment Asthma: Etiology The etiology or cause of asthma is not well understood at this time What is known: Asthma occurs in families Is associated with atopy (atopic dermatitis) Associated with allergen and chemical exposure Increased risk with small birth size Diet? Asthma: Airway Inflammation Contributes to: Airway hyperresponsiveness Airflow limitation Respiratory symptoms Disease chronicity Asthma: Airflow Limitation Airflow limitation due to: Acute bronchoconstriction Airway edema Mucus plug formation Airway remodeling Asthma: Histopathology Denudation of the airway epithelium (change in the lining of the airway) Collagen deposition beneath the basement membrane (hold on a diagram is coming) Edema (swelling) Mast cell activation (cells involved in allergic mediation) Presence of other inflammatory cells Michael W. Peterson, M.D., Associate Professor of Medicine Department of Internal Medicine The University of Iowa College of Medicine http://www.vh.org/Providers/ClinGuide/AsthmaIM/Figure2.html Asthma: Changes in Airway Morphology Asthma Triggers Allergen exposure Air pollution Respiratory infections Cigarette smoking Vigorous exercise Drugs Cold air Pets Dust Strong emotion (laughing, crying) Asthma: Factors That Exacerbate (Intensify Symptoms) Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs Asthma: Pathogenesis (What Happens) Due to the end result of inflammation and airway remodeling the lung becomes less efficient in exchanging oxygen The amount of air that can be exhaled per unit time is decreased Factors in Making Diagnosis History Wheeze, cough, shortness of breath Other causes If not infection or other disease process Consider GERD Document airway obstruction PEFR or spirometry Demonstrate reversibility of obstruction/symptoms Asthma: FEV1 Decreased Goals of Therapy Prevent chronic symptoms Maintain “normal” pulmonary function Prevent exacerbations Meet patient’s and families’ expectations of and satisfaction with asthma care Goals of Therapy Minimal (ideally no) need for quick relief beta2-agonist therapy No emergency visits to doctors or hospitals Maintain normal activity levels, including exercise Minimal or no adverse effects of medicine Major New Revisions Medications now classified as long-term control and quick relief Continued emphasis that most effective control for long-term control are those with anti- inflammatory effect New medications available Long-acting inhaled beta-agonists Leukotriene modifiers Nedocromil Major New Revisions (Continued) Address issues regarding safety of medications Stepwise approach emphasizes initiating therapy at a higher level and then stepping down Recommendations on estimated clinical comparability of inhaled corticosteroids Key Points: Inhaled Corticosteroids According to the NIH: Inhaled Steroids are the Most Effective Long-Term Control Medication for Persistent Asthma* The daily use of inhaled steroids can help: Diminish asthma symptoms. Improvement will continue gradually Reduce occurrence of severe exacerbations Decrease use of quick-relief medication Improve lung function significantly, as measured by peak flow, FEV1, and airway hyperresponsiveness Asthma symptoms may return if patients stop taking inhaled steroids. * Children usually begin with a trial of cromolyn or nedocromil. Reference: National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute. National Institutes of Health; April 1997. National Institute of Health publication No. 97- 4051. Improvement in PEF After Initiation of ICS Therapy in Patients With Different Duration of Asthma Symptoms Mean % Improvement in PEF 40 Duration of Symptoms 30 <6 mo 6-12 mo 20 1-2 yr 2-5 yr 5-10 yr 10 >10 yr 0 0 3 mo 1 yr 2 yr Time Reference: Selroos et al. Chest. 1995;108(5):1228-1234. Classification System: Based on Pre-treatment Symptoms. PEF or FEV1 Long Term Control Days w/ Sx’s Noc w/ sx’s PEF variability Daily Medications STEP 4 60% PEF or Inhaled steroid- Severe high dose plus Continual Frequent FEV1. Persistent Long acting β2 >30% agonist Variability LT Steroid STEP 3 Moderate >60% -- <80% Inhaled steroid- medium dose Persistent Daily 5/month >30% Variability OR low to med dose with LA STEP 2 80% Inhaled steroid- Mild low dose OR Persistent 3-4/month 3-6/week Cromolyn or 20-30% var. Nedocromil. Consider LT tx. STEP 1 >80% No daily medications. Mild 2/week 2/month Intermittent <20% var. Role of the Pharmacist 1. Educate patients about asthma medications. 2. Instruct patients about the proper techniques for inhaling medications. 3. Monitor medication use and refill intervals to help identify patients with poorly controlled asthma. Role of the Pharmacist 4. Encourage patients purchasing OTC asthma inhalers or tablets to seek medical care. 5. Help patients use peak flow meters appropriately. 6. Help patients discharged from the hospital understand their asthma management plan. Overview of Asthma Medications Long-term control Quick relief Corticosteroids Short-acting Cromolyn inhaled beta2- /Nedocromil agonists Long-acting beta2- Anticholinergics agonists Systemic Menthylxanthines corticosteroids Leukotriene modifiers Step 1 Classification of Severity: Step 2 Step 2 Interventions Step 3 Step 4 Step Down Medications of Interest: Serevet (Salmeterol) Available in MDI and DPI Long acting bronchodilator for long term control Not to be used in place of anti-inflammatory Used with inhaled steroid in step 3 May use one nightly dose for nocturnal symptoms Duration of bronchodilation 12 hours Not to be used for symptom relief or for exacerbations Medications of Interest: Flovent Fluticasone Inhaled steroids are most effective anti- inflammatory currently available. Twice daily dosing for improved compliance. Multiple strengths available. As with all steroids it is important to rinse mouth after use and spacers are helpful. Daily Inhaled Steroids Decrease Symptomatic Days in Asthmatics Summary Asthma is a significant cause of illness and death in the United States Asthma is a chronic disease and requires continuous surveillance Appropriate use of long term control medications can improve quality of life for people with asthma The End Questions?
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