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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




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posted:8/11/2011
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