Asthma Management

2. Asthma Management Fine Tuning • Maximum control with minimum medication • Start with mild asthma and work up the scale (BTS/SIGN 2004)

3. Asthma Management Fine Tuning • Asthma control means: • -Minimal symptoms during day and night • -Minimal need for reliever medication • -No exacerbations • -No limitation of physical activity • -Normal lung function(FEV1 and/or PEF >80% predicted or best)

4. Asthma Management Fine Tuning • Before initiating a new drug therapy: • -Check compliance with existing therapies • -Check inhaler technique ( Reconsider inhaler delivery system) • -Eliminate trigger factors

5. Asthma Management Fine Tuning

6. Asthma Management Adults Step 1:Mild intermittent asthma Step 2:Introduction of regular preventer therapy Step 3:Add-on therapy Step 4:Poor control on moderate dose of inhaled steroids + Add on Step 5:Use of oral steroids

7. Asthma Management Preventers: Inhaled corticosteroids (ICS) • 1st Choice • Moderate Dose: Adults  200-800 mcg/day Children  200-400 mcg/day • BDP= Becotide (Beclomethasone Dipropionate) • = Pulmicort (Budesonide) • Flexotide (Fluticasone) ½ dose of BDP • High Dose ICS Adults  2000 mcg/day • Children  800 mcg/day

8. Asthma Management Add-On therapy • 1st Choice LABA Adults/ Children 5-12 years • LABA should not be used without ICS • Others • 2nd choice: LTRAs • 3rd choice: SR Theophylline • 4rth choice: Oral LABA ( SR Be agonists tab) S.E

9. Asthma Management Step 1: Mild intermittent asthma -Prescribe inhaled short-acting 2 agonist as short term reliever therapy for all patients with symptomatic asthma -Review asthma management in patients with high usage of inhaled short acting 2 agonists

10. Asthma Management Step 2: Introduction of regular preventer therapy when? • Recent exacerbations • Nocturnal asthma • Impaired lung function • Using inhaled B2 agonist >once a day • Using inhaled B2 agonists > 3 times per week

11. Asthma Management Step 2: Introduction of regular preventer therapy • Inhaled steroids are the 1st line preventers • Give inhaled steroids initially twice daily • If good control, once a day inhaled steroids at the same total daily dose

12. Asthma Management Step 2: Introduction of regular preventer therapy • Start patients at inhaled steroid dose appropriate to disease severity • Adults: 400 mcg per day • Children 5-12 years: 200 mcg per day • Children under 5 years: higher doses may be required to ensure consistent drug delivery • Use lowest dose at which effective control is maintained • Monitor children’s height on a regular basis

13. Asthma Management Poor control • Still symptoms or • Sleep disturbance or • Restriction of activity • Despite use of regular inhaled steroid + PRN bronchodilator

14. Asthma Management Poor control – Therapeutic options • 1) check compliance • 2) check inhaler technique • 3) Add LABA 1st Choice: Adults/ children 5-12 • (in children <5 years LTRAs preferred) • 4) Suboptimal or no response : →  dose of inhaled steroid (800 mcg adult, 400 mcg children via spacer device • 5) Poor control persist→ consider additional therapy: • LTRAs, SR Theophylline or SR oral B 2 agonist + • Increase Inhaled steroid to 2000 mcg/day • 6) Oral steroids

15. Asthma Management Step 3: Add-on therapy

16. Asthma Management Step 3: Add-on therapy

17. Asthma Management Step 3: Add-on therapy

18. Asthma Management Step 3: Add-on therapy

19. Asthma Management Step 3

20. Asthma Management Step 3

21. Asthma Management Step 4: poor control on moderate dose of inhaled steroids + Add on •  inhaled steroids to 2000 mcg/day (adult) or 800 mcg/day (children) • LTRAs OR SR Theophylline OR Oral SR B2 agonist • Consider referring to specialist care before proceeding to step 5

22. Asthma Management Step 5: Use of oral steroids • Maintenance course (long term) • Plus drugs in step 4

23. Stepwise management ofasthma inadults Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

24. Stepwise management of asthma in adults Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

25. Stepwise management of asthma in adults Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

26. Stepwise management ofasthma in adults Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

27. Stepwise management ofasthma in adults Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

28. Stepwise management ofasthma in adults Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

29. Stepwise management ofasthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

30. Stepwise management ofasthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

31. Stepwise management ofasthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

32. Stepwise management ofasthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

33. Stepwise management ofasthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

34. Stepwise management ofasthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

35. Stepwise management ofasthma in children under5 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

36. Stepwise management ofasthma in children under 5 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

37. Stepwise management ofasthma in children under 5 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

38. Stepwise management ofasthma in children under 5 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

39. Stepwise management ofasthma in children under 5 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

40. Asthma Management Stepping down • Important to review patients regularly as they step down • Patients should be maintained at the lowest possible dose of inhaled steroids • Reductions should be considered every 3 months • Reducing the dose by 25-50% each time

41. Asthma Management Exercise Induced Asthma • Often indicates poorly controlled asthma • For patients taking inhaled steroids add: • LABA • LTRAs • Cromones • Oral B2 agonist • Theophylline • Inhaled short acting B2 agonists immediately before exercise

42. Asthma Management Seasonal asthma • Start prophylactic steroid therapy before season begin

43. Asthma Management Exacerbations Occasional attacks between period of good control which can predicted by warning signs

44. Asthma Management Exacerbations warning signs • Increase symptoms • Sleep disturbance • Fall in exercise tolerance • Increase need for bronchodilator • Decrease effectiveness of bronchodilator • falling PEF • wide variations in PEF • inability to achieve optimum PEF after B agonist

45. Asthma Management Exacerbations

46. Asthma Management Management of exacerbations • Provide emergency supply oral steroids (Rescue Course) → to take at the 1st warning sign • seek medical help • written action plan • Time spent with patient for “What to do and When” will help prevent acute attack

47. Asthma Management Rescue course oral steroid • 20 mg Children 2-5 years • 30-40 mg Children >5 y ↨3 days *The dose should be repeated if child vomited • 40-50 mg Adult: 5 days or until recovery

48. Asthma Management When do you stop medication?

49. Asthma Management When do you stop medication? • Adult with stable asthma is possible to reduce inhaled steroids without losing control • On average step down gradually by 25% (Hawkins et al 2003) • Keep patient under regular review even when well controlled

50. Asthma Management How do you know if a child is growing out of well controlled asthma if the prophylactic therapy is never reduced for a trial period? • Often patients stops medications themselves when they are better • Reducing treatment gradually to the minimum dose possible before medication is stopped • No exacerbations • No symptoms • No B 2 use • If symptoms recur medications should be restarted.