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

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) 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 Asthma Management

Fine Tuning Asthma Management Step-wise approach Adults 5 steps Children 5-12 Years 5 steps Children < 5 Years 4 steps

Asthma Management 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 Adults

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

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

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

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

Poor control – Therapeutic options 1) check compliance 2) check inhaler technique 3) Add LABA 1 st 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 Asthma Management

Step 3: Add-on therapy Inadequate control on low dose inhaled steroids Asthma Management

Step 3: Add-on therapy Inadequate control on low dose inhaled steroids Add inhaled long-acting ß 2 agonist (LABA) Asthma Management

Step 3: Add-on therapy Inadequate control on low dose inhaled steroids Assess control of asthma Add inhaled long-acting ß 2 agonist (LABA) Asthma Management

Step 3: Add-on therapy Good response to LABA: Continue LABA Continue LABA Inadequate control on low dose inhaled steroids Assess control of asthma Add inhaled long-acting ß 2 agonist (LABA) Benefit from LABA but control still inadequate: Continue LABA Continue LABA Increase inhaled steroid dose to 800mcg/day (adults) and 400mcg/day (children 5-12 years) Increase inhaled steroid dose to 800mcg/day (adults) and 400mcg/day (children 5-12 years) No response to LABA: Stop LABA Stop LABA Increase inhaled steroid dose to 800mcg/day (adults) and 400mcg/day (children 5-12 years) Increase inhaled steroid dose to 800mcg/day (adults) and 400mcg/day (children 5-12 years) Asthma Management

Good response to LABA: Continue LABA Inadequate control on low dose inhaled steroids Add inhaled long-acting ß 2 agonist (LABA) Benefit from LABA but control still inadequate: Continue LABA Increase inhaled steroid dose to 800mcg/day (adults) and 400mcg/day (children 5-12 years) Control still inadequate: Trial of other add-on therapy, e.g. leukotriene receptor antagonist or theophylline Trial of other add-on therapy, e.g. leukotriene receptor antagonist or theophylline No response to LABA: Stop LABA Increase inhaled steroid dose to 800mcg/day (adults) and 400mcg/day (children 5-12 years) Assess control of asthma Asthma Management Step 3

Inadequate control on low dose inhaled steroids If control still inadequate go to Step 4 Add inhaled long-acting ß 2 agonist (LABA) Benefit from LABA but control still inadequate: Continue LABA and Increase inhaled steroid dose to 800mcg/day (adults) and 400mcg/day (children 5-12 years) Control still inadequate: Trial of other add-on therapy, e.g. leukotriene receptor antagonist or theophylline If control still inadequate go to Step 4 Assess control of asthma No response to LABA: Stop LABA Increase inhaled steroid dose to 800mcg/day (adults) and 400mcg/day (children 5-12 years) Good response to LABA: Continue LABA Asthma Management Step 3

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 Asthma Management

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

Step 1: Mild intermittent asthma Inhaled short acting ß 2 agonist as required Stepwise management of asthma in adults Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

Stepwise management of asthma in adults Step 2: Regular preventer therapy Add inhaled steroid mcg/day * 400mcg is an appropriate starting dose for many patients Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

Stepwise management of asthma in adults Step 3: Add-on therapys 1. Add inhaled long-acting ß 2 agonist (LABA) 2. Assess control of asthma: good response to LABA – continue LABA good response to LABA – continue LABA benefit from LABA but control still inadequate – continue LABA and increase inhaled steroid dose to 800mcg/day * (if not already on this dose) benefit from LABA but control still inadequate – continue LABA and increase inhaled steroid dose to 800mcg/day * (if not already on this dose) no response to LABA – stop LABA and increase inhaled steroid to 800mcg/day *. If control still inadequate, institute trial of other therapies (e.g. leukotriene receptor antagonist or SR theophylline) no response to LABA – stop LABA and increase inhaled steroid to 800mcg/day *. If control still inadequate, institute trial of other therapies (e.g. leukotriene receptor antagonist or SR theophylline) Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

Stepwise management of asthma in adults Step 4: Persistent poor control Consider trials of: increasing inhaled steroid up to 2000mcg/day * increasing inhaled steroid up to 2000mcg/day * addition of fourth drug (e.g. leukotriene receptor antagonist, SR theophylline, ß 2 agonist tablet) addition of fourth drug (e.g. leukotriene receptor antagonist, SR theophylline, ß 2 agonist tablet) Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Step 3: Add-on therapy Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

Stepwise management of asthma in adults Step 5: Continuous or frequent use of oral steroids Use daily steroid tablet in lowest dose providing adequate control Maintain high dose inhaled steroid at 2000mcg/day * Consider other treatments to minimise the use of steroid tablets Refer patient for specialist care Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Step 3: Add-on therapy Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent Step 4: Persistent poor control

Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Stepwise management of asthma in adults Step 1: Mild intermittent asthma Step 5: Continuous or frequent use of oral steroids Step 4: Persistent poor control Step 3: Add-on therapy Step 2: Regular preventer therapy

Stepwise management of asthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Inhaled short acting ß 2 agonist as required

Stepwise management of asthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 2: Regular preventer therapy Add inhaled steroid mcg/day * (other preventer drug if inhaled steroid cannot be used) 200mcg is an appropriate starting dose for many patients Step 1: Mild intermittent asthma Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

Stepwise management of asthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 3: Add-on therapy 1. Add inhaled long-acting ß 2 agonist (LABA) 2. Assess control of asthma: good response to LABA – continue LABA. good response to LABA – continue LABA. benefit from LABA but control still inadequate – continue LABA and increase inhaled steroid dose to 400mcg/day * (if not already on this dose). benefit from LABA but control still inadequate – continue LABA and increase inhaled steroid dose to 400mcg/day * (if not already on this dose). no response to LABA – stop LABA and increase inhaled steroid to 400mcg/day *. If control still inadequate, institute trial of other therapies (e.g. leukotriene receptor antagonist or SR theophylline). no response to LABA – stop LABA and increase inhaled steroid to 400mcg/day *. If control still inadequate, institute trial of other therapies (e.g. leukotriene receptor antagonist or SR theophylline). Step 1: Mild intermittent asthma Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

Stepwise management of asthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 4: Persistent poor control Increase inhaled steroid up to 800mcg/day * Step 1: Mild intermittent asthma Step 3: Add-on therapy Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

Stepwise management of asthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 5: Continuous or frequent use of oral steroids Use daily steroid tablet in lowest dose providing adequate control Maintain high dose inhaled steroid at 800mcg/day * Refer patient to respiratory paediatrician Step 1: Mild intermittent asthma Step 3: Add-on therapy Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent Step 4: Persistent poor control

Stepwise management of asthma in children aged 5-12 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Step 5: Continuous or frequent use of oral steroids Step 4: Persistent poor control Step 3: Add-on therapy Step 2: Regular preventer therapy

Stepwise management of asthma in children under 5 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Inhaled short acting ß 2 agonist as required

Stepwise management of asthma in children under 5 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 2: Regular preventer therapy Add inhaled steroid mcg/day * † (leukotriene receptor antagonist if inhaled steroid cannot be used) Step 1: Mild intermittent asthma Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent † Higher nominal doses may be required if drug delivery is difficult required if drug delivery is difficult

Stepwise management of asthma in children under 5 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 3: Add-on therapy In children aged 2-5 years consider addition of leukotriene receptor antagonist In children under 2 years consider proceeding to step 4 Step 1: Mild intermittent asthma Step 2: Regular preventer therapy

Step 3: Add-on therapy Step 2: Regular preventer therapy Stepwise management of asthma in children under 5 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 4: Persistent poor control Refer to respiratory paediatrician Step 1: Mild intermittent asthma

Stepwise management of asthma in children under 5 years Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Step 4: Persistent poor control Step 3: Add-on therapy Step 2: Regular preventer therapy

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 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 Asthma Management

Seasonal asthma  Start prophylactic steroid therapy before season begin Asthma Management

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

Exacerbations 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 Asthma Management

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

When do you stop medication? 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 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. Asthma Management