1. Webinar: Managing Asthma in the Job Corps Student John Kulig, MD, MPH Lead Medical Specialist September 7 th and 15 th, 2011

2. Overview Summary: This webinar will review the comprehensive outpatient management of asthma with the goals of improving asthma control and enhancing employability. This course is offered at an intermediate level. It will consist of lecture, a pre-test, post-test and a question and answer period. No prerequisite knowledge is required for this course.

3. Learning Objectives After this presentation, participants will be able to:  Describe the current National Heart Lung and Blood Institute (NHLBI) Asthma Guidelines for classifying severity, control, and stepwise management of asthma.  Apply updated Job Corps Treatment Guidelines for management of students with asthma.  Implement case management for all Job Corps students with asthma.

4. Pre-Test 1. African American students have higher rates of asthma than their white peers. True or False? 2. Twice daily use of an albuterol inhaler prevents wheezing in most students with persistent asthma. True or False? 3. Inhaled corticosteroids are the preferred first choice for controller medications. True or False? 4. Efficacy of albuterol diminishes with long-term use. True or False?

5. Definition of Asthma  reversible obstructive airway disease  airway inflammation  increased airway responsiveness

7. Fast Facts  Every day in America:  40,000 people miss school or work due to asthma  30,000 people have an asthma attack  5,000 people visit the emergency room due to asthma  1,000 people are admitted to the hospital due to asthma  11 people die from asthma http://www.aafa.org

8. Key Points  In 2009, the prevalence of asthma increased to 7.7% among adults, 9.6% among all children, and 17.0% among black, non-Hispanic children.  In 2008, approximately half of persons with asthma reported having had at least one asthma attack during the preceding 12 months.  Medical expenses associated with asthma amounted to $3,259 per person per year during 2002--2007.  Good control of asthma includes self-management training, appropriate use of inhaled corticosteroids to prevent symptoms and attacks, and avoidance of environmental allergens and irritants. However, only approximately one third of persons with asthma had been given an asthma action plan as recommended. Ref: MMWR May 6, 2011 / 60(17);547-552

9. Asthma Mortality  Each day 11 Americans die from asthma. There are more than 4,000 deaths due to asthma each year, many of which are avoidable with proper treatment and care. In addition, asthma is indicated as “contributing factor” for nearly 7,000 other deaths each year.  Since 1980, asthma death rates overall have increased more than 50% among all genders, age groups and ethnic groups. The death rate for children under 19 years old has increased by nearly 80% percent since 1980.  More females die of asthma than males, and women account for nearly 65% of asthma deaths overall.  African Americans are three times more likely to die from asthma. African American women have the highest asthma mortality rate of all groups, more than 2.5 times higher than Caucasian women. http://www.aafa.org

10. Gonzalez v. Hanford Elementary School District Jury Awards $9 million in Asthma Death at School “A California jury that unanimously awarded a mother $9 million in damages for the death of her 11 year-old son from an asthma attack at school found the school district guilty of negligence for failing to inform parents of an unwritten school policy that would have allowed the child to carry an inhaler.” May 2002

11. Current asthma prevalence among adults --- Behavioral Risk Factor Surveillance System, United States, 2009

12. Current asthma prevalence,* by age group,† sex, and race/ethnicity --- National Health Interview Survey, United States, 2001--2009

15. Asthma Precipitants

16. Precipitants  allergens  respiratory irritants  respiratory infections  physical exertion  cold air  medications  food additives  emotional stress  gastroesophageal reflux

22. Clinical Assessment  classification of asthma severity  onset of wheezing/precipitant  current medication regimen adherence  office measurements of peak flow  past severity—ER, hospitalization, ICU  color, respiratory distress, vital signs  auscultation of lungs  objective measures: PEFR, pulse oximetry

23. Asthma Severity Intermittent  symptoms < 2 days a week  nighttime awakenings < 2 times a month  albuterol HFA use < 2 days a week  no interference with normal activity  normal FEV 1 between exacerbations

24. Asthma Severity Mild persistent  symptoms > 2 days a week, but not daily  nighttime awakenings 3-4 times a month  albuterol HFA use > 2 days a week, but not daily, and not more than one time on any day  minor limitation of normal activity  FEV1 > 80% of predicted

25. Asthma Severity Moderate persistent  symptoms daily  nighttime awakenings > once a week, but not nightly  albuterol HFA use daily  some limitation of normal activity  FEV1 > 60% but < 80% of predicted

26. Asthma Severity Severe persistent  symptoms throughout the day  nighttime awakenings often 7 times a week  albuterol HFA use several times per day  extremely limited activity  FEV1 < 60% of predicted

27. Classification of Asthma Control Well controlled:  symptoms < 2 days per week  albuterol HFA use < 2 days per week Not well controlled:  symptoms > 2 days per week  albuterol HFA use > 2 days per week Very poorly controlled:  symptoms throughout the day  albuterol HFA use several times per day

28. Peak Flow Meters

29. Environmental Control Measures  eliminate indoor allergens  house dust  animal dander/saliva  mites  cockroaches  indoor molds  vacuum cleaners  humidifiers  avoid outdoor allergens  pollen  molds  avoid indoor irritants  tobacco smoke  wood smoke  strong odors/sprays  air pollutants

30. Immunotherapy for Asthma  controversial in asthma  effective in certain allergies  monthly injections of allergen required  3 to 5 year course of treatment  risk of anaphylaxis

31. Asthma Medications  long term control medications to prevent symptoms, maintain normal activity levels, and prevent exacerbations  quick relief medications to treat symptoms and exacerbations  all patients with persistent asthma require both classes of medication

34. Asthma Medication: Patient Concerns  fear of addiction  belief that efficacy diminishes with long-term use  confusing corticosteroids with anabolic steroids  fear of side effects  confusing preventive therapy with acute treatment of symptoms

35. Quick Relief: Steps 1-6  short-acting bronchodilator: inhaled  2 agonists as need for symptoms  intensity of treatment depends on severity of exacerbation – up to 3 treatments at 20 minute intervals  increasing use of short-acting inhaled  2 agonists indicates the need for initial or additional long-term control therapy

36. Step 1  No daily medication needed  SABA (albuterol HFA) only as needed

37. Step 2 One daily medication:  inhaled corticosteroid - low dose (preferred)  inhaled cromolyn or nedocromil  oral leukotriene receptor antagonist  oral sustained-release theophylline

38. Step 3 Daily medication:  low dose inhaled corticosteroid plus long-acting inhaled  2 agonist (preferred) or  medium dose inhaled corticosteroid (preferred)  low dose inhaled corticosteroid plus oral leukotriene receptor antagonist, theophylline or zileuton

39. Step 4 Daily medication:  medium dose inhaled corticosteroid plus long-acting inhaled  2 agonist (preferred)  medium dose inhaled corticosteroid plus oral leukotriene receptor antagonist, theophylline or zileuton

40. Step 5 Daily medication:  high dose inhaled corticosteroid plus long-acting inhaled  2 agonist (preferred) and  consider omalizumab for patients who have allergies

41. Step 6 Daily medication:  high dose inhaled corticosteroid plus long-acting inhaled  2 agonist plus oral corticosteroid (preferred) and  consider omalizumab for patients who have allergies

42. Short-Acting Inhaled  2 Agonists (SABA)  albuterol HFA (Ventolin/Proventil/ProAir) 2 puffs qid max  terbutaline (Brethaire) 2 puffs qid max  pirbuterol (Maxair) 2 puffs qid max  levalbuterol (Xopenex) inhalation solution

43. Inhaled Anticholinergic Bronchodilators  ipratropium bromide (Atrovent)  2 puffs qid  ipratropium/albuterol (Combivent)  2 puffs qid  both primarily indicated in adult COPD, not in asthma

44. Inhaled Mast Cell Stabilizers  cromolyn sodium (Intal)  2-4 puffs qid  nedocromil (Tilade)  2-4 puffs bid after control established

45. Inhaled Corticosteroids  beclomethasone (Qvar)  budesonide (Pulmicort) - Respules/Turbuhaler  flunisolide (Aerobid/Aerobid-M)  fluticasone (Flovent 44/110/220)  mometasone (Asmanex Twisthaler)  triamcinolone (Azmacort)

46. Oral Corticosteroids  prednisone  prednisolone  methylprednisolone  dosage 40-60 mg per day in single or two divided doses for 3-10 days

47. Long-Acting Inhaled  2 Agonist (LABA)  salmeterol (Serevent)  MDI aerosol - 2 puffs bid  DPI Diskus - 1 inhalation bid  formoterol (Foradil)  DPI Aerolizer - 1 capsule bid  LABA for long-term control only  leave inhaler at home  not indicated for quick relief use  use LABA only in combination with inhaled corticosteroids

48. Combination Therapy  fluticasone/salmeterol (Advair Diskus)  1 inhalation bid  low steroid dose: 100/50 mcg  medium steroid dose: 250/50 mcg  high steroid dose: 500/50 mcg  budesonide/formoterol (Symbicort)  1 inhalation bid  low steroid dose: 80/4.5 mcg  high steroid dose: 160/4.5 mcg

49. Oral Leukotriene Modifiers  montelukast (Singulair)  10 mg once qhs  zafirlukast (Accolate)  20 mg bid  one hour ac or two hours pc  zileuton (Zyflo)  600 mg qid  monitor liver enzymes

50. Oral Sustained-Release Theophylline  sustained release preparations (Theo-Dur/Uni-Dur/Uniphyl/Slo-Phyllin)  10-15 mg/kg/day divided q 8, 12, or 24 hr  monitor steady state theophylline levels  therapeutic peak blood level 5-15 mcg/mL

51. Omalizumab (Xolair)  recombinant DNA-derived monoclonal antibody  patients > age 12 with moderate to severe persistent asthma who have a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids  pretreatment serum IgE level and body weight are used to determine doses and dosing frequency  given by subcutaneous injection every 2-4 weeks  $10,000 - $30,000 cost per year

52. Oral Antihistamines  no longer contraindicated in asthma  loratadine (Claritin/Alavert)  10 mg once qd  cetirizine (Zyrtec)  10 mg once qd  fexofenadine (Allegra)  180 mg once qd or 60 mg bid

53. Step Therapy  Step down  review treatment every 3 months  gradual stepwise reduction in treatment may be possible  Step up  if control not maintained, consider additional treatment options  first review patient medication technique, adherence and environmental control

55. Post-Test 1. African American students have higher rates of asthma than their white peers. True or False? 2. Twice daily use of an albuterol inhaler prevents wheezing in most students with persistent asthma. True or False? 3. Inhaled corticosteroids are the preferred first choice for controller medications. True or False? 4. Efficacy of albuterol diminishes with long-term use. True or False?

56. Post-Test 1. African American students have higher rates of asthma than their white peers. True 2. Twice daily use of an albuterol inhaler prevents wheezing in most students with persistent asthma. False 3. Inhaled corticosteroids are the preferred first choice for controller medications. True 4. Efficacy of albuterol diminishes with long-term use. False