1. Classification and guideline treatment
Bronchial asthma
Classification and guideline treatment
Prepared by:
Reem Ahmed Abd el Moneim
PharmD 4

2. Bronchial asthma
Source: Peter J. Barnes, MD

3. Classification According to etiology: 1-Allergic or extrinsic asthma
2-Non-allergic or intrinsic asthma
3-Mixed forms
According to degree of severity:
Grade 1: Intermittent
Grade 2: Persistent, mild
Grade 3: Persistent, moderate
Grade 4: Persistent, severe

4. FEV1/PEFR
Nocturnal symptoms
Symptoms
>80% predicted
<2 times a month
<1 time a week
Stage 1
intermittent
>80% predicted,variability 20-30%
> 2 times a month
> 1 time a week but <1 time a day
Stage 2
Mild-persistant
60-80%predicted,
variability >30%
> 1 time a week
daily
Stage 3
Moderate-persistant
<60%predicted,
frequent
continous
Stage 4
Severe-persistant

5. According to level of asthma control:
Characteristic
Controlled
(All of the following)
Partly controlled (Any present in any week)
Uncontrolled
Daytime symptoms
None (2 or less / week)
More than twice / week
3 or more features of partly controlled asthma present in any week
Limitations of activities
None
Any
Nocturnal symptoms / awakening
Need for rescue / “reliever” treatment
More than twice / week
Lung function (PEF or FEV1)
Normal
< 80% predicted or personal best (if known) on any day
Exacerbation
One or more / year in any week

6. Asthma Management and prevention
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations

7. Reliever Medications Rapid-acting inhaled β2-agonists
Short-acting oral β2-agonists
Systemic glucocorticosteroids
Theophylline
Anticholinergics

8. Controller Medications
Inhaled glucocorticosteroids
Systemic glucocorticosteroids
Long-acting inhaled β2-agonists
Long-acting oral β2-agonists
Theophylline
Cromones
Anti-IgE
Leukotriene modifiers

9. Other treatment option
Daily controller medication
Stage
Sustained release theophylline
Low dose ICS
Mild
-Moderate dose ICS+either sustained release theophylline or long acting β 2 agonist or leukotriene inhibitor.
-High dose ICS
Moderate dose ICS+inhaled long acting β 2 agonist or leukotriene inhibitor
Moderate
Oral glucocorticoid
Anti-IgE(omlizumab)
High dose ICS+inhaled long acting β 2 agonist or leukotriene inhibitor
Severe

11. Step 1 – As-needed reliever medication
Treating to Achieve Asthma Control
Step 1 – As-needed reliever medication
Patients with occasional daytime symptoms of short duration
A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)
When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)

12. Treating to Achieve Asthma Control
Step 2 – Reliever medication plus a single controller
A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)
Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids

13. Treating to Achieve Asthma Control
Step 3 – Reliever medication plus one or two controllers
For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)
Inhaled long-acting β2-agonist must not be used as monotherapy
For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)

14. Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more controllers
Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3
Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma

15. Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)
Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)

16. Leukotriene-Inhibiting Drugs
Leukotriene inhibitors are either leukotriene receptor antagonists or leukotriene synthesis inhibitors, which act by blocking 5-lipoxygenase activity. The leukotriene receptor antagonists include zafirlukast (Accolate) and montelukast (Singulair); zileuton (Zyflo) is the only leukotriene synthesis inhibitor.

17. Clinical recommendation
-Leukotriene inhibitors are effective in the treatment of asthma but are less effective than inhaled corticosteroids (evidence A)
-Leukotriene inhibitors added to inhaled corticosteroids are less effective than long-acting beta agonists added to inhaled corticosteroids in the treatment of asthma (evidence A)
-Leukotriene inhibitors are alternative treatments in exercise-induced asthma and can be of benefit for children when oral therapy is preferred over inhalers (evidence B)
-Leukotriene inhibitors are effective in the treatment of allergic rhinitis but are less effective than intranasal corticosteroids (evidence A)

18. Age and recommended oral dose Drug
Therapeutic issues
Age and recommended oral dose
Drug
Renal adjustments: none
Hepatic adjustments: in mild to moderate disease
Adults: 10 mg before bed
Children six to 14 years: 5 mg before bed
Children two to five years: 4 mg before bed
Montelukast (Singulair)
Hepatic adjustments: not defined
Monitor hepatic enzymes every two to three months
Administration with meals decreases bioavailability; take at least one hour before meals or two hours after
Inhibits metabolism of warfarin (Coumadin), increasing prothrombin time
Patients older than 11 years: 20 mg twice daily
Children seven to 11 years: 10 mg twice daily
Zafirlukast (Accolate)
(Ventair)

19. Can inhibit metabolism of warfarin, theophylline, and propranolol (Inderal)
Monitor hepatic enzymes every two to three months
Patients older than 12 years: 600 mg four times daily
Zileuton (Zyflo)

20. Anti-IgE treatment: Omalizumab(Xolair®)
Omalizumab blocks the receptors on the surfaces of the mast cells and basophils to which antibodies attach, thereby preventing antibodies from attaching to the cells. As a result, the cells do not release their chemicals, and the allergic reaction and inflammation are prevented.

21. DOSING:
Omalizumab is injected under the skin. The recommended dose is mg every 2 to 4 weeks. The dose and frequency is based on body weight and levels of serum IgE, a type of antibody. Doses greater than 150 mg should be divided and administered at different sites so that no more than 150 mg is administered at each injection site.

22. SIDE EFFECTS
Headaches, viral infections, upper respiratory tract infections and injection-site reactions such as pain, redness, swelling, itching and bruising.
Use of omalizumab may also lead to serious, life-threatening allergic reactions (anaphylaxis).

23. Signs and symptoms of anaphylaxis
-Wheezing, shortness of breath, cough, chest tightness, or trouble breathing.
-Low blood pressure, dizziness, fainting, rapid or weak heartbeat, anxiety.
-Flushing, itching or feeling warm.
-Swelling of the throat or tongue, throat tightness, hoarse voice, or trouble swallowing.

24. It is recommended that patients be observed for these reactions for at least two hours after injection of omalizumab; however, these reactions can occur up to 24 hours or longer after the injections. 
Cancer occurs more frequently in patients who take omalizumab.

25. Non pharmacological treatment:
-Reduce exposure to indoor allergens
-Avoid tobacco smoke
-Avoid vehicle emission
-Identify irritants in the workplace
-Explore role of infections on asthma development, especially in children and young infants

26. Influenza Vaccination
Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised
However, routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control