1. Asthma Guidelines: Stepwise Approach to Managing Asthma Karen Meyerson, MSN, RN, FNP-C, AE-C Asthma Network of West Michigan April 21, 2009 Acknowledgements: LeRoy M. Graham, MD, Atlanta, GA Allan T. Luskin, MD, Madison, WI

2. PREVIOUS NHLBI/GINA GUIDELINES SeveritySymptomsNocturnal Symptoms FEV 1 or PEF Mild Intermittent < 1 x/week, asymptomatic between attacks < 2 x / month> 80% predicted variability < 20% Mild Persistent > 1 x/week but not daily > 2 x / month> 80% predicted variability 20-30% Moderate Persistent Daily, affecting activity> 1 time / week60 -80% predicted variability > 30% Severe Persistent Continuous, limiting activity Frequent 30%

3. Asthma Severity Asthma severity is the intrinsic intensity of disease. Initial assessment of patients who have confirmed asthma begins with a severity classification because the therapy should then correspond to the level of asthma severity. This initial assessment of asthma severity is made immediately after diagnosis, or when the patient is first encountered, generally before the patient is taking some form of long-term control medication. Assessment is made on the basis of current spirometry and the patient’s recall of symptoms over the previous 2–4 weeks, because detailed recall of symptoms decreases over time.

4. Asthma Severity Intermittent Mild Persistent Moderate Persistent Severe Persistent

5. Classification of Asthma Severity Persistent Intermittent MildModerateSevere Components of Severity Impairment Risk Recommended Step for Initiating Treatment Symptoms Nighttime Awakenings SABA use for sx control Interference with normal activity Exacerbations (consider frequency and severity) In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy accordingly Step 1Step 2Step 3 0-1/year <2 days/week>2 days/week not dailyDailyContinuous 01-2x/month3-4x/month >1x/week noneMinor limitationSome limitationExtremely limited <2 days/week>2 days/week not dailyDailySeveral times daily Consider short course of oral steroids CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN CHILDREN 0-4 YEARS OF AGE >2 exacerbations in 6 months requiring oral steroids, or >4 wheezing episodes/ year lasting >1 day AND risk factors for persistent asthma Frequency and severity of may fluctuate over time Exacerbations of any severity may occur in patients in any category EPR-3, p72, 307

6. Pulmonary Function Tests FEV 1 (Forced Expiratory Volume in 1 Second) – this is the volume of air expired in the first second during maximal expiratory effort. The FEV 1 is reduced in both obstructive and restrictive lung disease. FVC (Forced Vital Capacity) – this is the total volume of air expired after a full inspiration. FEV 1 /FVC – this is the percentage of the vital capacity which is expired in the first second of maximal expiration.

7. Classification of Asthma Severity Persistent Intermittent MildModerateSevere Components of Severity Impairment Risk Recommended Step for Initiating Treatment Symptoms Nighttime Awakenings SABA use for sx control Interference with normal activity Lung Function Exacerbations (consider frequency and severity) In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy Step 2 Relative annual risk of exacerbations may be related to FEV 0-2/year > 2 /year Frequency and severity may vary over time for patients in any category <2 days/week>2 days/week not dailyDailyContinuous <2x/month3-4x/month >1x/week not nightly Often nightly noneMinor limitationSome limitationExtremely limited <2 days/week>2 days/week not dailyDailySeveral times daily Normal FEV 1 between exacerbations FEV 1 > 80% FEV 1 /FVC> 85% FEV 1 >80% FEV 1 /FVC> 80% FEV 1 =60% - 80% FEV 1 /FVC=75% -80% FEV 1 <60% FEV 1 /FVC < 75% CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN CHILDREN 5 - 11 YEARS OF AGE Step 1 Step3 medium- dose ICS option Step 3 or 4 Consider short course of oral steroids EPR-3, p73, 308

8. Classification of Asthma Severity Persistent Intermittent MildModerateSevere Components of Severity Impairment Normal FEV 1 /FVC 8-19 yr 85% 20-39 yr 80% 40-59 yr 75% 60-80 yr 70% Risk Recommended Step for Initiating Treatment Symptoms Nighttime Awakenings SABA use for sx control Interference with normal activity Lung Function Exacerbations (consider frequency and severity) In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy accordingly Step 1Step 2Step 3Step 4 or 5 Relative annual risk of exacerbations may be related to FEV 0-2/year> 2 /year Frequency and severity may vary over time for patients in any category <2 days/week>2 days/week not dailyDailyContinuous <2x/month3-4x/month >1x/week not nightly Often nightly noneMinor limitationSome limitationExtremely limited <2 days/week>2 days/week not dailyDailySeveral times daily Consider short course of oral steroids Normal FEV 1 between exacerbations FEV 1 > 80% FEV 1 /FVC normal FEV 1 >80% FEV 1 /FVC normal FEV 1 >60% but< 80% FEV 1 /FVC reduced 5% FEV 1 <60% FEV 1 /FVC reduced> 5% CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS > 12 YEARS AND ADULTS EPR-3, p74, 344

9. Asthma Control The purpose of periodic assessment and ongoing monitoring is to determine whether the goals of asthma therapy are being achieved and asthma is controlled. l Well Controlled l Not Well Controlled l Very Poorly Controlled

10. Asthma Control Reducing Current Impairment Reducing Future Risk

11. Classification of Asthma Control Components of Control ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 0 - 4 YEARS OF AGE IMPAIRMENT RISK Recommended Action For Treatment Well Controlled Not Well Controlled Very Poorly Controlled Symptoms Nighttime awakenings Interference with normal activity SABA use Exacerbations Progressive loss of lung function Rx-related adverse effectsConsider in overall assessment of risk Evaluation requires long-term follow up care 0- 1 per year2 - 3 per year> 3 per year noneSome limitationExtremely limited 2 days/week Throughout the day 2 x/month >2x/week 2 days/week Several times/day Maintain current step REGULAR FOLLOW UP EVERY 3 - 6 MONTHS Consider step down if well controlled at least 3 months Step up 1 step Reevaluate in 2 - 6 weeks If no clear benefit in 4-6 weeks, consider alternative dx or adjust therapy Consider oral steroids Step up (1-2 steps) and reevaluate in 2 weeks If no clear benefit in 4-6 weeks, consider alternative dx or adjust therapy EPR-3, p75, 309

12. Classification of Asthma Control Components of Control ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 5 - 11 YEARS OF AGE IMPAIRMENT RISK Recommended Action For Treatment Well Controlled Not Well Controlled Very Poorly Controlled Symptoms Nighttime awakenings Interference with normal activity SABA use FEV 1 or peak flow Exacerbations Progressive loss of lung function Rx-related adverse effectsConsider in overall assessment of risk Evaluation requires long-term follow up care 0- 1 per year2 - 3 per year> 3 per year noneSome limitationExtremely limited 2 days/week Throughout the day 2 x/month >2x/week 2 days/week Several times/day > 80% predicted/ personal best 60-80% predicted/ personal best <60% predicted/ personal best Maintain current step Consider step down if well controlled at least 3 months Step up 1 step Reevaluate in 2 - 6 weeks Consider oral steroids Step up 1-2 weeks and reevaluate in 2 weeks FEV 1 /FVC > 80% predicted 75-80% predicted <75% predicted EPR-3, p76, 310

13. Classification of Asthma Control Components of Control ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTHS > 12 YEARS OF AGE AND ADULTS IMPAIRMENT RISK Recommended Action For Treatment Well Controlled Not Well Controlled Very Poorly Controlled Symptoms Nighttime awakenings Interference with normal activity SABA use FEV 1 or peak flow Validated questionnaires ATAQ/ACT Exacerbations Progressive loss of lung function Rx-related adverse effectsConsider in overall assessment of risk Evaluation requires long-term follow up care 0- 1 per year2 - 3 per year> 3 per year noneSome limitationExtremely limited 2 days/week Throughout the day 4/week 2 days/week Several times/day > 80% predicted/ personal best 60-80% predicted/ personal best <60% predicted/ personal best 0/> 20 1-2/16-19 3-4/< 15 Maintain current step Consider step down if well controlled at least 3 months Step up 1 step Reevaluate in 2 - 6 weeks Consider oral steroids Step up 1-2 weeks and reevaluate in 2 weeks EPR-3, p77, 345

14. Asthma Control Test ™ (ACT) for Patients 12 Years and Older 1.In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? 2.During the past 4 weeks, how often have you had shortness of breath? 3.During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night, or earlier than usual in the morning? 4.During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 5.How would you rate your asthma control during the past 4 weeks? Score Patient Total Score Copyright 2002, QualityMetric Incorporated. Asthma Control Test Is a Trademark of QualityMetric Incorporated.

15. Childhood Asthma Control Test ™ (ACT): Questions Completed by Child 3210 3. Do you cough because of your asthma? 4. Do you wake up during the night because of your asthma? 3210 3 210 1. How is your asthma today? 2. How much of a problem is your asthma when you run, exercise or play sports? 3210 It’s a big problem, I can’t do what I want to do. It’s a problem and I don’t like it. It’s a little problem but it’s okay. It’s not a problem Very badBadGoodVery Good Yes, all of the time.Yes, most of the time.Yes, some of the time.No, none of the time Yes, all of the time.Yes, most of the time.Yes, some of the time.No, none of the time SCORE

16. Childhood Asthma Control Test ™ (ACT): Questions Completed by Parent/Caregiver 5. During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms? 5 Not at all 6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma? 7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma? 4 1-3 days/mo 3 4-10 days/mo 1 19-24 days/mo 0 Everyday 2 11-18 days/mo 5 Not at all 4 1-3 days/mo 3 4-10 days/mo 1 19-24 days/mo 0 Everyday 2 11-18 days/mo 5 Not at all 4 1-3 days/mo 3 4-10 days/mo 1 19-24 days/mo 0 Everyday 2 11-18 days/mo TOTAL

17. Monitoring Asthma Control Ask the patient  Has your asthma awakened you at night or early morning?  Have you needed more rescue inhaler than usual?  Have you needed urgent care for asthma? (office, ED, etc)  Are you participating in your usual or desired activities?  What are your triggers? (and how can we manage them?) Actions to consider  Assess whether medications are being taken as prescribed  Assess whether inhalation technique is correct  Assess spirometry and compare to previous measurements  Adjust medications, as needed to achieve best control with the lowest dose needed to maintain control  Environmental mitigation strategy NAEPP Draft Report, ERP 2007 EPR-3, Page 78

18. Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 3 or higher care is required Consider consultation at step 2 Patient Education and Environmental Control at Each Step Step 1 Preferred: SABA prn Step 2 Preferred: Low-dose ICS Alternative: LTRA Cromolyn Step 3 Preferred: Medium-dose ICS Step 4 Preferred: Medium-dose ICS AND either LTRA Or LABA Step 5 Preferred: High dose ICS AND either LTRA Or LABA Step 6 AND either LTRA Or LABA AND Oral Corticosteroid Assess Control STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 0 - 4 YEARS OF AGE Step up if needed (check adherence, environmental control ) Step down if possible (asthma well controlled for 3 months) EPR-3, p291-296 Intermittent Mild Persistent Moderate Persistent Severe Persistent

19. Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Patient Education and Environmental Control at Each Step Step 1 Preferred: SABA prn Step 2 Preferred: Low-dose ICS Alternative: LTRA Cromolyn Theophylline Step 3 Preferred: Medium-dose ICS OR Low-dose ICS+ either LABA, LTRA, or Theophylline Step 4 Preferred: Medium-dose ICS+LABA Alternative: Medium-dose ICS+either LTRA, or Theophlline Step 5 Preferred: High dose ICS + LABA Alternative: High-dose ICS+ either LTRA or Theophylline AND Consider Olamizumab for patients with allergies Step 6 Preferred: High-dose ICS + LABA + oral Corticosteroid Alternative: High-dose ICS +either LTRA or Theophylline + oral corticosteroid AND Consider Olamizumab for patients with allergies Assess Control STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5-11 YEARS OF AGE Step up if needed (check adherence, environmental control and comorbidities) Step down if possible (asthma well controlled for 3 months) EPR-3, p296-304

20. Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Patient Education and Environmental Control at Each Step Step 1 Preferred: SABA prn Step 2 Preferred: Low-dose ICS Alternative: LTRA Cromolyn Theophylline Step 3 Preferred: Medium-dose ICS OR Low-dose ICS+ either LABA, LTRA, Theophylline Or Zileutin Step 4 Preferred: Medium-dose ICS+LABA Alternative: Medium-dose ICS+either LTRA, Theophlline Or Zileutin Step 5 Preferred: High dose ICS + LABA AND Consider Olamizumab for patients with allergies Step 6 Preferred: High-dose ICS + LABA + oral Corticosteroid AND Consider Olamizumab for patients with allergies Assess Control STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS > 12 YEARS AND ADULTS Step up if needed (check adherence, environmental control and comorbidities) Step down if possible (asthma well controlled for 3 months) EPR-3, p333-343

21. Recommended Action for Treatment Based on Assessment of Control Well Controlled Controlled Not Well Controlled Controlled Very Poorly Controlled Maintain current stepStep up 1 step and reevaluate in 2-6 weeks Consider short course of oral corticosteroids Consider step down if well controlled for at least 3 months For side effects, consider alternative treatment options Step up 1-2 steps and reevaluate in 2 weeks For side effects, consider alternative treatment options NAEPP Draft Report, ERP 2007 Before stepping up check adherence and environmental control EPR-3, Page 330

22. Treatment Strategies Gain Control!!!  Aggressive, intensive initial therapy to suppress airway inflammation and gain prompt control Maintain Control  Frequent follow-up, clinically and physiologically  Therapeutic modifications depending on severity and clinical course  “Step down” long-term control medications to maintain control with minimal side effects

23. Patients Are Candidates for Maintenance Therapy if The “RULES OF TWO”™* Apply… n They are using a quick-relief inhaler more than 2 times per week n They awaken at night due to asthma more than 2 times per month n They refill a quick-relief inhaler Rx more than 2 times per year *“RULES OF TWO”™ is a trademark of the Baylor Health Care System.

24. Out of Control! Rules of Two TM n If your patient can answer “YES” to ANY of these questions, his/her asthma is probably not under good control. n These rules define persistent asthma.

25. Asthma Pharmacotherapy Quick-relief l Short-acting beta- agonists l Inhaled anticholinergics l Systemic corticosteroids Long-term control l Corticosteroids l Cromolyn sodium/nedocromil l Long-acting inhaled beta-agonists l Theophylline l Leukotriene modifiers

26. Quick-Relief Medications l Short-acting beta 2 -agonists (SABA): Albuterol, Ventolin®, Proventil®, Maxair®, Xopenex®, etc. l Relax bronchial smooth muscles l Short-acting l Work within 10 - 15 minutes l Last 4 - 6 hours l Side effects can include shakiness (tremors), tachycardia l Danger of over-use

27. Short-acting  2 -agonists Most effective medication for relief of acute symptoms  RED FLAG more than 1 canister per month Regularly scheduled use not generally recommended  May “lower” effectiveness  May increase airway hyperresponsiveness

28. Anticholinergics Not specifically indicated for “usual” quick- relief medication in asthma  contrast with COPD Now well-studied as adjunct to beta-agonists in emergency departments  i.e., acute exacerbations

29. Long-term Control Medications l Inhaled corticosteroids (ICS): Advair®, Flovent®, Azmacort®, Q-Var®, Pulmicort®, Asmanex®, Aerobid®, Symbicort® l Non-steroidal anti-inflammatories: Intal®, Tilade® l Leukotriene modifiers (LTM): Singulair®, Accolate® l Theophylline: Theo-Dur®, Slo-bid l Long-acting beta 2 -agonists (LABA): Serevent®, Foradil® l Taken daily and chronically to maintain control of persistent asthma and to prevent exacerbations: wSoothes airway swelling wHelps prevent asthma flares - very effective for long- term control but must be taken daily wOften under-used

30. Inhaled Corticosteroids Actions:  potentiate  -receptor responsiveness  reduce mucus production and hypersecretion  inhibit inflammatory response at all levels Best effects if started early after diagnosis Symptomatic and spirometric improvement within 2 weeks  maximum effects within 4-8 weeks

31. Inhaled Corticosteroids (continued) Most effective long term control medication for persistent asthma Small risk for adverse events at usual doses  Risk can be reduced even further by: Using spacer and rinsing mouth Using lowest effective dose Using with long-acting  2 -agonist when appropriate Monitoring growth in children

32. Low dose ICS and the Prevention of Asthma Deaths ICS protects patients from asthma-related deaths Users of > 6 canisters/yr. had a death rate ~ 50% lower than non-users of ICS Death rate decreased by 21% for each additional ICS canister used during the previous year. Suissa et al. N Eng J Med 2000;343:332-336.

33. ICS May Help Prevent the Risk of Asthma Related Hospitalizations Adapted from Donahue et. al. JAMA 1997;277(11):887-891. Short-acting B 2 prescriptions dispensed per person-year 876543210876543210 Relative Risk of Hospitalization None 1-2 2-3 3-55-8 8+0-1 Total Inhaled Steroids  2 -agonists Total

34. Inhaled Corticosteroids (continued) HPA Suppression  no need to test in children receiving < 400 mcg/day (BEC), or adults < 1500 mcg/day (BEC) Cataracts Long bone growth  growing understanding of this risk Osteoporosis/Bone Fractures  some attention at high doses, high risk patients Candidiasis Dysphonia

35. Leukotriene Modifiers Two mechanisms  5-lipoxygenase inhibitors zileution (Zyflo)  Cysteinyl leukotriene receptor antagonists zafirlukast (Accolate), montelukast (Singulair) Indications  Generally, alternative therapy in mild persistent asthma or as add-on in higher stages Improve lung function Decrease short-acting  2 -agonist use Prevent exacerbations

36. Methylxanthines (Theophylline) (continued) Places in therapy:  primary therapy when inhaled corticosteroids not possible  patient’s who can’t/won’t use inhalers  additive therapy at later Stages ADR’s/Serum Levels/Drug Interactions  Therapeutic Range 5-15 mcg/mL, or 10-20 mcg/mL levels > 20 mcg/mL: N/V/D, HA, irritability, insomnia, tachycardia levels > 30 mcg/mL: seizures, toxic encephalopathy, hyperthermia, brain damage ADR’s/Serum Levels/Drug Interactions  Drug Interactions: PLENTY!!

37. Long-acting  2 -agonists Not a substitute for anti-inflammatory therapy Not appropriate for monotherapy  RED FLAG Literature supporting role in addition to inhaled corticosteroids Not for acute symptoms or exacerbations Salmeterol (Serevent) first of class in US Formoterol (Foradil)  Newer long-acting beta-agonist  Has rapid onset and long duration  Available as dry powder inhaler and in combination with inhaled steroid (Symbicort)

38. Long-acting  2 -agonists Salmeterol Multicenter Asthma Research Trial (SMART) A comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Nelson HS, Weiss ST, Bleecker ER, et al. Chest 2006; 129:15-26.

40. Patients > 12 years old with asthma Sought to evaluate the effects of salmeterol or placebo added to usual asthma care on  respiratory and asthma related deaths  life-threatening episodes Initial aim to enroll 30,000 patients; later changed with aim to enroll 60,000 Long-acting  2 -agonists

41. Two methods of recruitment  Phase 1 1996-1999 Recruited by advertising and assigned to study investigator by geography  Phase 2 2000-2003 Recruitment by study investigators and more investigators added Long-acting  2 -agonists

42. Increase in adverse events in salmeterol group during SMART trial:  Particularly in those recruited in Phase 1  Particularly among African-Americans who were noted to have markers of more severe asthma and less likely to be using ICS Increase in adverse events in salmeterol group  Due to adverse effect of salmeterol?  Due to inappropriate bronchodilator use? (affected patients were more severe at baseline and less likely to be using ICS) Long-acting  2 -agonists

43. FDA Advisory Panel Recommends Ban of Long-acting  2 -agonists in Asthma A panel of outside advisers has told the FDA that two long- acting asthma drugs -- Serevent and Foradil -- should be banned for use in asthma treatment because they are alleged to be more dangerous than they are helpful, particularly in children and adolescents. If the FDA takes this advice, it would remove the indication for asthma from the label for these drugs but they could still be prescribed for chronic obstructive pulmonary disease. But the advisers unanimously supported the continued use of the far more popular drugs Advair and Symbicort. Advisers overwhelmingly agreed these drugs provided great benefits to patients, though they expressed some concern about lack of information about how safe they are for adolescents and children. ~December 2008

44. Conclusions:  Black Box warning  Do not use long-acting bronchodilators alone  Always use with inhaled corticosteroids Long-acting  2 -agonists

45. Xolair ® Indication Xolair is indicated for adults and adolescents (12 years of age and above)  With moderate to severe, persistent asthma  Who have a positive skin test or in vitro reactivity to a perennial aeroallergen  Whose symptoms are inadequately controlled with inhaled corticosteroids  Elevated serum IgE level (≥30-700 IU/mL) Xolair has been shown to decrease the incidence of asthma exacerbations in these patients Safety and efficacy have not been established in other allergic conditions

46. Referral to an Asthma Specialist for Consultation and Co-Management Patient has had a life-threatening asthma exacerbation (hospitalization is a risk factor for mortality) Patient is not meeting the goals of therapy after 3-6 months Signs and symptoms are atypical; differential diagnosis ? Co-morbid conditions complicate asthma (GERD, VCD etc) Additional diagnostic studies are indicated (allergy skin testing, pulmonary function studies, bronchoscopy) Patient requires additional education/guidance Patient has required more than two bursts of oral corticosteroids in 1 year Patient requires “Step 4” care or higher (“Step 3” for children 0–4 years of age). Consider referral if patient requires step 3 care (“Step 2” for children 0–4 years of age) Expert Panel Report-3, Page 68

47. The Outpatient Asthma Visit Assess “severity” and “control” (NAEPP Classification Criteria)  Reduce current impairment  Reduce future risk Address “Inflammation vs. bronchoconstriction” Differentiate “controller vs. rescue medication” Prescribe an inhaled steroid for all patients with persistent asthma Teach spacer device technique Write an Asthma Action Plan  Daily management and recognizing early s/s of worsening  Step-up “Yellow Zone” plan for home management Follow-up in 4-6 weeks: step-up/step-down & modify Action Plan Inhaler Law; Albuterol and spacer for school Annual Influenza vaccine, regardless of severity EPR-3, p121-139

48. What is Success: How do we measure it and how do we get there? Severity Begin therapy based on Severity Monitor and adjust therapy based on Control and Risk and Responsiveness to Therapy Use routine standardized multifaceted measures The goal of therapy is to achieve control Individualize therapy based on likelihood of response and patient needs, desires, and goals

49. Inhaler Technique Metered-dose inhalers:  Proper MDI technique  Proper inhaler/spacer technique  Care and cleaning  Methods to determine amount of medication left in inhaler Dry-powder inhalers:  Proper technique  Care and cleaning  Methods to determine amount of medication left in inhaler Nebulizers

50. Six Key Messages Most Important: 1. Inhaled corticosteroids are the most effective anti- inflammatory medication for long term management of persistent asthma. All patients should receive: 2. Written asthma action plan 3. Initial assessment of asthma severity 4. Review of the level of asthma control (impairment and risk) at all follow up visits 5. Periodic, follow-up visits (at least every 6 months) 6. Assessment of exposure and sensitivity to allergens and irritants and recommendation to reduce relevant exposures.

51. Guidelines for the Diagnosis and Management of Asthma NAEPP/NHLBI Expert Panel Report-3 Case Scenarios

52. A 3-year old male currently not on any asthma medications has visited your outpatient clinic 3 times in the past 6 months for acute wheezing, each episode lasting 2-3 days. In between episodes, his mother reports nighttime cough about 4 nights per month. This patient’s asthma severity can be BEST classified as: A. Mild Persistent Asthma (Step 2) B. Moderate Persistent Asthma (Step 3) C. Severe Persistent Asthma (Step 4) D. I would not diagnose this child with asthma Case # 1

53. A 3-year old male currently not on any asthma medications has visited your outpatient clinic 3 times in the past 6 months for acute wheezing, each episode lasting 2-3 days. In between episodes, his mother reports nighttime cough about 4 nights per month. This patient’s asthma severity can be BEST classified as: A. Mild Persistent Asthma (Step 2) B. Moderate Persistent Asthma (Step 3) C. Severe Persistent Asthma (Step 4) D. I would not diagnose this child with asthma Case # 1

54. A 7-year old female with asthma reports nighttime awakenings about 2 times per week and requires albuterol about 3 times per week. She is currently taking fluticasone 44 mcg 2 puffs twice daily. The BEST next step in your step-up treatment plan would be to: A.Increase the dose of the inhaled steroid B.Add a leukotriene modifier C.Add a long-acting B-agonist D.Encourage albuterol more frequently, every 4 hours Case # 2

55. Classification of Asthma Control Components of Control ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 5 - 11 YEARS OF AGE IMPAIRMENT RISK Recommended Action For Treatment Well Controlled Not Well Controlled Very Poorly Controlled Symptoms Nighttime awakenings Interference with normal activity SABA use FEV 1 or peak flow Exacerbations Progressive loss of lung function Rx-related adverse effectsConsider in overall assessment of risk Evaluation requires long-term follow up care 0- 1 per year2 - 3 per year> 3 per year noneSome limitationExtremely limited 2 days/week Throughout the day 2 x/month >2x/week 2 days/week Several times/day > 80% predicted/ personal best 60-80% predicted/ personal best <60% predicted/ personal best Maintain current step Consider step down if well controlled at least 3 months Step up 1 step Reevaluate in 2 - 6 weeks Consider oral steroids Step up 1-2 steps and reevaluate in 2 weeks FEV 1 /FVC > 80% predicted 75-80% predicted <75% predicted EPR-3, p76, 310

56. Recommended Action for Treatment Based on Assessment of Control Well Controlled Controlled Not Well Controlled Controlled Very Poorly Controlled Maintain current stepStep up 1 step and reevaluate in 2-6 weeks Consider short course of oral corticosteroids Consider step down if well controlled for at least 3 months For side effects, consider alternative treatment options Step up 1-2 steps and reevaluate in 2 weeks For side effects, consider alternative treatment options NAEPP Draft Report, ERP 2007 Before stepping up check adherence and environmental control

57. Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Patient Education and Environmental Control at Each Step Step 1 Preferred: SABA prn Step 2 Preferred: Low-dose ICS Alternative: LTRA Cromolyn Theophylline Step 3 Preferred: Medium-dose ICS OR Low-dose ICS+ either LABA, LTRA, or Theophylline Step 4 Preferred: Medium-dose ICS+LABA Alternative: Medium-dose ICS+either LTRA, or Theophlline Step 5 Preferred: High dose ICS + LABA Alternative: High-dose ICS+ either LTRA or Theophylline AND Consider Olamizumab for patients with allergies Step 6 Preferred: High-dose ICS + LABA + oral Corticosteroid Alternative: High-dose ICS +either LTRA or Theophylline + oral corticosteroid AND Consider Olamizumab for patients with allergies Assess Control STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5-11 YEARS OF AGE Step up if needed (check adherence, environmental control and comorbidities) Step down if possible (asthma well controlled for 3 months) EPR-3, p296-304

58. A 7-year old female with asthma reports nighttime awakenings about 2 times per week and requires albuterol about 3 times per week. She is currently taking fluticasone 44 mcg 2 puffs twice daily. The BEST next step in your step-up treatment plan would be to: A.Increase the dose of the inhaled steroid B.Add a leukotriene modifier C.Add a long-acting B-agonist D.Encourage albuterol more frequently, every 4 hours Case # 2

59. Referral to an asthma specialist for consultation and co-management should be sought when a patient: A. Is hospitalized twice in the past year or once in the past month B. Requires more than two bursts of oral corticosteroids in one year C. Requires “Step 3” care or higher or is not responding to a treatment plan that is appropriate for patient with “Moderate Persistent Asthma” D. Any of the above Case # 3

60. Referral to an asthma specialist for consultation and co-management should be sought when a patient: A. Is hospitalized twice in the past year or once in the past month B. Requires more than two bursts of oral corticosteroids in one year C. Requires “Step 3” care or higher or is not responding to a treatment plan that is appropriate for patient with “Moderate Persistent Asthma” D. Any of the above Case # 3

61. Questions?  Download the Guidelines at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf  Download the Summary Report at: http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf