3. Corticosteroid Therapy in Asthma Attaran D, MD,Pulmonologist, Associate professor, Mashhad University of Medical Sciences Attaran D, MD,Pulmonologist, Associate professor, Mashhad University of Medical Sciences

4. A chronic inflammatory disorder of the airways Many cells and cellular elements play a role Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing Widespread, variable, and often reversible airflow limitation A chronic inflammatory disorder of the airways Many cells and cellular elements play a role Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing Widespread, variable, and often reversible airflow limitation

5.  Steroids are the most effective therapy for asthma  Steroids are recommended as the first line therapy for all patients  Inhaled steroids have been a great advance in the management of asthma  Inhaled steroids control inflammation & symptoms without significant side effects

6.  Anti inflammatory gene activation  Switching off inflammatory genes  Inflammatory cell inhibition ( lymph, Mast cell, Eos, Mac )  Increased B2 receptor effects  Steroids have no distinct effects on airway muscle Molecular effects of corticosteroids

7. Source: Peter J. Barnes, MD Asthma Inflammation: Cells and Mediators

9. Source: Peter J. Barnes, MD AsthmaInflammation: Cells and Mediators Asthma Inflammation: Cells and Mediators

11.  A single dose of steroids has no effect on the early response to allergen But does inhibit the late response  The fraction of steroid that is inhaled acts locally on the airway mucosa  Systemic absorption from airway, alveolar surface & oropharyngeal swallowing  Absorbed fraction metabolized in the liver ( first pass metabolism )  Budesonide & Fluticasone have a greater first pass metabolism Clinlcal use

12. Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age Beclomethasone200-500 100-200 >500-1000 >200-400 >1000 >400 Budesonide200-600 100-200 600-1000 >200-400>1000 >400 Budesonide-Neb Inhalation Suspension 250-500 >500-1000 >1000 Ciclesonide 80 – 160 80-160 >160-320 >160-320>320-1280 >320 Flunisolide500-1000 500-750>1000-2000 >750-1250 >2000 >1250 Fluticasone100-250 100-200 >250-500 >200-500 >500 >500 Mometasone furoate200-400 100-200 > 400-800 >200-400>800-1200 >400 Triamcinolone acetonide400-1000 400-800>1000-2000 >800-1200>2000 >1200

14.  Use of spacer reduce oropharyngeal deposition and complications  Low dose inhaled steroid up to 400mcg BDP ( 250mcg Fluticasone )  Medium dose inhaled steroid up to 1000mcg BDP ( 500mcg F )  High dose inhaled steroid up to 2000mcg BDP (1000mcg F )

15.  Usual maintenance dose is 10-15 mg  Oral steroids are usually given as a single dose in the morning  In acute severe asthma maximal beneficial effect is usually achieved with 30-40 mg Prednisolone daily

16. Steroid Complications  Suppression of HPA axis (dose dependent & duration)  Systemic effects  Localized effects

19. Steroid Insensitive Asthma

20. Diagnosis

21. Management of SR or SI Asthma  Evaluation for comorbid or masquerading conditions  VCD,GERD, ABPA,HP,Upper airway dis  Assessing of persistent tissue inflammation ( e NO, ECP )  Ensure adequate treatment adherence

22.  Possible microbial infection ( MP, CP )  Combination therapy with LABA  Final step is use of alternative anti inflammatory & immunomedulatory ( Omalizomab,Cyclospurine,IV Ig )

24. خدايا به من آرامشي عطا فرما تا بپذيرم آنچه را نمي توانم تغيير دهم و شهامتي تا تغيير دهم آنچه را مي توانم و دركي تا بفهم تفاوت اين دو را