1. ASTHMA UPDATE Chad Fowler, M.D. 10/27/04

2. Asthma: Why do we care? It’s common: Affects 14-15 million persons in U.S. Most common chronic disease of childhood: 4.8 million children Hospitalizations and mortality are NOT insignificant Prevalence, hospitalization rates, and mortality rates have been on the rise (CDC data ’82-’92) (CDC data ’82-’92)

3. What is Asthma? Chronic inflammatory disease of the airways Key features include reversible airway obstruction, airway inflammation, and release of inflammatory mediators (bronchial mast cells) in response to a Trigger

4. Triggers Animal allergens (cat/dog/rodent) Pollen allergens (trees/grasses/weeds) Mold allergens (outdoor fungi/indoor fungi) Cockroach allergen URI’s House dust mites Nonallergenic airborne irritants: Tobacco smoke, wood-burning stoves/fireplaces, perfumes, strong odors Cold air Exercise

5. Clinical Features WheezingDyspneaCough Chest tightness Typically episodic Sx’s exacerbated when exposed to triggers

6. Diagnosis Demonstration of reversibility of airway obstruction (15% increase FEV1 post B- agonist) If spirometry normal, challenge tests may be useful (histamine, methacholine) Personal or family hx of asthma, eczema, uticaria, rhinitis is helpful Disease course followed with Peak Expiratory Flow Rates or FEV1

7. DDx Wheezing AsthmaCOPDGERD Foreign body PEILD Cardiac asthma Lymphoma Infections (pneumonia, bronchitis, bronchiolitis, epiglotitis) Anaphylaxis Obstruction (tumor, hemorrhage, edema)

8. Classification Mild Intermittent Sx’s < 2 days/wk < 2 nights/month PEF/FEV1 > 80% PEF Variability < 20%

9. Mild Persistent Sx’s > 2 days/week ( 2 days/week (<1x/day) > 2 nights/month PEF/FEV1 > 80% PEF Variability 20-30%

10. Moderate Persistent Sx’s daily > 1 night/week PEF/FEV1 60-80% PEF Variability > 30%

11. Severe Persistent Sx’s continual daytime frequent nighttime PEF/FEV1 < 60% PEF Variability > 30%

12. Treatment Goals for ALL Asthma patients: - Minimal/no chronic day/night sx’s - Minimal/no exacerbations - No limitations on activities (work/school) - PEF > 80% of personal best - Minimal use of rescue med (Albuterol) - Minimal/no adverse effects from medications - Educate on self-management and controlling triggers

13. Rescue medication: Albuterol MDI vs Neb Controller medications: Inhaled corticosteroids (ICS) Leukotriene modifiers Cromolyn/NedocromilTheophylline Rule of 2’s: If more than one of the following, pt needs a controller medication: Sx’s >2x/week (day) Sx’s >2x/month (night) >2 ER visits or hosp/yr

14. Mild Intermittent No daily medication (controller) needed Rescue medication (Albuterol MDI vs Neb) Tx exacerbations: oral systemic corticosteroids

16. Severe Persistent High Dose Inhaled Corticosteroids AND AND Long-acting beta2-agonists If needed Corticosteroid tablets/syrup (always attempt to reduce systemic tx and control with high dose ICS) Refer

18. Comparative Daily Doses of Inhaled Corticosteroids (ICS)

19. New Recommendations (NAEPP) Mild Persistent: Low-dose ICS preferred tx adults, children > 5yo, and preschool children. Cromolyn/Nedocromil now alternative to low-dose ICS in adults and children >5 yo. Cromolyn/Nedocromil now alternative to low-dose ICS in adults and children >5 yo. Cromolyn is also alternative to low- dose ICS in preschool children

20. CAMP (Childhood Asthma Management Program) Study Children 5-12yo Budesonide vs Nedocromil Budesonide provided greater reduction in Sx’s and Albuterol use, lower hospitalization rates and urgent care visits, less need for additional meds/prednisone.

21. Moderate Persistent: Adults and children >5yo - low-medium dose ICS + LABA (Salmeterol) Preschool children - low-dose ICS + LABA LABAs are not recommended for use without an ICS

22. Controller Medications: Dosing in Kids ICS: Fluticasone (Flovent) down to 4yo Budesonide nebulized inhalation suspension (Pulmocort Respules) down to 12 mo of age Budesonide nebulized inhalation suspension (Pulmocort Respules) down to 12 mo of age LABA: Formoterol (Loradil) down to 5yo Salmeterol (Serevent Diskus) down to 4yo Salmeterol (Serevent Diskus) down to 4yo Cromolyn sodium nebulizer solution down to 2yo

23. Leukotriene modifier: Montelukast (Singulair) - Oral granule formation down to 1yo - Oral granule formation down to 1yo chewable tablets 2-5yo chewable tablets 2-5yo Zafirlukast (Accolate) approved for children 5 years and older Zafirlukast (Accolate) approved for children 5 years and older Theophylline approved for any age

24. Safety of ICS Long-term use (labeled doses) is safe in children (growth, bone mineral density, adrenal function). Should always step down to lowest effective dose. Review every 1-6 months. Low-medium dose ICS are not associated with development of cataracts/glaucoma. High cumulative lifetime doses may slightly increase prevalence of cataracts in adults and elderly.

25. We have come a long way with the treatment of Asthma since the 1940’s….

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27. In Summary Classify Asthma early Treatment guided by classification/sx’s (don’t forget to reassess) Persistent Asthma = need for controller medication (rule of 2’s) ICS preferred treatment of all ages with persistent asthma (Cromoly/nedocromil alternatives) LABA use with ICSs for moderate/severe persistent asthma (not to be used as sole controller agent)