Asthma Management Fine Tuning Maximum control with minimum medication Start with mild asthma and work up the scale (BTS/SIGN 2004)

Asthma Management

Fine TuningMaximum control with minimum medication

Start with mild asthma and work up the scale (BTS/SIGN 2004)

Fine Tuning

Asthma control means:-Minimal symptoms during day and night

-Minimal need for reliever medication-No exacerbations

-No limitation of physical activity

-Normal lung function (FEV1 and/or PEF >80% predicted or best)

Asthma Management

Fine TuningBefore initiating a new drug therapy:

-Check compliance with existing therapies

-Check inhaler technique ( Reconsider inhaler delivery system)

-Eliminate trigger factors

Asthma Management

Fine Tuning

Asthma Management

Step-wise approachStep-wise approach

AdultsAdults ChildrenChildren5-125-12 YearsYears

ChildrenChildren < <55 YearsYears

55 stepssteps 55 stepssteps 44 stepssteps

Asthma Management

Step 1:Mild intermittent asthma

Step 2:Introduction of regular preventer therapy

Step 3:Add-on therapy

Step 4:Poor control on moderate dose of inhaled steroids + Add on

Step 5:Use of oral steroids

Adults

Preventers: Inhaled corticosteroids (ICS)• 1st Choice Moderate Dose: Adults 200-800 mcg/day

Children 200-400 mcg/day

•BDP= Becotide (Beclomethasone Dipropionate) = Pulmicort (Budesonide)

•Flexotide (Fluticasone) ½ dose of BDP

High Dose ICS Adults 2000 mcg/dayChildren 800

mcg/day

Asthma Management

Add-On therapy

• 1st Choice LABA Adults/ Children 5-12 years

•LABA should not be used without ICS

• Others•2nd choice: LTRAs

•3rd choice: SR Theophylline•4rth choice: Oral LABA ( SR Be agonists tab) S.E

Asthma Management

Step 1: Mild intermittent asthma-Prescribe inhaled short-acting 2 agonist as short term reliever

therapy for all patients with symptomatic asthma

-Review asthma management in patients with high usage of inhaled short acting 2 agonists

Asthma Management

Step 2: Introduction of regular preventer

therapy when?Recent exacerbations

Nocturnal asthma

Impaired lung function

Using inhaled B2 agonist >once a day

Using inhaled B2 agonists > 3 times per week

Asthma Management


therapy Inhaled steroids are the 1st line preventers

Give inhaled steroids initially twice daily

If good control, once a day inhaled steroids at the same

total daily dose

Asthma Management


therapyStart patients at inhaled steroid dose appropriate to

disease severity

Adults: 400 mcg per day

Children 5-12 years: 200 mcg per day

Children under 5 years: higher doses may be required

to ensure consistent drug delivery

Use lowest dose at which effective control is maintained

Monitor children’s height on a regular basis

Asthma Management

Poor controlStill symptoms or

Sleep disturbance or

Restriction of activity

Despite use of regular inhaled steroid + PRN bronchodilator

Asthma Management

Poor control – Therapeutic options 1) check compliance

2) check inhaler technique3) Add LABA 1st Choice: Adults/ children 5-12

(in children <5 years LTRAs preferred)4) Suboptimal or no response : → dose of

inhaled steroid (800 mcg adult, 400 mcg children via spacer device

5) Poor control persist→ consider additional therapy: LTRAs, SR Theophylline or SR oral B 2 agonist +

Increase Inhaled steroid to 2000 mcg/day6) Oral steroids

Asthma Management

Step 3: Add-on therapy

Inadequate control on low dose inhaled steroidsInadequate control on low dose inhaled steroids

Asthma Management


Inadequate control on low dose inhaled steroids

Add inhaled long-acting ßAdd inhaled long-acting ß2 2 agonist (LABA)agonist (LABA)

Asthma Management



Assess control of asthmaAssess control of asthma

Add inhaled long-acting ß2 agonist (LABA)

Asthma Management


Good response to Good response to LABA:LABA:• Continue LABAContinue LABA


Assess control of asthma


Benefit from LABA but control Benefit from LABA but control still inadequate:still inadequate:

• Continue LABAContinue LABA• Increase inhaled steroid dose to Increase inhaled steroid dose to

800mcg/day (adults) and 800mcg/day (adults) and 400mcg/day (children 5-12 years)400mcg/day (children 5-12 years)

No response to LABA:No response to LABA:• Stop LABAStop LABA• Increase inhaled steroid dose Increase inhaled steroid dose

to 800mcg/day (adults) and to 800mcg/day (adults) and 400mcg/day (children400mcg/day (children5-12 years)5-12 years)

Asthma Management

Good response to LABA:• Continue LABA



Benefit from LABA but control still inadequate:• Continue LABA• Increase inhaled steroid dose to

800mcg/day (adults) and 400mcg/day (children 5-12 years)

Control still inadequate:Control still inadequate:• Trial of other add-on therapy, Trial of other add-on therapy,

e.g. leukotriene receptor e.g. leukotriene receptor antagonist or theophyllineantagonist or theophylline

No response to LABA:• Stop LABA• Increase inhaled steroid dose

to 800mcg/day (adults) and 400mcg/day (children5-12 years)


Asthma Management

Step 3


If control still inadequate If control still inadequate go to Step 4go to Step 4


Benefit from LABA but control still inadequate:• Continue LABA and• Increase inhaled steroid dose to

800mcg/day (adults) and 400mcg/day (children 5-12 years)

Control still inadequate:• Trial of other add-on therapy,

e.g. leukotriene receptor antagonist or theophylline

If control still inadequate go If control still inadequate go to Step 4to Step 4


No response to LABA:• Stop LABA• Increase inhaled steroid dose

to 800mcg/day (adults) and 400mcg/day (children5-12 years)

Good response to LABA:• Continue LABA

Asthma Management

Step 3

Step 4: poor control on moderate dose of

inhaled steroids + Add on inhaled steroids to 2000 mcg/day (adult) or 800 mcg/day

(children)

LTRAs OR SR Theophylline OR Oral SR B2 agonist

Consider referring to specialist care before proceeding to step 5

Asthma Management

Step 5: Use of oral steroidsMaintenance course (long term)

Plus drugs in step 4

Asthma Management

Step 1: Mild intermittent asthmaStep 1: Mild intermittent asthma

Inhaled short acting ßInhaled short acting ß22 agonist as required agonist as required

Stepwise management ofStepwise management ofasthma inasthma in adultsadults

Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

Stepwise management ofStepwise management ofasthma in asthma in adultsadults

Step 2: Regular preventer therapyStep 2: Regular preventer therapy

Add inhaled steroid 200-800mcg/day *Add inhaled steroid 200-800mcg/day *400mcg is an appropriate starting dose for many patients400mcg is an appropriate starting dose for many patients


Step 1: Mild intermittent asthma

Start at dose of inhaled Start at dose of inhaled steroid appropriate to steroid appropriate to severity of disease.severity of disease.

* BDP or equivalent* BDP or equivalent


Step 3: Add-on therapysStep 3: Add-on therapys

1. Add inhaled long-acting ß1. Add inhaled long-acting ß22 agonist (LABA) agonist (LABA)

2. Assess control of asthma:2. Assess control of asthma:• goodgood response to LABAresponse to LABA – continue LABA – continue LABA• benefit from LABA but control still inadequatebenefit from LABA but control still inadequate – continue LABA and – continue LABA and

increase inhaled steroid dose to 800mcg/day * (if not already on this dose)increase inhaled steroid dose to 800mcg/day * (if not already on this dose)• no response to LABAno response to LABA – stop LABA and increase inhaled steroid to – stop LABA and increase inhaled steroid to

800mcg/day *. If control still inadequate, institute trial of other therapies800mcg/day *. If control still inadequate, institute trial of other therapies(e.g. leukotriene receptor antagonist or SR theophylline)(e.g. leukotriene receptor antagonist or SR theophylline)



Step 2: Regular preventer therapy Start at dose of inhaled Start at dose of inhaled steroid appropriate to steroid appropriate to severity of disease.severity of disease.



Step 4: Persistent poor controlStep 4: Persistent poor control

Consider trials of:Consider trials of:• increasing inhaled steroid up to 2000mcg/day *increasing inhaled steroid up to 2000mcg/day *• addition of fourth drug (e.g. leukotriene receptor addition of fourth drug (e.g. leukotriene receptor

antagonist, SR theophylline, ßantagonist, SR theophylline, ß22 agonist tablet) agonist tablet)







Step 5: Continuous or frequent use of oral steroidsStep 5: Continuous or frequent use of oral steroids

Use daily steroid tablet Use daily steroid tablet in lowest dose providing adequate controlin lowest dose providing adequate controlMaintain high dose inhaled steroid at 2000mcg/day *Maintain high dose inhaled steroid at 2000mcg/day *Consider other treatments to minimise the use of steroid tabletsConsider other treatments to minimise the use of steroid tabletsRefer patient for specialist careRefer patient for specialist care






Step 4: Persistent poor control




Step 5: Continuous or frequent Step 5: Continuous or frequent use of oral steroidsuse of oral steroids


Step 3: Add-on therapyStep 3: Add-on therapy


Stepwise management ofStepwise management ofasthma in children aged asthma in children aged 5-12 years5-12 years







Add inhaled steroid 200-400mcg/day *Add inhaled steroid 200-400mcg/day *(other preventer drug if inhaled steroid cannot be used)(other preventer drug if inhaled steroid cannot be used)200mcg is an appropriate starting dose for many patients200mcg is an appropriate starting dose for many patients


Start at dose of inhaled Start at dose of inhaled steroid appropriate to steroid appropriate to severity of disease.severity of disease.





1. Add inhaled long-acting ß1. Add inhaled long-acting ß22 agonist (LABA) agonist (LABA)

2. Assess control of asthma:2. Assess control of asthma:• goodgood response to LABAresponse to LABA – continue LABA. – continue LABA.• benefit from LABA but control still inadequatebenefit from LABA but control still inadequate – continue LABA and – continue LABA and

increase inhaled steroid dose to 400mcg/day * (if not already on this dose).increase inhaled steroid dose to 400mcg/day * (if not already on this dose).• no response to LABAno response to LABA – stop LABA and increase inhaled steroid to – stop LABA and increase inhaled steroid to

400mcg/day *. If control still inadequate, institute trial of other therapies 400mcg/day *. If control still inadequate, institute trial of other therapies (e.g. leukotriene receptor antagonist or SR theophylline).(e.g. leukotriene receptor antagonist or SR theophylline).







Increase inhaled steroid up to 800mcg/day *Increase inhaled steroid up to 800mcg/day *







Step 5: Continuous or frequent use of oral steroidsStep 5: Continuous or frequent use of oral steroids

Use daily steroid tablet Use daily steroid tablet in lowest dose providing adequate controlin lowest dose providing adequate controlMaintain high dose inhaled steroid at 800mcg/day *Maintain high dose inhaled steroid at 800mcg/day *Refer patient to respiratory paediatricianRefer patient to respiratory paediatrician





Step 4: Persistent poor control




Step 5: Continuous or frequent Step 5: Continuous or frequent use of oral steroidsuse of oral steroids




Stepwise management ofStepwise management ofasthma in children asthma in children underunder 5 years5 years




Stepwise management ofStepwise management ofasthma in children asthma in children under 5 yearsunder 5 years



Add inhaled steroid 200-400mcg/day * Add inhaled steroid 200-400mcg/day * ††

(leukotriene receptor antagonist if inhaled steroid cannot be used)(leukotriene receptor antagonist if inhaled steroid cannot be used)


Start at dose of inhaled steroid Start at dose of inhaled steroid appropriate to severity of disease.appropriate to severity of disease.

* BDP or equivalent* BDP or equivalent†† Higher nominal doses may beHigher nominal doses may be required if drug delivery is difficultrequired if drug delivery is difficult




In children aged 2-5 years consider addition of leukotriene In children aged 2-5 years consider addition of leukotriene receptor antagonistreceptor antagonist

In children under 2 years consider proceeding to step 4In children under 2 years consider proceeding to step 4


Step 2: Regular preventer therapy


Step 2: Regular preventer therapy




Refer to respiratory paediatricianRefer to respiratory paediatrician








Stepping downImportant to review patients regularly as they step down

Patients should be maintained at the lowest possible

dose of inhaled steroids

Reductions should be considered every 3 months

Reducing the dose by 25-50% each time

Asthma Management

Exercise Induced AsthmaOften indicates poorly controlled asthma

For patients taking inhaled steroids add:

LABA

LTRAs

Cromones

Oral B2 agonist

Theophylline

Inhaled short acting B2 agonists immediately before

exercise

Asthma Management

Seasonal asthmaStart prophylactic steroid therapy before season begin

Asthma Management

Exacerbations

Occasional attacks between period of good control which can predicted by warning signs

Asthma Management

Exacerbations

warning signs

Increase symptomsSleep disturbanceFall in exercise toleranceIncrease need for bronchodilator Decrease effectiveness of bronchodilatorfalling PEFwide variations in PEFinability to achieve optimum PEF after B agonist

Asthma Management

Exacerbations

Asthma Management

Management of exacerbationsProvide emergency supply oral steroids (Rescue

Course) → to take at the 1st warning sign

seek medical help

written action plan

Time spent with patient for “What to do and

When” will help prevent acute attack

Asthma Management

Rescue course oral steroid20 mg Children 2-5 years

30-40 mg Children >5 y ↨3 days *The dose should be repeated if child vomited

40-50 mg Adult: 5 days or until recovery

Asthma Management

When do you stop medication?

Asthma Management

When do you stop medication?

Adult with stable asthma is possible to reduce inhaled steroids without losing control

On average step down gradually by 25% (Hawkins et al 2003)

Keep patient under regular review even when well controlled

Asthma Management

How do you know if a child is growing out of well controlled asthma if the prophylactic therapy is never reduced for a trial period?

Often patients stops medications themselves when they are betterReducing treatment gradually to the minimum dose possible before medication is stoppedNo exacerbationsNo symptomsNo B 2 useIf symptoms recur medications should be restarted.

Asthma Management

Documents

Asthma Management Fine Tuning Maximum control with minimum medication Start with mild asthma and work up the scale (BTS/SIGN 2004)