is a disease of diffuse airway inflammation is a disease of diffuse airway inflammation

caused by a variety of triggering stimuli caused by a variety of triggering stimuli

resulting in partially or completely resulting in partially or completely

reversible bronchoconstriction. reversible bronchoconstriction.

Factors that can contribute to asthma or airway hyperreactivity may include any of the following:

Environmental allergens (eg, house dust mites; animal allergens, especially cat and dog; cockroach allergens; and fungi)

Viral respiratory tract infections

Exercise, hyperventilation

Chronic sinusitis or rhinitis

Aspirin or nonsteroidal anti-inflammatory drug (NSAID)

Use of beta-adrenergic receptor blockers

(including ophthalmic preparations)

Obesity

Environmental pollutants, tobacco smoke

Irritants (eg, household sprays, paint fumes)

Emotional factors or stress

Perinatal factors

Epidemiology.Epidemiology. Asthma affects 5-10% of

the population or an estimated 23.4 million

persons, including 7 million children.

Mortality/Morbidity:Mortality/Morbidity: About 4000 deaths

occur from asthma annually in the US.

Asthma involves: bronchoconstriction, airway edema and inflammation, airway hyperreactivity, airway remodeling.

Asthma severity is categorized as Intermittent, Mild persistent, Moderate persistent, Severe persistent.

The term status asthmaticus status asthmaticus describes

severe, intense, prolonged bronchospasm

that is resistant to treatment.

Shortness of breath, especially with exertion or at night

Wheezing is a whistling or hissing sound when breathing out

Coughing may be chronic, is usually worse at night and early morning

Pulsus paradoxus, tachypnea, tachycardia Visible efforts to breathe (use of neck and

suprasternal muscles, upright posture, pursed lips, inability to speak)

The expiratory phase of respiration is prolonged

Treatment includes control of triggers, drug therapy, monitoring, patient education, treatment of acute exacerbations.

Asthma medications are generally divided into 2 categories:

quick relief (also called reliever medications);

long-term control (also called controller medications).

QUICK RELIEF MEDICATIONS are used to relieve acute asthma

exacerbations and to prevent exercise-induced asthma or exercise-induced

bronchospasm symptoms.

These medications include Short-acting beta agonists (SABAs) Anticholinergics (used only for severe

exacerbation) Systemic corticosteroids.

Short-acting beta2 agonists (SABAs)Short-acting beta2 agonists (SABAs) Albuterol sulfateAlbuterol sulfate..

Dosing and Uses:0.5 mL of 0.5% solution (2.5 mg) nebulized

q4-8hr PRN. Inhaler: 2 puffs inhaled PO q4-6hr. Tablets: 2-4 mg PO TID/QID; 32 mg/day

maximum.

Short-acting beta2 agonists (SABAs)Short-acting beta2 agonists (SABAs) Pirbuterol. Pirbuterol.

Dosing and Uses:Autohaler: 1-2 actuations q4-6hr PRN, no more than 12 actuations/day. Levalbuterol.Levalbuterol.

Dosing and Uses:Neb Solution: 1.25-2.5 mg q20min for 3

doses, then 1.25-5 mg q1-4hr PRN.MDI: 4-8 puffs q20min for up to 4 hr, then q1-4hr PRN.

Anticholinergic AgentAnticholinergic Agent

Ipratropium Ipratropium Dosing and Uses:

Inhaler: 8 actuations q20 min PRN for up to 3 hr.

Nebulizer: 500 mcg q20 min for 3 doses; then PRN.

Systemic steroidsSystemic steroids. In acute asthma . In acute asthma exacerbation, early use of systemic exacerbation, early use of systemic corticosteroids often aborts the corticosteroids often aborts the exacerbation, decreases the need for exacerbation, decreases the need for hospitalization, prevents relapse, and hospitalization, prevents relapse, and speeds recovery. speeds recovery.

PrednisonePrednisone.. Dosing and Uses: 40-60 mg q 6 h or q 8 h

for 48 h, then 60–80 mg/day 40–60 mg IV has no advantage over oral

administration if GI function is normal.  

Systemic steroidsSystemic steroids. .

Prednisolone. Dosing and Uses: 5-60 mg PO qDay

Methylprednisolone. Dosing and Uses: 2-60 mg/day divided

QD/QID PO.

Long-term control medications include

Inhaled corticosteroids (ICSs), Mast cell stabilizers, Long-acting beta agonists (LABAs), Combination inhaled corticosteroids and long-acting beta agonists, Methylxanthines, Leukotriene antagonists, Immunomodulators.

Inhaled corticosteroids Inhaled corticosteroids are indicated for long-term suppression, control, and reversal of inflammation and symptoms.

CiclesonideCiclesonide Receiving Bronchodilators or Inhaled

Corticosteroids: 80 mcg inhaled PO BID initially; may increase to 160 mcg BID.

Receiving Oral Corticosteroids: 80 mcg inhaled PO BID initially; may increase to 320 mcg BID.

Inhaled corticosteroidsInhaled corticosteroids

Beclomethasone.Beclomethasone.Dosing and Uses:

40-80 mcg inhaled PO BID if never used corticosteroid inhalers before;

40-160 mcg inhaled PO BID if used corticosteroids inhalers before;

320 mcg inhaled PO BID highest recommended dose.

Inhaled corticosteroidsInhaled corticosteroids Fluticasone inhaled.Fluticasone inhaled.It is available as a metered-dose inhaler

aerosolized product (HFA) or DPI (Diskus). Dosing and Uses.

Flovent HFA inhaler: Initial 88 mcg (2 puffs) inhaled PO BID; may increases to max 440 mcg inhaled PO BID.

Flovent Diskus: Initial 100 mcg inhaled PO BID; may increases to max 500 mcg BID

Inhaled corticosteroidsInhaled corticosteroids BudesonideBudesonide inhaledinhaled

Dosing and Uses.360 mcg inhaled PO BID; in some patients,

may initiate at 180 mcg BID; 720 mcg BID maximum.

Mometasone Mometasone Dosing and Uses.

220 mcg inhaled PO qDay/BID.

Inhaled corticosteroidsInhaled corticosteroids Triamcinolone inhaled.Triamcinolone inhaled.

Dosing and Uses.Inhaler: 2 puffs (150 mcg) TID/QID; no more than 16 puffs/day. Discontinue if

inadequate relief after 3 weeks. Flunisolide.Flunisolide.

Dosing and Uses.2 actuations (160 mcg) inhaled PO BID; may

titrate upward, not to exceed 4 actuations (320 mcg) BID.

Long-acting Long-acting ββ2-agonists 2-agonists are active for up to 12 h and are used for moderate and severe asthma but should never be used as monotherapy.

FormoterolFormoterol.. Dosing and Uses: 12 mcg inhaled q12hr.

SalmeterolSalmeterol.. Dosing and Uses: 1 inhalation (50 mcg) BID OR.

Arformoterol. Arformoterol. Dosing and Uses: 15 mcg inhaled via nebulization BID. Not to exceed 30 mcg/day.

Beta2-Agonist/Corticosteroid Beta2-Agonist/Corticosteroid CombinationsCombinations.

Budesonide and formoterol Budesonide and formoterol [Symbicort].[Symbicort].Budesonide 80 mcg/formoterol 4.5 mcg orBudesonide 160 mcg/formoterol 4.5 mcg

Dosing and Uses:Never treated with corticosteroids:2 inhalations twice daily depending on severity

of asthma. Previously treated with corticosteroids:

budesonide 160 mcg/formoterol 4.5 mcg 2 inhalations BID.

Beta2-Agonist/Corticosteroid Beta2-Agonist/Corticosteroid CombinationsCombinations

Fluticasone and salmeterol.Fluticasone and salmeterol.Dosing and Uses: 2 inhalations PO BID.

Inhaled medium dose corticosteroids: 100 mcg/5 mcg – 2 inhalations PO BID; not to exceed daily dose of 400 mcg/20 mcg.

Inhaled high dose corticosteroids: 200 mcg/5 mcg – 2 inhalations PO BID; not to exceed daily dose of 800 mcg/20 mcg.

Beta2-Agonist/Corticosteroid CombinationsBeta2-Agonist/Corticosteroid Combinations Mometasone and formoterolMometasone and formoterol..

Dosing and Uses. Initial dose based on asthma severity.

Diskus: initially 1 inhalation PO BID of 50/100 or 50/250. Not to exceed 1 inhalation PO BID of 50/500.

Metered dose inhaler (HFA): 2 inhalations PO BID. Not to exceed 2 inhalations PO BID of 21/230.

Mast cell stabilizers Mast cell stabilizers are given by inhalation prophylactically to patients with exercise-induced or allergen-induced asthma.

Cromolyn sodiumCromolyn sodium (Intal) (Intal). Dosing and Uses:

200 mg PO QID; may double dose if effect not satisfactory

within 2-3 weeks; not to exceed 400 mg PO QID.

Leukotriene modifiersLeukotriene modifiers are taken orally and can be used for long-term control and prevention of symptoms in patients with mild persistent to severe persistent asthma.

ZileutonZileutonDosing and Uses:

Extended Release: 1200 mg PO BID, within 1 hour after morning and evening meals.

Conventional (discontinued): 600 mg PO QID.

MethylxanthinesMethylxanthines are used for long-term control as an adjunct to β2-agonists.

TheophyllineTheophylline.. Dosing and Uses:

Patients not currently taking theophylline: 5-7 mg/kg IV/PO;

not to exceed 25 mg/min IV.

Maintenance: 0.4-0.6 mg/kg/hr IV infusion or 4.8-7.2 mg/kg PO (SR) q12hr to maintain levels

10-15 mg/L.

Monoclonal AntibodyMonoclonal Antibody. An anti-IgE antibody developed for use in severely allergic patients with asthma who have elevated IgE levels.

OmalizumabOmalizumabDosing and Uses:

150-375 mg SC q2-4Weeks.

Leukotriene Receptor AntagonistLeukotriene Receptor Antagonistis a selective competitive inhibitor of LTD4 and LTE4 receptors. Indicated for

chronic asthma treatment and prophylaxis

ZafirlukastZafirlukast 20 mg PO BID.

Montelukast.Montelukast. 10 mg PO qEvening (use 10 mg tablet).

Asthma Management

Pharmacotherapy is increased in a stepwise fashion until the best control of impairment

and risk is achieved (step-up). Before therapy is stepped up, adherence, exposure to

environmental factors (eg, trigger exposure), and presence of comorbid

conditions are reviewed. These factors should be addressed before increasing drug therapy. Once asthma has been well controlled for at least 3 mo, drug therapy is reduced if

possible to the minimum that maintains good control (step-down). 

Steps of Asthma Management

Step 1 (starting point for intermittent

asthma)

Preferred Treatment

Short-acting β2-agonist PRN

Steps of Asthma Management

Step II ( starting point for mild persistent

asthma)

Preferred Treatment Low-dose inhaled corticosteroid

Alternate TreatmentMast cell stabilizer,

leukotriene receptor antagonist, or theophylline

Steps of Asthma Management

Step III(starting point for moderate persistent asthma)

Preferred Treatment Medium-dose inhaled corticosteroid or Low-dose inhaled corticosteroid

plus long-acting β2-agonist

Alternate TreatmentLow-dose inhaled corticosteroid

plus one of the following: a leukotriene receptor antagonist,

theophylline or zileuton

Steps of Asthma Management

Step IV(starting point for severe persistent

asthma )

Preferred Treatment High-dose inhaled corticosteroid

plus

long-acting β2-agonist 

and possibly omalizumab for patients with allergies

Steps of Asthma Management

Step IV(starting point for severe persistent

asthma )

Preferred Treatment High-dose inhaled corticosteroid

plus

long-acting β2-agonist 

plus

oral corticosteroid 

and possibly omalizumab for patients with allergies