Asthma – 2005

“Why We Do the Things We Do”

A Miniature Literature Review

Michael E. Ruff, MD

Dallas, Texas

Photo: Personal collection, Dr. Dennis Williams Pharm.D.

Effect of Inhaled Corticosteroids on Inflammation

Pre– and post–3-month treatment with budesonide (BUD) 600 mcg b.i.d.

E = Epithelium

BM = Basement Membrane

Laitinen et al. J Allergy Clin Immunol. 1992;90:32-42. Reprinted with permission.

Mean Annual Increase in FEV1 During ICS Therapy

12

10

8

6

4

2

0

AnnualChange in

% PredictedFEV1

<2 2-3 3-5 >5

Asthma Duration at Start of ICS therapy (yrs)

Agertoft L, Pederson S. Respir Med. 1994; 88:373-381.

Assessment of the Effects of Inhaled Corticosteroids on Growth

cm

0 1 2 3 4

Time (y)

0

130

135

140

150

160

145

155

Standing Height

*Children aged 5 to 12 years.Childhood Asthma Management Program Research Group. N Engl J Med. 2000;343:1054-63.

Standing-Height Velocity

cm

/y

Time (y)0 1 2 3 4

0.0

4.5

5.0

5.5

6.5

6.0

Nedocromil PlaceboBudesonide

Girls

Boys

Mea

sure

d A

dult

Hei

ght

(cm

)

Target Adult Height (cm)

200

190

180

170

160

150150 160 170 180 190 200

Effect of Long-term Treatment with Inhaled Budesonide on Adult Height in Children with Asthma

Agertoft L, Pedersen S. N Engl J Med. 2000;343:1064-1069.

NIH Treatment Guidelines

NIH-preferred options are highlighted.

Guidelines for the Diagnosis and Management of Asthma. 2002.NIH Publication No. 02-5075.

• Step 1 - Mild Intermittent Asthma– No daily medication

• Step 2 - Mild Persistent Asthma– Low-dose inhaled corticosteroid (ICS)– Cromolyn/nedocromil, theophylline or leukotriene modifier

(alternative Rx)• Step 3 - Moderate Persistent Asthma

– Low to medium dose ICS + long-acting β2-agonist (LABA)– Medium-dose ICS – Low or medium ICS + LTRA or theophylline (alternative Rx)

• Step 4 - Severe Persistent Asthma– High-dose ICS + LABA– If needed, add oral steroids

NIH Treatment Guidelines

NIH-preferred options are highlighted.

Guidelines for the Diagnosis and Management of Asthma. 2002.NIH Publication No. 02-5075.

• Step 1 - Mild Intermittent Asthma– No daily medication

• Step 2 - Mild Persistent Asthma– Low-dose inhaled corticosteroid (ICS)– Cromolyn/nedocromil, theophylline or leukotriene modifier

(alternative Rx)• Step 3 - Moderate Persistent Asthma

– Low to medium dose ICS + long-acting β2-agonist (LABA)– Medium-dose ICS – Low or medium ICS + LTRA or theophylline (alternative Rx)

• Step 4 - Severe Persistent Asthma– High-dose ICS + LABA– If needed, add oral steroids

• Teach and re-teach and re-check inhaler technique• Always assume that patients are poorly compliant,

especially if their asthma is poorly controlled • Monitor objective parameters of airway function (i.e.,

spirometry)• Assume that most asthmatics (and almost all children with

asthma) are allergic• Identify and counsel avoidance for triggering factors• Treat allergic rhinitis• Consider allergen-specific immunotherapy (i.e.,

allergy shots)• Realize that the natural history of persistent asthma is not

benign• Identify persistent asthmatics as early as possible and

institute treatment with anti-inflammatory agents• Monitor for drug side effects (e.g., plot growth curves), and

attempt to use the lowest effective therapeutic dose of inhaled corticosteroids