Upload
alisha-robertson
View
222
Download
0
Tags:
Embed Size (px)
Citation preview
Bronchial asthma
Classification and guideline treatment
Prepared by:
Reem Ahmed Abd el Moneim
PharmD 4
Bronchial asthma
Source: Peter J. Barnes, Source: Peter J. Barnes, MDMD
Classification
According to etiology:1-Allergic or extrinsic asthma 2-Non-allergic or intrinsic asthma 3-Mixed forms
According to degree of severity:
Grade 1: Intermittent Grade 2: Persistent, mild Grade 3: Persistent, moderate Grade 4: Persistent, severe
SymptomsNocturnal symptoms
FEV1/PEFR
Stage 1
intermittent
<1 time a week
<2 times a month
>80% predicted
Stage 2
Mild-persistant
>1 time a week but >1 time a day
>2 times a month
>80% predicted,variability 20-30%
Stage 3
Moderate-persistant
daily >1 time a week
60-80%predicted,
variability <30%
Stage 4
Severe-persistant
continousfrequent<60%predicted,
variability <30%
According to level of asthma control:
CharacteristicControlled
(All of the following)Partly controlled
(Any present in any week)Uncontrolled
Daytime symptomsNone (2 or less /
week)More than
twice / week
3 or more features of
partly controlled
asthma present in any
week
Limitations of activities
NoneAny
Nocturnal symptoms / awakening
NoneAny
Need for rescue / “reliever” treatment
None (2 or less / week)
More than twice / week
Lung function (PEF or FEV1)
Normal <80% predicted or
personal best (if known) on any day
ExacerbationNone One or more / year 1 in any week
Asthma Management and prevention
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
Reliever MedicationsReliever Medications
Rapid-acting inhaled β2-agonists
Short-acting oral β2-agonists
Systemic glucocorticosteroids
Theophylline
Anticholinergics
Rapid-acting inhaled β2-agonists
Short-acting oral β2-agonists
Systemic glucocorticosteroids
Theophylline
Anticholinergics
Controller MedicationsController Medications
Inhaled glucocorticosteroids Systemic glucocorticosteroids Long-acting inhaled β2-agonists Long-acting oral β2-agonists Theophylline Cromones Anti-IgE Leukotriene modifiers
Inhaled glucocorticosteroids Systemic glucocorticosteroids Long-acting inhaled β2-agonists Long-acting oral β2-agonists Theophylline Cromones Anti-IgE Leukotriene modifiers
StageDaily controller medication
Other treatment option
MildLow dose ICSSustained release theophylline
ModerateModerate dose ICS+inhaled long acting β 2 agonist or leukotriene inhibitor
-Moderate dose ICS+either sustained release theophylline or long acting β 2 agonist or leukotriene inhibitor.
-High dose ICS
SevereHigh dose ICS+inhaled long acting β 2 agonist or leukotriene inhibitor
Oral glucocorticoid
Anti-IgE(omlizumab)
Step 1 – As-needed reliever medication
Patients with occasional daytime symptoms of short duration
A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)
When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)
Treating to Achieve Asthma Control
Step 2 – Reliever medication plus a single controller
A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)
Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids
Treating to Achieve Asthma Control
Step 3 – Reliever medication plus one or two controllers
For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)
Inhaled long-acting β2-agonist must not be used as monotherapy
For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more controllers
Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3
Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma
Treating to Achieve Asthma Control
Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)
Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)
Leukotriene-Inhibiting Drugs
Leukotriene inhibitors are either leukotriene receptor antagonists or leukotriene synthesis inhibitors, which act by blocking 5-lipoxygenase activity. The leukotriene receptor antagonists include zafirlukast (Accolate) and montelukast (Singulair); zileuton (Zyflo) is the only leukotriene synthesis inhibitor.
Clinical recommendation
-Leukotriene inhibitors are effective in the treatment of asthma but are less effective than inhaled corticosteroids (evidence A)
-Leukotriene inhibitors added to inhaled corticosteroids are less effective than long-acting beta agonists added to inhaled corticosteroids in the treatment of asthma (evidence A)
-Leukotriene inhibitors are alternative treatments in exercise-induced asthma and can be of benefit for children when oral therapy is preferred over inhalers (evidence B)
-Leukotriene inhibitors are effective in the treatment of allergic rhinitis but are less effective than intranasal corticosteroids (evidence A)
DrugAge and recommended oral dose
Therapeutic issues
Montelukast (Singulair)
Adults: 10 mg before bed
Children six to 14 years: 5 mg before bed
Children two to five years: 4 mg before bed
Renal adjustments: none
Hepatic adjustments: in mild to moderate disease
Zafirlukast (Accolate)
)Ventair(
Patients older than 11 years: 20 mg twice daily
Children seven to 11 years: 10 mg twice daily
Renal adjustments: none
Hepatic adjustments: not defined
Monitor hepatic enzymes every two to three months
Administration with meals decreases bioavailability; take at least one hour before meals or two hours after
Inhibits metabolism of warfarin (Coumadin), increasing prothrombin time
Zileuton (Zyflo)Patients older than 12 years: 600 mg four times daily
Can inhibit metabolism of warfarin, theophylline, and propranolol (Inderal)
Monitor hepatic enzymes every two to three months
Anti-IgE treatment:Omalizumab(Xolair®)
Omalizumab blocks the receptors on the surfaces of the mast cells and basophils to which antibodies attach, thereby preventing antibodies from attaching to the cells. As a result, the cells do not release their chemicals, and the allergic reaction and inflammation are prevented.
DOSING:
Omalizumab is injected under the skin. The recommended dose is 150-375 mg every 2 to 4 weeks. The dose and frequency is based on body weight and levels of serum IgE, a type of antibody. Doses greater than 150 mg should be divided and administered at different sites so that no more than 150 mg is administered at each injection site.
SIDE EFFECTS
Headaches, viral infections, upper respiratory tract infections and injection-site reactions such as pain, redness, swelling, itching and bruising.
Use of omalizumab may also lead to serious, life-threatening allergic reactions (anaphylaxis) .
Signs and symptoms of anaphylaxis
-Wheezing, shortness of breath, cough, chest tightness, or trouble breathing.
-Low blood pressure, dizziness, fainting, rapid or weak heartbeat, anxiety.
-Flushing, itching or feeling warm.
-Swelling of the throat or tongue, throat tightness, hoarse voice, or trouble
swallowing.
It is recommended that patients be observed for these reactions for at least two hours after injection of omalizumab; however, these reactions can occur up to 24 hours or longer after the injections.
Cancer occurs more frequently in patients who take omalizumab .
Non pharmacological treatment:
-Reduce exposure to indoor allergens
-Avoid tobacco smoke
-Avoid vehicle emission
-Identify irritants in the workplace
-Explore role of infections on asthma development, especially in children and young infants
Influenza VaccinationInfluenza Vaccination
Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised
However, routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control