based on version 4 dudley asthma treatment guidelines may ... · the aim of asthma managemen t is...
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Based on Version 4 Dudley Asthma Treatment Guidelines May 2017
ASTHMA TREATMENT GUIDELINES
SPACERDEVICESSpacer devices are recommended for use with
Metered Dose Inhalers (MDI’s) in all age groups.
CLEANING– Wash the spacer once a month using detergent,
such as washing-up liquid.
– Don’t scrub the inside of the spacer as this affects the way it works.
– Leave it to air-dry as this helps to prevent the medicine sticking to the sides of the chamber and reduces the static.
– Wipe the mouthpiece clean of detergent before using it again. Don’t worry if the spacer looks cloudy - that doesn’t mean its dirty.
– The spacer should be replaced at least every year, especially if used daily, but some may need to be replaced sooner.
– Ensure the inhaler is compatible with the spacer device
Aerochamber Child Device with mask (Yellow)
1 - 5 years
Volumatic
3+ years
Aerochamber Plus (Blue)
5+ years
Aerochamber Plus with mask (Blue)
5+ years
Volumatic with Face Mask
0+ years
©2017 Produced by Dudley Respiratory Group Chairman Dr Mark Hopkin. www.dudleyrespiratorygroup.org
ASTHMA TREATMENT GUIDELINES
forall ages
Version 2.4.2 June 2017 Based on Version 4 of Dudley Asthma Treatment Guidelines May 2017
• This has been produced, based on Dudley Asthma Guidelines V4 May 2017, BTS/SIGN 2016
• The purpose is to assist Health Care Professionals, who are managing patients with a Diagnosis of Asthma, to select an appropriate inhaler device.
• There are many devices available, withdifferent steroid potencies, which has caused much confusion.
• The total daily steroid load equivalent to Beclometasone is highlighted in each box.
Definition of Asthma
Central to all definitions is the presence of
symptoms (more than one of wheeze,
breathlessness, chest tightness, cough) and of
variable airflow obstruction.
More recent descriptions of asthma in both
children and adults have included airway
hyper-responsiveness and airway inflammation
as components of the disease. (BTS/SIGN 2016)
BEST PRACTICE
- Review patients regularly Considering Step Up & Down accordingly- A Spacer device is recommended when using a MDI (see back sheet)- Check Inhaler technique and compliance at each appointment and before starting any additional therapy- Use an in-check device to measure inspiratory effort- Consider total steroid load when reviewing patient- All patients should have a written Personal Asthma Action Plan (PAAP)- Reconsider the diagnosis in patients who continue to have symptoms- Follow up patients who have an asthma attack within 2 working days – see Acute Guidelines
Asthma is not controlled at any step if using Short Acting B2 Agonists (SABAs)3 times a week or more: having symptoms 3 times a week or more: waking at least once a week.
A WELL CONTROLLED ASTHMATIC SHOULD NOT REQUIRE MORE THAN ONE TO TWO SABAINHALERS PER YEAR
The aim of asthma management is control of the disease. Complete control of asthma is defined as:
• No daytime symptoms • No asthma attacks• No night time awakening due to asthma • Normal lung function• No need for rescue medication • Minimal side effects from medication• No limitations on activity including exercise
INHALED CORTICOSTEROIDS ARE THE CORNERSTONE OF TREATMENT IN ASTHMASpacer devices should be replaced every 6-12 months.
Aerochamber Infant Device with mask (Orange)
0-18 months
In adults and adolescents over the age of 12 combined maintenance and relievertherapy can be considered for patients who have a history of asthma attacks, onmedium dose ICS or ICS/LABA (800-1000mcgs BDP/day) - BTS/SIGN 2016.
Version 2.4.2 June 2017 www.dudleyrespiratorygroup.org
Spiriva Respimat 2.5 mcgs
• Two inhalations once a day
This is indicated as an add on brochodilator treatment in adult patients with asthma who are currently treated with a maintenance combination inhaler (ICS+LABA) at 800mcgs/day BDP equivalent and who experience one or more severe exacerbations in the previous year.
LAMA - Long Acting MuscarinicAntagonist 18+ years
12+ yearsHow to Use Symbicort SMART
18+ yearsHow to use Fostair MART
The use of separate reliever inhaler( SABA) is NOT required
ADDITIONALINFORMATIONSUPPLEMENT
• Symbicort SMART means patients use Symbicort as both their preventer and their reliever
• The SMART dosing regimen applies to both the Symbicort 100/6 and 200/6
• Adult and adolescent patients (≥12 years)• Recommended maintenance dose is two inhalations per day• Patients should take one additional inhalation as needed in response to symptoms
• A total daily dose of more than 8 inhalations is not normally needed:• No more than 6 inhalations on any single occasion• Patients using >8 inhalations daily should be strongly recommended to seek medical advice
• Fostair MART means patients use Fostair as both their preventer and their reliever
• The MART dosing regimen applies to the Fostair 100/6 Metered Dose Inhaler (MDI)
• Adult patients (>18+ years)• Recommended maintenance dose is one inhalation twice a daypatients should take one additional inhalation as needed in response to symptoms
• A maximum of 8 inhalations per day (Maintenance & Reliever)
• Patients requiring frequent use of rescue inhalations daily should be strongly recommended to seek medical advice. Their asthma should be reassessed and their maintenance therapy reconsidered
New 2017
INITIAL ADD ON PREVENTER
ASTHMA TREATMENT G
UID
ELI
NES
REGULAR PREVENTER
Sym
bic
ort
10
0/6
Turb
oh
aler
1 puff twice a day
Sym
bic
ort
10
0/6
Turb
oh
aler
2 puffs twice a day
Flu
tifo
rm 5
0/5
MD
I
2 puffs twice a day
ADDITIONAL ADD ON THERAPIES
Cle
nil
50
MD
I
2 puffs twice a day
(Spacer recommended)
Pu
lmic
ort
10
0Tu
rbo
hal
er
1 puff twice a day
Cle
nil
10
0 M
DI
2 puffs twice a day
(Spacer Recommended)
Pu
lmic
ort
20
0Tu
rbo
hal
er
1 puff twice a day
Key
for
asth
ma
guid
elin
es
< 5
years
5-11
years
12-1
7 years
18+
years
MOVE UP TO IMPROVE CONTROL AS NEEDED
REFER
Sym
bic
ort
10
0/6
& 2
00
/6
Turb
oh
aler
Fo
stai
r 1
00
/6M
DI
2 puffs daily plus 1 puff as
required (max 12/day)
1 puff twice a day plus 1 puff
as required (max 8/day)
Flu
tifo
rm 2
50
/10
MD
I
2 puffs twice a day
Fost
air
20
0/6
MD
I
2 puffs twice a day
Fost
air
20
0/6
Nex
thal
er
2 puffs twice a day
SHORT ACTING B2AGONIST (SABA)
Salb
uta
mo
l 10
0 M
DI
2 puffs as required
Sala
mo
l 10
0 E
asi-
Bre
ath
e M
DI
2 puffs as required
Bri
cany
l 50
0 T
urb
oh
aler
1 puff as required
STOP
SABA
REFER
REFER
Co
nsi
der
RE
FE
R
HIGH DOSE THERAPIES
Spir
iva
Res
pim
at 2
.5m
cgs
2 puffs once a day
Long Acting
Muscarinic
Antagonist - LAMA
MOVE DOWN AND MAINTAIN LOWEST CONTROLLING THERAPY
Version 2.4.2 June 2017 ©2016 Produced by Dudley Respiratory Group Chairman Dr Mark Hopkin. Adapted from BTS/SIGN 2016 - 153
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w.d
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leyr
esp
irat
ory
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up
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LTR
A**
(See
bel
ow
)
*Bec
lom
etas
on
e (B
DP
) Eq
uiv
alen
t To
tal D
aily
Do
se
*200
0mcgs/day
ICS + LABA
MART
SMART
BDP
ICS
Budesonide
ICS
Fluticasone
Propionate IC
SBDP
Extra fine: IC
SFormoterol
LABA
Salmeterol
LABA
Tiotropium
LAM
A
Cle
nil
�
Pu
lmic
ort
�
Sym
bic
ort
��
Flu
tifo
rm�
�
Fost
air
��
Sere
tid
e�
�
Spir
iva
�
**LT
RA
(Leu
kotr
ine
Rec
epto
r A
nta
gon
ist)
*BD
P - Beclomethasone Dipropionate
ICS -Inhaled Corticosteroid
LAB
A -Long Acting Beta 2Agonist
MD
I- Metered Dose Inhaler
DP
I- Dry Powder Inhaler
Montelukast 4mg Chewtab
or4mg Granules (do not mix with fluid
can be mixed with food)
Once a day at night
Montelukast 5mg Chewtab
once a day at night
Montelukast 10mg Tablet
once a day at night
6 m
on
ths
to
5 y
ears
6-1
4 y
ears
15
+ y
ears
11
LAM
A10
1110
73
2
61
*400mcgs/dayICS
Cle
nil
10
0 M
DI
2 puffs twice a day
(Spacer Recommended)
Pu
lmic
ort
20
0Tu
rbo
hal
er
1 puff twice a day
4
Cle
nil
20
0 M
DI
2 puffs twice a day
Pu
lmic
ort
40
0 T
urb
oh
aler
1 puff twice a day
8
incr
ease
ICS
to4
00
mcg
s/d
ay
bef
ore
ad
din
g in
LA
BA
6+
Sym
bic
ort
20
0/6
Turb
oh
aler
2 puffs twice a day
Flu
tifo
rm 1
25
/5M
DI
2 puffs twice a day
Fost
air
10
0/6
MD
I
2 puffs twice a day
Fost
air
10
0/6
Nex
hal
er
2 puffs twice a day
99
Sym
bic
ort
10
0/6
Turb
oh
aler
***
2 puffs twice a day
Sere
tid
e 5
0M
DI
2 puffs twice a day
(Spacer Recommended)
5
6+
ALWAYS
• P
resc
rib
e by
bra
nd
• C
hec
k in
hal
er t
ech
niq
ue
• C
hec
k C
om
plia
nce
• Is
it A
sth
ma?
• U
se a
sp
acer
wit
h M
DI
5 y
rs6
-11
yrs
wh
o c
ann
ot
use
Tu
rbo
hal
er(D
PI)
OR
Cle
nil
10
0 M
DI
2 puffs twice a day
(Spacer Recommended)
OR
Asthma is not
controlled at any
step if:
•using SABA 3
times a week
or more.
• having symptoms
3 times a week
or more.
• waking at least
once a week.
LTR
A**
LTR
A**
LTR
A**
*20
0mcgs/day
ICS+LABA
In a
combination
inhaler
2
*40
0mcgs/day
3 ICS
GOOD RESPONSE - continue
IF BENEFIT from LABA but
control still inadequate...
increase ICS in a
Combination Inhaler (ICS+LABA)
consider trial of
LTR
A**
48
*40
0mcgs/day
ICS
10LA
MA
*80
0mcgs/day
ICS 9
*80
0 *
10
00
mcgs/day
ICS+LABA
REFER
*20
0mcgs/day
ICS1
*40
0mcgs/day
ICS6
*40
0mcgs/day
ICS+LABA
In a
combination
inhaler
7
NO RESPONSE
from LABA
STOP and INCREASE ICS
*40
0mcgs/day
ICS+LABA
5
*2000mcgsICS + LABA
Based on Version 4 of Dudley Asthma Treatment Guidelines May 2017
See
sep
arat
en
ote
s
*800mcgs
ICS + LABA
*200mcgs
ICS + LABA
Very Low dose ICS
Lowdose ICS
Mediumdose ICS
Highdose ICS
POTENCY KEY
*200mcgs/dayICS
*400mcgs/dayICS
*400mcgsICS + LABA
Maintenance & Reliever Therapy
*800mcgsICS
*400mcgsICS + LABA
*1000mcgsICS + LABA
either
or
< 12 years
12+ years
New 2017