Lecture 10 Adult Asthma Dahri

SIGNS AND SYMPTOMS:

Episodic breathlessness

Wheezing

Cough with or without sputum

Chest tightness

Sx worse at night and early morning

Sx occur in response to exercise, exposure to allergens or cold air

Sx occur after taking ASAS or beta-blockers

QUESTIONS TO CONSIDER IN THE DIAGNOSIS OF ASTHMA:

Has the pt had an attack or recurrent attacks of wheezing?

Does the pt have a troublesome cough at night?

Does the pt wheeze or cough after exercise?

Does the pt experience wheezing, chest tightness or cough after exposure to airborne allergens or pollutants?

Does the pts’ cold “go to the chest” or take more than 10 days to clear up?

Are symptoms improved by appropriate asthma treatment?

GOALS OF THERAPY:

Achieve and maintain control of sx

Maintain normal activity levels, including exercise

Maintain pulmonary fxn as close to normal levels as possible

Prevent asthma exacerbations

Avoid AEs from asthma medications

Prevent asthma related mortality

ASSESSMENT OF ASTHMA: 1. Asthma control:

a. Assess sx control over last 4 weeks Well-

controlled Partly controlled

Un-controlled

Daytime asthma sx > 2 times/wk

None of these

1-2 of these

3-4 of these

Night time waking

Reliever use > 2 times/wk *

Activity limitation?

* excludes use before exercise

b. Assess risk factors for poor outcomes: Risk factors for …

Exacerbations Fixed airflow limitation Medication SEs

Ever intubated for asthma

Uncontrolled asthma sx

≥ 1 exacerbation in last 12 mo

Low FEV1*

Incorrect inhaler technique and/or poor adherence

Smoking, obesity, pregnancy, blood eosinophilia

No ICS treatment

Smoking

Occupational exposure

Mucus hypersecretion

Blood eosinophilia

Frequent oral steroids

High dose/ potent ICS

P450 inhibitors

* measure FEV1 at start of txt, after 3-6 mo for personal best, then periodically

2. Treatment issues a. Check inhaler technique & adherence

Factors Involved in Non-Adherence

Medication Usage Non-medication factors

Difficulties associated with inhalers

Complicated regimens

Fears about, or actual SEs

Cost

Distance to pharmacies

Misunderstanding/lack of info

Fears about SEs

Inappropriate expectations

Underestimation of severity

Attitudes toward ill health

Cultural factors

Poor communication

b. Ask about SEs c. Written asthma action plan? d. Attitudes and goals for asthma?

3. Comorbidities – may contribute to sx and poor QOL

Conditions Drugs

Rhinosinusitis

GERD

Obesity

Obstructive sleep apnea

Depression/anxiety

Smoking

Beta-blockers

NSAIDs

NON-PHARMACOLOGICAL MANAGEMENT:

Identify & avoid precipitating factors (environmental allergens & occupational irritants)

Smoking cessation

Some evidence to encase bedding in impermeable covers for house dust mite allergens in children

TREATMENT GUIDELINES:

Lecture 10 Adult Asthma Dahri

STEP 1: AS-NEEDED RELIEVER INHALER

Preferred option: as-needed inhaled SABA

Highly effective for relief of asthma symptoms

Pts with infrequent symptoms (<2/mo) of short duration, and no risk factors for exacerbations

Other options: adding regular low dose ICS for pts at risk of exacerbations

SHORT ACTING BETA-AGONISTS

MOA Stimulates beta2-adrenergic receptors, ↑cAMP, bronchodilation

Efficacy Improves symptoms

Adverse effects Tremor, nervousness, ↑ HR, ↑ QT, headache, hypokalemia, ↑ insulin secretion

STEP 2: LOW DOSE CONTROLLER + PRN SABA

Preferred option: regular low dose ICS with as-needed inhaled SABA

Low dose ICS reduces sx and reduces risk of exacerbations and asthma-related hospitalization & death

Other options: o LTRA with as-needed SABA

Less effective than low dose ICS

May be used for some pts with both asthma & allergic rhinitis, or if pt will not use ICS

Increase outcomes in patients with no baseline ICS (only have bronchodilator without addressing inflammatory pathophysiology)

o Low dose ICS/LABA combination with as-needed SABA

Reduces sx and increases lung function compared with ICS

More expensive and does not further reduce exacerbations o Intermittent ICS with as-needed SABA for purely seasonal allergic asthma with no interval sx

Start ICS immediately when sx commence, and continue for 4 weeks after pollen seasonal ends

INHAED CORTICOSTEROIDS

Adverse Effects ICS: oral thrush (5%), hoarseness (5-20%)

Long-term high dose use: adrenal insufficiency, hyperglycemia, osteoporosis, pneumonia, cataracts, dermal thinning

STEP 3: ONE OR TWO CONTROLLERS + PRN SABA

Preferred option: Low dose ICS/LABA combination with as-needed SABA

↓ rate of exacerbations & time taken to achieve well-controlled asthma over

Other options:

Med/high dose ICS

Low dose ICS + LTRA

LEUKOTRIENE RECEPTOR ANTAGONISTS

MOA Inhibits cysteinyl leukotriene receptor whose occupation has been correlated with airway edema, smooth muscle contraction, and altered cellular activity associated with the inflammatory process

Adverse Effects Headache, diarrhea

Lecture 10 Adult Asthma Dahri

STEP 4: TWO OR MORE CONTROLLERS + PRN SABA

Before considering step-up: check inhaler technique and adherence

Preferred options: o Combination low dose ICS/formoterol as maintenance and reliever regimen (SYMBICORT SMART)

o Combination medium dose ICS/LABA with PRN SABA o CHILDREN: refer for expert advice

Other options: o Add on tiotropium (LAMA) for adult patients (≥ 18 years) with a history of exacerbation o High dose ICS + LTRA (however studies show little extra benefit & increased risk of SEs) o Increase dosing frequency (for budenoside-containing inhalers) o Add-on LTRA or low dose theophylline

Symbicort: budenoside + formoterol

Maintenance: Symbicort 100 or 200 – 1 to 2 inh BID or 2 inh once daily

Reliever: Symbiort 100 or 200 – 1 additional inh PRN, repeat if no relief x 6 inh total (max 8 inh/day)

STEP 5: HIGHER LEVEL CARE AND/OR ADD-ON TREATMENT

Preferred option: referral for specialist investigation and consideration of add-on treatment

If sx uncontrolled or exacerbations persist Step 4 txt, check inhaler technique & adherence before referral

Add-on omalizumab (anti-IgE) – for pts with mod-severe allergic asthma that is uncontrolled on Step 4 txt

Other options:

Tiotropium: for adults (≥ 18 yo) with a history of exacerbations despite Step 4 txt; reduces exacerbations

Sputum-guided txt: in specialized centers; reduces exacerbations and/or corticosteroid dose

Add-on low dose oral corticosteroids (≤ 7.5 mg/day prednisone equivalent) May benefit some pts, but has significant systemic side-effects (monitor for osteoporosis)

Anti-IgEs

MOA IgE-neutralizing antibody

ADRs Injection site reactions, viral infections, URTI, headache, sinusitis, pharyngitis

ORAL STEROID ADRS

Cardiovascular (15%) Dyslipidemia, electrolyte imbalance, edema, renal/heart dysfunction, HTN

Infections (15%) Viral, bacterial, skin6

GI (10%) PUD, pancreatitis

Psychological (9%) Steroid psychosis, minor mood disturbances

Endocrine (7%) Diabetes, fat redistribution, interference with hormone secretion

Dermatologic (5%) Subcutaneous atrophy, acne, hirsutism, alopecia

MSK (4%) Osteoporosis, osteonecrosis, myopathy

Opthamologic (4%) Glaucoma, cataract