Effective Therapy Management for Chronic Asthma - Goals, Program, and Measures

1. Revised 2006

2. Goals of Therapy • Therapy for chronic asthma is directed at suppressing the underlying inflammatory response and normalizing pulmonary function. • The goals of treatment for chronic asthma are to: • Reduce impairment • prevent chronic, troublesome symptoms • require infrequent use (≤ 2 days a week) of inhaled SABA for quick relief of symptoms • maintain (near-) normal pulmonary function • maintain normal activity levels, including exercise and other physical activities; • meet patients’ & families’ expectations of and satisfaction with care • Reduce risk • prevent recurrent exacerbations • minimize need for ER visits/hospitalizations • prevent loss of lung function • prevent reduced lung growth in children • minimal adverse effects of therapy

3. A Four-PART PROGRAMTO MANAGE ANDCONTROL ASTHMA • Develop Patient/Doctor Partnership • 2. Identify and Reduce Exposure to Risk Factors • 3. Assess, Treat and Monitor Asthma • 4. Manage Asthma Exacerbations

5. Measures to prevent the development of asthma, and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible. Asthma exacerbations may be caused by a variety of risk factors – allergens, viral infections, pollutants and drugs. Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs. Component 2: Identify and Reduce Exposure to Risk Factors

7. Reducing Exposure to House Dust Mites • Use bedding encasements • Wash bed linens weekly • Avoid down fillings • Limit stuffed animals to those that can be washed • Reduce humidity level

8. Reducing Exposure to Cockroaches Remove as many water and food sources as possible to avoid cockroaches.

9. Reducing Exposure to Pets • People allergic to pets should not have them in the house. • At a minimum, do not allow pets in the bedroom.

10. Reducing Exposure to Mold Eliminating mold may help control asthma exacerbations.

11. Component 3: Assess, Treat and Monitor Asthma

12. Classification of Severity

13. Classifying Asthma Severity for Patients who Are Not Currently Taking Long-Term Control Medications

14. New Guideline :Classification of asthma by severity is usefulwhen decisions are being made about management at theinitial assessment of a patient.

17. Asthma control

18. Depending on level of asthma control, the patient is assigned to one of five treatment steps Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves: - Assessing Asthma Control - Treating to Achieve Control - Monitoring to Maintain Control Component 3: Assess, Treat and Monitor Asthma

21. For Children Older Than 5 Years, Adolescents and Adults

28. Treating to Maintain Asthma Control • When control as been achieved, ongoing monitoring is essential to: - maintain control - establish lowest step/dose treatment • Asthma control should be monitored by the health care professional and by the patient

30. Treating to Maintain Asthma Control Stepping down treatment when asthma is controlled • When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B) • When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)

31. When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B) • If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)

32. Treating to Maintain Asthma Control Stepping up treatment in response to loss of control • Rapid-onset, short-acting or long-acting inhaled β2-agonist bronchodilators provide temporary relief. • Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy

33. Stepping up treatment in response to loss of control Use of a combination rapid and long-acting inhaled β2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A) Doubling the dose of inhaled glucocorticosteroids is not effective, and is not recommended (Evidence A)

35. Special Population • Young children, especially 0-4 years • many recommendations based on extrapolated data • studies of ICS show improvement • combination therapy inadequately studied • Elderly • osteoporosis risk increased with high dose ICS • Pregnancy • budesonide preferred ICS • albuterol preferred for quick relief

36. Monitoring Therapy • Regular follow up • 1 to 6 month intervals depending on control • 3 month interval if step down anticipated • Evaluate asthma control • symptoms • lung function • validated questionnaires • medication adverse effects • adherence, environmental control, comorbid condition

37. Question • A 4-year-old Caucasian girl is newly diagnosed with severe persistent asthma. The most appropriate longterm control therapy for this patient would be: • Consider a short course of oral systemic corticosteroids and start budesonide inhalation suspension, 0.5 mg nebulized twice a day. • Consider a short course of oral systemic corticosteroids and start cromolyn sodium 1 mg/ inhalation, two puffs four times a day • Consider a short course of oral systemic corticosteroids and start montelukast 4 mg granules sprinkled on food at bedtime • Consider a short course of oral systemic corticosteroids and start montelukast 4 mg granules sprinkled on food at bedtime, and budesonide inhalation suspension, 0.5 mg nebulized twice a day

38. Question • LK is a 7-year-old African-American boy with moderate persistent asthma who was started on fluticasone dry powder inhalers (DPI) 100 mcg/ inhalation, two inhalations twice a day and albuterolhydrofluoroalkane (HFA) 90 mcg/inhalation, two inhalations twice a day. Four weeks after starting therapy, he returns to the clinic for follow-up. At this time he states that he uses his albuterol approximately once a week for symptoms, can participate in any physical activity he desires, and wakes up approximately once a week at night short of breath or coughing. His peak expiratory flow (PEF) is 81% of predicted. His inhaler technique is appropriate and he adheres to his medication therapy plan. Based on an evaluation of LK’s asthma control, which of the following actions would be most appropriate? • Maintain his current medication regimen and reevaluate him in 1 to 6 months • Decrease his ICS dose to fluticasone DPI 100 mcg/ inhalation, one inhalation twice a day • Add salmeterol 50 mcg/inhalation, one inhalation twice a day. • Increase the fluticasone dose to 250 mcg/inhalation, one inhalation twice a day

39. e.g DRP in asthma

40. Teach basic facts about asthma • Assist with relevant environmental control measures • Explain roles of medications • Long-term control and quick-relief medications • Help patients develop necessary skills • Inhalers, spacers, symptom and peak flow monitoring, early warning signs of attack How Can a Pharmacist Help a PatientWith Asthma?