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PHARM 311 Respiratory System > 7. Asthma Management > Flashcards

7. Asthma Management Flashcards

1
Q

Asthma treatment

A

Management of acute symptoms

Prevention of recurrent symptoms

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2
Q

Agents used for acute / prophylaxis depends on

A
  • Patient age & preference
  • Severity of asthma
  • Side effects / tolerance & response

A stepwise pathway is required to determine optimal level

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3
Q

Inhaled Corticosteroids

A

Mainstay of treatment

ICS - most benefits at low doses

All patients should be on ICS

  • Most will not need more than low dose ICS for preventing attacks
  • ICS halves risk of serious exacerbations even in patients with symptoms ≤1 days a week
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4
Q

Anti-inflammatory reliever (AIR)

A

AIR refers to budesonide/formoterol combination inhaler - also known as Single Combination ICS/LABA Inhaler Maintenance And Reliever Therapy (SMART)

Contains ICS + LABA (formoterol)

Bronchodilation with formoterol within 1-3 minutes - rapid onset of action

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5
Q

Short-acting beta-agonists (SABA)

A

Used for relief as mono therapy in the past

Changed in 2019 - SABA only no longer recommended

PRN SABA only provides rapid relief BUT increases risks of severe attacks

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6
Q

Risks of SABA only treatment

A

Regular/frequent use of SABA is associated with adverse effects

  • Beta-receptor downregulation, decreased bronchoprotection, rebound hyperresponsiveness, decreased bronchodilator response
  • Increased allergic response & increased eosinophilic airway inflammation

Higher use of SABA is associated with adverse clinical outcomes

  • Dispensing of ≥ 3 canisters per year (~1.7 puffs/day) is associated with higher risk of ED presentations
  • Dispensing of ≥ 12 canisters per year is associated with a higher risk of death
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7
Q

Asthma management: Step 1

A

For patients with symptoms less than twice a month & no exacerbation risk factors

Step 1 - two options:

  • PRN low dose ICS whenever SABA used
  • PRN low dose ICS-formoterol (1st line)

Key counselling point: ICS reduce risk of asthma attacks & should be used whenever patients would normally use a reliever for their symptoms

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8
Q

Option 1.1: PRN low-dose ICS whenever SABA used

A
  • Adding any ICS reduces the risk of attacks
  • All adults & adolescents with asthma should receive symptom-driven (for mild asthma) or regular ICS-containing controller treatment to reduce the risk of serious exacerbations
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9
Q

Option 1.2: PRN low dose ICS-formoterol

A

Formoterol is a LABA with a quick onset of action

  • Only LABA that can be used for immediate relief
  • Provides rapid relief of symptoms similar to SABA
  • Should only be used with ICS in a combination inhaler

Only registered for use in 12+ years
- Children under 12 have a different treatment regimen

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10
Q

Asthma management: Step 2

A

Escalate to next step based on patient assessment & symptoms
- Consider inhaler technique & comorbidities before stepping up

Step 2 - 2 options:

  • Regular low dose ICS + PRN SABA
  • As-needed low dose ICS-formoterol (1st line)
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11
Q

Option 2.1: Regular low dose ICS + PRN SABA

A

Low dose ICS substantially reduces risk of severe exacerbations, hospitalisations & death

  • Serious exacerbations were halved even in patients with symptoms 0-1 days per week
  • Improved symptom control & reduced exercise-induced bronchoconstriction

Consider:
- Effect of ICS on preventing asthma deaths & severe exacerbations

Key practice point: Poor adherence is common in mild asthma, so this option would expose patients to the risk of SABA-only treatment of they do not take their ICS regularly

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12
Q

Option 2.2: As-needed low dose ICS-formoterol

A

Budesonide/formoterol as needed only for symptom relief i.e. without maintenance treatment

Effects:

  • Positive effects on preventing severe exacerbations, avoiding need for daily ICS in patients with mild or infrequent symptoms
  • Study confirm safety of as-needed ICS-formoterol in maintenance & reliever therapy, with no new safety issues
  • Reduces exercise-induced bronchoconstriction, with reduce symptoms

Key practice point: PRN ICS-formoterol option (AIR) makes common-sense to patients as usually behaviour is to use treatment when needed for symptom relief. By using combination ICS-formoterol inhaler, it delivers both relief & prevention together

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13
Q

Step 2: Other options

A

Low dose ICS taken whenever SABA taken

Leukotriene receptor antagonists (LTRA)

  • Targets one part of the inflammatory pathway
  • Less effective than regular ICS particularly for experiencing exacerbations
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14
Q

Asthma management: Step 3

A

Budesonide/formoterol (AIR) for maintenance treatment with an additional as needed dose for symptomatic relief

Also known as Single Combination ICS/LABA inhaler Maintenance And Reliever Therapy (SMART)

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15
Q

Long-acting bronchodilators

A

LABA only carries an increased risk of mortality:

  • LABA should never be used by themselves
  • Always use with a preventer (ICS)

LABA opens airways but does not treat underlying inflammation

  • LABA + ICS combination should be used
  • ICS - mainstay of treatment

Do not mix different types of LABA - if on AIR, do not use other types of LABA

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16
Q

LABA safety

A

For the management of chronic asthma, LABAs (formoterol, salmeterol & vilanterol) should:

  • ONLY be used in combination with ICS
  • Be added only if regular use of standard-dose ICS has failed to control asthma adequately
  • Not be started in patients with rapidly deteriorating asthma
  • Be introduced at a low dose & the effect properly monitored before considering dose increase
  • Be discontinued if no benefit
  • Not be used for relief of exercised-induced asthma unless regular ICS are also used
  • Be reviewed as clinically appropriate - stepping down should be considered when good long-term asthma controlled achieved
17
Q

Asthma management: Step 4 - Increasing inhaled corticosteroid doses

A

Low dose ICS provides most of the clinical benefits for most patients

  • However, response to ICS is variable between patients
  • Some may need medium dose ICS if asthma is uncontrolled despite good adherence & correct inhaler technique with low dose ICS

High dose ICS is needed by very few patients

  • Long-term use is associated with an increased risk of local & systemic side-effects
  • Always review & step down if not required
18
Q

Difference between steroids & their side effects

A

Potency

Frequency
- Inhaled usually twice daily, fluticasone furoate is once daily

Route:

  • Oral vs inhaled steroids
  • Oral more systemic effects, consider duration of treatment

Side effects:

  • Bone mineral density - osteoporosis risk
  • Eye - glaucoma
  • Adrenal suppression
  • Effect on mood
  • Oral thrush
19
Q

Step 4: Other treatments

A

Luekotriene-receptor antagonist:
- Add on to ICS less effective than using ICS-LABA

Tiotropium:

  • An add on at step 4 or 5
  • Consider for patients with a history of attacks despite ICS +/- LABA
20
Q

Asthma management: Step 5

A

GINA guide difficult to treat & severe asthma

  • Assessment & management of adults & adolescents with uncontrolled asthma or exacerbations despite step 4-5 treatment
  • Includes strategies for clinical settings in which biologic therapy is not available or affordable
Biologics:
Omalizumab:
- Monoclonal Ab binding IgE
- For persistent severe asthma
- Proven IgE-mediated asthma

Mepolizumab:

  • Humanised monoclonal Ab that binds & inhibits IL-5
  • Reduces production & survival of eosinophils
  • Approved for eosinophilic asthma

Extension of biologic treatment trial to 6-12 months if response to initial therapy is unclear

Steroids (systemic)

21
Q

Acute symptomatic relief - day to day

A

PRN ICS/formoterol:
- Better choice for relief as one inhaler can give relief & reduce long-term risk of attacks
- Preferred choice for patients
+ No need to use 2 inhalers
+ Less risk of using SABA alone without ICS protection

Note: Do not use ICS-formoterol as the relievers for patients taking combination ICS-LABA medications with a different LABA. For these patients use PRN SABA

22
Q

Asthma action plan - save lives

A

Asthma self-management key to good outcomes

  • Written action plans
  • Peak flow monitoring
  • Adherence support

Provision of a written asthma action plan - reduces risk of death by 70%

Use of oral steroids for severe acute attacks reduces risk of death by 90%

Use of a peak flow meter reduces mortality

23
Q

Pharmacist role

A

Education by pharmacists key for asthma control:

  • Provide consistent messaging about the goals of asthma treatment, including prevention of exacerbations, across the spectrum of asthma severity
  • Avoid establishing patient reliance on SABA early in the course of the disease
  • Review ongoing therapy & need for step up/down treatment
  • Education about rationale for treatment - needs to make sense to patient
  • Management of side effects

GINA emphasised poor adherence as a modifiable risk factor for exacerbations

  • Asthma deaths & attacks are preventable
  • When the reliever is SABA, poor adherence with maintenance controller exposes the patient to risks of SABA-only treatment

PHARM 311 Respiratory System (10 decks)

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