7. Asthma Management Flashcards
Asthma treatment
Management of acute symptoms
Prevention of recurrent symptoms
Agents used for acute / prophylaxis depends on
- Patient age & preference
- Severity of asthma
- Side effects / tolerance & response
A stepwise pathway is required to determine optimal level
Inhaled Corticosteroids
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
Anti-inflammatory reliever (AIR)
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
Short-acting beta-agonists (SABA)
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
Risks of SABA only treatment
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
Asthma management: Step 1
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
Option 1.1: PRN low-dose ICS whenever SABA used
- 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
Option 1.2: PRN low dose ICS-formoterol
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
Asthma management: Step 2
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)
Option 2.1: Regular low dose ICS + PRN SABA
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
Option 2.2: As-needed low dose ICS-formoterol
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
Step 2: Other options
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
Asthma management: Step 3
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)
Long-acting bronchodilators
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
LABA safety
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
Asthma management: Step 4 - Increasing inhaled corticosteroid doses
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
Difference between steroids & their side effects
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
Step 4: Other treatments
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
Asthma management: Step 5
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)
Acute symptomatic relief - day to day
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
Asthma action plan - save lives
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
Pharmacist role
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