Treatment Steps for Chronic Persistent Asthma in SA Flashcards
What must be the mainstay of asthma treatment unless there is a compelling reason to the contrary?
Inhaled corticosteroid must be mainstay of treatment
- most effective
- least SE
What is the only compelling reason to not use ICS as a mainstay of asthma therapy?
Allergic reaction
- then can change to leukotriene modifier
Level 1 Asthma: what treatment should be used?
Short-acting beta-2 agonist as required
only for mild, intermittent asthma
Level 2 Asthma: what treatment should be used?
- Low dose ICS
2. Short acting beta-2 agonist as required for acute symptom relief
Level 3 Asthma: what treatment should be used?
- Low dose ICS
- Long acting beta-2 agonist
OR
Leukotriene modifier - Short acting beta-2 agonist as required for acute symptom relief
Level 4 Asthma: what treatment should be used?
- Moderate dose ICS
- Long acting beta-2 agonist
OR
Leukotriene modifier
OR
SR Theophylline - Short acting beta-2 agonist as required for acute symptom relief
Level 5 Asthma: what treatment should be used?
- High dose ICS
- Long acting beta-2 agonist
+/-
Leukotriene modifier
+/-
SR Theophylline - Short acting beta-2 agonist as required for acute symptom relief
Level 6 Asthma: what treatment should be used?
- High dose ICS
- Long acting beta-2 agonist
+/-
Leukotriene modifier
+/-
SR Theophylline
+/-
Oral Corticosteroid - Short acting beta-2 agonist as required for acute symptom relief
When should specialist referral be considered?
Step 4, refer to pulmonologist!
Consider specialist referral at level 4-6
Step 1 in the management of asthma, what is the preferred option?
As needed SABA
Step 1 in the management of asthma, what are other recommended options?
Consider low dose ICS in addition to as needed SABA for patients at risk for exacerbations
Step 2 in the management of asthma, what is the preferred option?
Low dose ICS, plus as needed SABA
Step 2 in the management of asthma, what are other recommended options?
LRTA
Low dose ICS / LABA
ICS started with symptoms of allergic asthma for seasonal treatment only
Step 3 in the management of asthma, what is the preferred option?
Low dose ICS / LABA, plus as needed SABA for adults / adolescents
Step 3 in the management of asthma, what are other recommended options?
Medium dose ICS for adults / adolescents
Low dose ICS plus LRTA or low dose sustained release theophylline
Step 4 in the management of asthma, what is the preferred option?
Medium dose ICS / LABA, plus as needed SABA for adult / adolescents
OR
Medium dose ICS / formoterol as both maintenance and reliever
Step 4 in the management of asthma, what are other recommended options?
Add on therapy with Tiotropium for adults with exacerbation history
Step 5 in the management of asthma, what is the preferred option?
Refer to specialist and consideration of add on treatment
Step 5 in the management of asthma, what are other recommended options?
Tiotropium if <18 years
Omalizumab for moderate to severe allergic asthma
Sputum guided add on low dose OCS (<7.5mg/day prednisone equivalent)
What 5 steps should be followed for poor control?
- Watch patient using their inhaler, discuss adherence barriers to use
- Confirm the diagnosis of asthma
- If possible, remove potential risk factors. Assess and manage comorbidities
- Consider treatment step-up
- Refer to a specialist or severe asthma clinic
What is step 1 for a poorly controlled patient?
- Watch patient use their inhalers, check against inhaler checklist.
- show correct method, and recheck up to 3 times
- repeat check each visit - Have empathetic discussion to identify poor adherence
- ask about beliefs, cost of medications and refill frequency
What is step 2 for a poorly controlled patient?
If no evidence of variable airflow limitation on spirometry or other testing consider halving ICS dose and repeating lung function after 2-3 weeks, check patient has action plan.
- consider referring for a challenge test
What is step 3 for a poorly controlled patient?
- Check risk factors or inducers such as smoking, beta-blockers or NSAIDs or occupational or domestic allergen exposure
- Check for and manage comorbidities (e.g. rhinitis, obesity, GERD, obstructive sleep apnea, depression / anxiety) that may contribute to symptoms
What is step 4 for a poorly controlled patient?
Consider step up to next treatment level or alternative option on present level
- use shared decision making and balance potential benefits and risks
What is step 5 for a poorly controlled patient?
If asthma is still uncontrolled after 3-6 months on high dose ICS/LABA, or with ongoing risk factors, refer to a specialist or severe asthma clinic
- refer earlier than 6 months if asthma very severe or difficult to manage or if doubts about diagnosis
