Transcript Bronchial asthma

Bronchial asthma
Classification and guideline treatment
Prepared by:
Reem Ahmed Abd el Moneim
PharmD 4
Bronchial asthma
Source: Peter J. Barnes, MD
Classification
According to etiology:
1-Allergic or extrinsic asthma
2-Non-allergic or intrinsic asthma
3-Mixed forms
According to degree of severity:
Grade 1: Intermittent
Grade 2: Persistent, mild
Grade 3: Persistent, moderate
Grade 4: Persistent, severe
Symptoms
Nocturnal
symptoms
FEV1/PEFR
Stage 1
intermittent
<1 time a
week
<2 times a
month
>80% predicted
Stage 2
Mildpersistant
> 1 time a
week but <1
time a day
> 2 times a
month
>80%
predicted,variability
20-30%
Stage 3
Moderatepersistant
daily
> 1 time a
week
60-80%predicted,
variability >30%
Stage 4
Severepersistant
continous
frequent
<60%predicted,
variability >30%
According to level of asthma control:
Characteristic
Controlled
Partly controlled
(All of the following)
(Any present in any week)
Daytime symptoms
None (2 or less /
week)
More than
twice / week
Limitations of
activities
None
Any
Nocturnal symptoms
/ awakening
None
Any
Need for rescue /
“reliever” treatment
None (2 or less /
week)
More than
twice / week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or
personal best (if
known) on any day
Exacerbation
None
One or more / year
Uncontrolled
3 or more
features of
partly
controlled
asthma
present in any
week
1 in any week
Asthma Management and prevention
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk
Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
Reliever Medications
 Rapid-acting inhaled β2-agonists
 Short-acting oral β2-agonists
 Systemic glucocorticosteroids
 Theophylline
 Anticholinergics
Controller Medications








Inhaled glucocorticosteroids
Systemic glucocorticosteroids
Long-acting inhaled β2-agonists
Long-acting oral β2-agonists
Theophylline
Cromones
Anti-IgE
Leukotriene modifiers
Stage
Daily controller
medication
Other treatment
option
Mild
Low dose ICS
Sustained release
theophylline
Moderate
Moderate dose
ICS+inhaled long
acting β 2 agonist or
leukotriene inhibitor
-Moderate dose
ICS+either sustained
release theophylline or
long acting β 2 agonist
or leukotriene inhibitor.
-High dose ICS
Severe
High dose
Oral glucocorticoid
ICS+inhaled long
Anti-IgE(omlizumab)
acting β 2 agonist or
leukotriene inhibitor
Treating to Achieve Asthma Control
Step 1 – As-needed reliever medication
 Patients with occasional daytime symptoms of
short duration
 A rapid-acting inhaled β2-agonist is the
recommended reliever treatment (Evidence A)
 When symptoms are more frequent, and/or
worsen periodically, patients require regular
controller treatment (step 2 or higher)
Treating to Achieve Asthma Control
Step 2 – Reliever medication plus a single
controller
 A low-dose inhaled glucocorticosteroid is
recommended as the initial controller
treatment for patients of all ages (Evidence A)
 Alternative controller medications include
leukotriene modifiers (Evidence A)
appropriate for patients unable/unwilling to
use inhaled glucocorticosteroids
Treating to Achieve Asthma Control
Step 3 – Reliever medication plus one or two
controllers
 For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled longacting β2-agonist either in a combination inhaler
device or as separate components (Evidence A)
 Inhaled long-acting β2-agonist must not be used
as monotherapy
 For children, increase to a medium-dose inhaled
glucocorticosteroid (Evidence A)
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more
controllers
 Selection of treatment at Step 4 depends
on prior selections at Steps 2 and 3
 Where possible, patients not controlled on
Step 3 treatments should be referred to a
health professional with expertise in the
management of asthma
Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller
options
 Addition of oral glucocorticosteroids to other
controller medications may be effective
(Evidence D) but is associated with severe
side effects (Evidence A)
 Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications (Evidence A)
Leukotriene-Inhibiting Drugs
Leukotriene inhibitors are either leukotriene
receptor antagonists or leukotriene synthesis
inhibitors, which act by blocking 5lipoxygenase activity. The leukotriene
receptor antagonists include zafirlukast
(Accolate) and montelukast (Singulair);
zileuton (Zyflo) is the only leukotriene
synthesis inhibitor.
Clinical recommendation
-Leukotriene inhibitors are effective in the treatment of
asthma but are less effective than inhaled
corticosteroids (evidence A)
-Leukotriene inhibitors added to inhaled corticosteroids are
less effective than long-acting beta agonists added to
inhaled corticosteroids in the treatment of asthma
(evidence A)
-Leukotriene inhibitors are alternative treatments in exerciseinduced asthma and can be of benefit for children when
oral therapy is preferred over inhalers (evidence B)
-Leukotriene inhibitors are effective in the treatment of
allergic rhinitis but are less effective than intranasal
corticosteroids (evidence A)
Drug
Age and
recommended oral
dose
Therapeutic issues
Montelukast
(Singulair)
Adults: 10 mg before bed
Children six to 14 years: 5 mg
before bed
Children two to five years: 4 mg
before bed
Renal adjustments: none
Hepatic adjustments: in mild to
moderate disease
Zafirlukast
(Accolate)
(Ventair)
Patients older than 11 years: 20
mg twice daily
Children seven to 11 years: 10
mg twice daily
Renal adjustments: none
Hepatic adjustments: not
defined
Monitor hepatic enzymes every
two to three months
Administration with meals
decreases bioavailability; take
at least one hour before meals
or two hours after
Inhibits metabolism of warfarin
(Coumadin), increasing
prothrombin time
Zileuton (Zyflo)
Patients older than 12
years: 600 mg four times
daily
Can inhibit metabolism
of warfarin, theophylline,
and propranolol (Inderal)
Monitor hepatic enzymes
every two to three
months
Anti-IgE treatment:
Omalizumab(Xolair®)
Omalizumab blocks the receptors on the
surfaces of the mast cells and basophils to
which antibodies attach, thereby preventing
antibodies from attaching to the cells. As a
result, the cells do not release their
chemicals, and the allergic reaction and
inflammation are prevented.
DOSING:
Omalizumab is injected under the skin. The
recommended dose is 150-375 mg every 2 to 4
weeks. The dose and frequency is based on
body weight and levels of serum IgE, a type of
antibody. Doses greater than 150 mg should be
divided and administered at different sites so
that no more than 150 mg is administered at
each injection site.
SIDE EFFECTS
Headaches, viral infections, upper respiratory
tract infections and injection-site reactions
such as pain, redness, swelling, itching and
bruising.
Use of omalizumab may also lead to serious,
life-threatening allergic reactions
(anaphylaxis).
Signs and symptoms of
anaphylaxis
-Wheezing, shortness of breath, cough, chest
tightness, or trouble breathing.
-Low blood pressure, dizziness, fainting, rapid
or weak heartbeat, anxiety.
-Flushing, itching or feeling warm.
-Swelling of the throat or tongue, throat
tightness, hoarse voice, or trouble
swallowing.
It is recommended that patients be observed for
these reactions for at least two hours after injection
of omalizumab; however, these reactions can occur
up to 24 hours or longer after the injections.
Cancer occurs more frequently in patients who take
omalizumab.
Non pharmacological
treatment:
-Reduce exposure to indoor allergens
-Avoid tobacco smoke
-Avoid vehicle emission
-Identify irritants in the workplace
-Explore role of infections on asthma
development, especially in children and
young infants
Influenza Vaccination
 Influenza vaccination should be
provided to patients with asthma when
vaccination of the general population is
advised
 However, routine influenza vaccination
of children and adults with asthma
does not appear to protect them from
asthma exacerbations or improve
asthma control