Transcript Definition of Asthma - American Cities Project

Improving the Lives of Our
Patients with Asthma
Asthma Interventions for Busy Pharmacists
Controlling Asthma in American Cities Project
of Minneapolis & St Paul
Definition of Asthma

A chronic, non-contagious inflammatory
disorder of the airways consisting of an
infiltration of mast cells, eosinophils,
lymphocytes, neutrophils, and epithelial cells

Recurrent episodes of wheezing, chest
tightness, shortness of breath, and cough

Widespread, variable, and reversible (not
always completely) airflow obstruction

Airway hyperresponsiveness
Pathologic Airway Changes Induced in Asthma
Mucous
gland
hypertrophy
Edema
Mucus
Thickening of
basement
membrane
Epithelial
damage
Airway smooth
muscle
Inflammatory
cell infiltration
Vascular
dilatation
Adapted from National Asthma Education and Prevention Program. Expert Panel Report:
Guidelines for the diagnosis and management of asthma. NHLBI, NIH. 1991.
Percent of US Population with
Asthma
6
5
Age (yrs)
4
5-14
15-35
35-64
3
2
1
0
1980
1990
1999
Source: Surveillance for Asthma – United States, 1980-1999. Morbidity and Mortality
Weekly Report, 51(SS01): 1-13.
The Goals of Asthma Therapy:
(Asthma Control)
 Reducing impairment
 prevent chronic and troublesome symptoms

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
require infrequent use (≤ 2 days a week) of inhaled SABA for
symptoms
maintain (near) “normal” pulmonary function
maintain normal activity levels
meet patients’ and families’ satisfaction with care
 Reducing risk
 prevent recurrent exacerbations of asthma (ED/inpatient)


prevent progressive loss of lung function
provide optimal pharmacotherapy
Rationale for Pharmacologic
Therapy
 Underlying cause of asthma:
inflammatory airway disorder
 Key principle of therapy:
regulation of chronic airway
inflammation
Guidelines For The Diagnosis and
Management of Asthma (EPR-3)
released: August 28, 2007
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(Almost) no new medications
Restructuring into “severity” and “control”
Domains of “impairment” and “risk”
Six treatment steps (step-up/step-down)
More careful thought into the ongoing management
issues
Summarizes the extensively-validated scientific
evidence that the guidelines, when followed, lead to a
significant reduction in the frequency and severity of
asthma symptoms and improve quality of life
Classifying Severity for Patients
Currently Taking Controller Medications
Medications

Controller Medications - Daily
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
Corticosteroids (inhaled and systemic)
Long-acting beta2-agonists
Leukotriene modifiers
Cromolyn sodium - Nedocromil sodium
Sustained-release theophylline
Allergy Immunotherapy
Reliever (or Rescue) Medications
 Short acting beta2-agonists
 Systemic corticosteroids: “Burst Therapy”
 Anticholinergics (used with nebulizer in ER)
Methods of Medication Delivery
 Metered-dose inhaler (MDI)
 Spacer/holding chamber/face mask
 Dry-powder inhaler (DPI)
 Nebulizer
 Oral Medication
 Tablets, Liquids
 Intravenous Medication
 IV Corticosteroids, IV Aminophylline
Overview of Asthma Medications:
Controllers
 Prevent and treat inflammation
 Corticosteroids (inhaled and systemic)
 Prevent inflammation
 Leukotriene modifiers
 Cromolyn/Nedocromil sodium
 Bronchodilators
 Long-acting beta2-agonists
 Theophylline
CONTROLLERS
Corticosteroids

Inhaled
 Beclomethasone (QVAR®)
 Fluticasone (Flovent®)
 Triamcinolone (Azmacort®)
 Budesonide (Pulmicort®)
 Flunisolide (AeroBid®)
CONTROLLERS
Common Steroid Inhalers
Azmacort
®
Pulmicort
®
Flovent
®
®
QVAR
CONTROLLERS
Inhaled Corticosteroids
 Most effective long-term control therapy
for persistent asthma
 Benefit of daily use:
 Fewer symptoms
 Fewer severe exacerbations
 Reduced use of quick-relief medicine
(albuterol)
 Improved lung function
CONTROLLERS
Inhaled Corticosteroids
 Reduced airway inflammation
 Decreases airway hyperresponsiveness
 Maximum Effects
 Oral: 6 to 24 hours
 Inhaled: Weeks (maybe months)
 **NEVER FOR RESCUE PURPOSES**
CONTROLLERS
Estimated Comparative Dosages of Inhaled
Corticosteroids
 Preparations not equivalent per puff/per
microgram
 Comparative doses estimated
 Few studies directly compare preparations
 Clinician judgment: most important
determinant of dosing
 Monitor clinical response to therapy
 Adjust dose accordingly
CONTROLLERS
Systemic Effects & Inhaled Steroids
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Individuals might experience side effects at high
doses
More susceptible individuals may experience side
effects at medium doses
Potential Systemic Effects:
 Adrenal suppression
 Rare individuals more susceptible
 Potential impaired growth velocity in children
 Decreased bone density (adults)
 Other (cataracts, etc. in adults)
Inhaled Corticosteroids and
Effect on Linear Growth

Untreated or poorly treated asthma is detrimental to
height growth

Long term studies using medium dose inhaled
steroids had no adverse effect on ultimate adult
height

There is some slowed growth in the first year after
starting ICS(1 cm/yr) however “catch up” occurs
despite continuing on the medication
Corticosteroid Systemic Effects
 All inhaled corticosteroids exhibit doserelated systemic adverse effects, but much
less than comparable doses of oral
corticosteroids.
Corticosteroid Side Effects
Inhaled Local
 Dysphonia
 Cough/throat irritation
 Thrush
 Impaired growth (high
dose)?
Systemic (oral, IV)
 Fluid retention
 Muscle weakness
 Ulcers
 Malaise
 Impaired wound healing
 Nausea/Vomiting, HA
 Osteoporosis (adults)
 Cataracts (adults)
 Glaucoma (adults)
CONTROLLERS
Long-acting Beta2-agonists
Serevent
®
Diskus
Foradil
®
Aerolizer
CONTROLLERS
Long-acting Beta2-agonists
 Salmeterol (Serevent®), Formoterol (Foradil®)

Indication: Daily long-term control
Bronchodilate by long-term stimulation of beta2 receptors
 Advantages

Blunt exercise induced symptoms for longer time

Decrease nocturnal symptoms

Improve quality of life
 Combination therapy beneficial when added to
inhaled corticosteroids

May decrease the need to increase inhaled corticosteroid
dose dose
CONTROLLERS
Long-acting Beta2-agonists
 NOT for acute symptoms or exacerbations
 Onset of effect  30 minutes
 Peak effect  1-2 hours
 Duration of effect  up to 12 hours
 NOT a substitute for anti-inflammatory therapy
 NOT appropriate for monotherapy
Serevent® Black Box Warning
WARNING: Data from a large placebo-controlled
US study that compared the safety of salmeterol
(SEREVENT® Inhalation Aerosol) or placebo
added to usual asthma therapy showed a small
but significant increase in asthma-related deaths
in patients receiving salmeterol (13 deaths out of
13,176 patients treated for 28 weeks) versus
those on placebo (3 of 13,179) (see WARNINGS
and CLINICAL TRIALS: Asthma: Salmeterol Multicenter Asthma Research Trial).
From Serevent® Inhalation Aerosol Package Insert
CONTROLLERS
Leukotriene Modifiers
 Indications
 Long-term control therapy in mild persistent
asthma
 Improved lung function
 Prevent need for short-acting beta2-agonists
 Prevent exacerbations by preventing
inflammation
 Combination therapy with an inhaled
corticosteroid in moderate persistent asthma
CONTROLLERS
Leukotriene Modifiers

Cysteinyl Leukotriene Receptor Antagonists
 Montelukast (Singulair®)– Once a day in PM –
indicated at age 1
 Zafirlukast(Accolate®) – Twice daily – Empty
Stomach

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Many drug interactions
5-Lipoxygenase inhibitors
 Zileuton(Zyflo®) – Four times daily
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Many drug interactions
CONTROLLERS
Leukotriene Modifiers
 Montelukast (Singulair®)
 4mg granules (in C.A.I.R), 4 mg, 5 mg
chewable and 10 mg tablet
 Once daily dosing (evening)
 Pediatric indication > 1 year
 No food restrictions
RELIEVERS
Short-Acting Beta2-agonist
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Albuterol (Proventil®, Ventolin®)
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Pirbuterol (Maxair®)
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Terbutaline (Brethaire®, Brethine® MDI)
RELIEVERS
Short Acting Beta2-agonist
Proventil®
Proventil® HFA Maxair® Autohaler Ventolin®
RELIEVERS
Short-Acting Beta2-Agonists
 Most effective medication for relief of acute
bronchospasm
 Preferably use inhaled rather than oral preparations
 Increased need for these medications indicates
uncontrolled asthma (and inflammation)
 Regularly scheduled use not generally
recommended – use “as needed”
 May lower effectiveness
 May increase airway hyperresponsiveness
RELIEVERS
New Short-Acting Beta-Agonists
 Levalbuterol (Xopenex®)
 R-Isomer of albuterol (active molecule)
 Only available as Nebulized Solution
 Give 1/2 dose-because give active
component
 POSSIBLY less side effects
 Marketed as 3 times a day neb
RELIEVERS
Short-Acting Beta2-Agonists
 Side Effects:
 Increased Heart Rate
 Palpitations
 Nervousness
 Sleeplessness
 Headache
 Tremor
RELIEVERS
Systemic Corticosteroids “Burst Therapy”
Indication - quick (6-24 hours) relief of
inflammation
 Beta2 agonist unresponsiveness
 Gradual deterioration
 Yellow zone  48 hours
 With or without prior therapy
 Establish “control”
 ER/Urgent Care visit
NOTE: Will NOT stop a flare-up but is used
to reduce inflammation after a flare-up
RELIEVERS
Systemic Corticosteroids “Burst Therapy”
 Dosing for 3 to 10 days:
 1-2 mg/kg/day (60mg/day max)
 Once or twice daily dosing
 < 1 year – 10 mg prednisone
 1-4 years – 20 mg prednisone
 > 5 years – 30 mg prednisone
 NO taper required
The Asthma Action Plan

Helps patients/caregivers manage asthma
 Uses Peak Flows
 Spells out medication instructions
Green Zone 80-100% Peak Flow
 Yellow Zone 50-80% Peak Flow
 Red Zone Below 50% Peak Flow
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Indicators of Poor Asthma Control
 Step up therapy if patient:
 Awakens at night with symptoms
 Has an urgent care visit
 Has increased need for albuterol
 Rules of “two”
Short Acting Beta2-Agonists
Rules of Two
 Do you use a quick relief inhaler more than 2
times per week?
 Do you awaken at night due to asthma more than
2 times per month?
 Do you refill your quick relief inhaler prescription
more than 2 times per year?
If you answer “YES” to any of these questions,
it’s a sign your asthma may be poorly controlled.
®
Baylor Healthcare System
Indicators of Poor Asthma Control
 Before increasing medications, check:
 Inhaler technique
 Adherence to prescribed regimen
 Environmental changes
 Also consider alternative diagnoses
Monitoring Pharmacotherapy
 Monitor:
 Patient adherence to regimen
 Inhaler technique
 Frequency of albuterol use
 Frequency of oral corticosteroid “burst”
therapy
 Side effects of medications
Over-the-Counter Medications
 Patients with asthma may be using the following for
treatment of shortness of breath:
 Inhaled epinephrine
 Asthma Haler, Primatene Mist, Bronkaid Mist
 Oral ephedrine
 These medications:
 have more side effects than Rx products
 are not as effective as Rx products
 have short duration of action overuse
 To be removed from the market in 2005 because
products contain CFCs
Omalizumab (Xolair)

(Omalizumab) is indicated for adults
and adolescents (12 years of age and
above) with moderate to severe
persistent asthma who have a positive
skin test or in vitro reactivity to a
perennial aeroallergen and whose
symptoms are inadequately controlled
with inhaled corticosteroids.
Xolair Dosing
Teaching Proper Inhaler Use
The successful use of Metered Dose Inhalers
requires that patients:
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Inspire at actuation
Inhale slowly
Hold their breath
Exhale slowly
Incorrect Inhaler Technique

In a study published in the American Journal of
Respiratory and Critical Care Medicine, only 25% of
patients with asthma achieved all four criteria.
Goodman, DE et al. (1994). Amer. J Resp & Crit. Care Medicine, 150(5 Pt 1), 1256-61.

Even more surprising:
 Up to two-thirds of MDI users and health
professionals who teach MDI use do not perform
the procedure properly.
Fink JB (2000). Respiratory Care, 45(6), 623-635.
Replacement / Refill
for Metered Dose Inhalers

The correct amount of medication in each inhalation cannot
be assured, and the canister should be discarded, when
the labeled number of actuations has been used.

You can estimate how many days it will last by dividing
total inhalations in a unit by the number of inhalations
normally used in a day.

Tracking actual use is the only accurate method.
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Do not immerse the inhaler in water to find out if it
is empty.
Spacers and Holding
Chambers
A spacer device enhances delivery by decreasing
the velocity of the particles and reducing the
number of large particles, allowing smaller
particles of drug to be inhaled.
 A spacer device with a one-way valve, i.e., holding
chamber, eliminates the need for the patient to
coordinate actuation with inhalation and optimizes
drug delivery.
 A simple spacer device without a valve requires
coordination between inhalation and actuation.
Medication Delivery
Demonstrations
 Breath Actuated Inhalers
Example: Maxair® Autohaler
 Metered Dose Inhalers with Spacer/Holding
Chamber
 Dry Powder Inhalers
Examples: Diskus®, Turbuhaler®, & Foradil®
 Nebulizers
Break Time
5-10 Minutes
Why Should Pharmacists Provide
Asthma Education?
Most knowledgeable about medications
 Accessible health care providers
 Patients routinely see their pharmacist
 Pharmacist is integral part of the health
care team

Assess Reasons for Poor Asthma
Control - ICE
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Inhaler Technique
 Check the patient’s technique
Compliance
 Ask when, what, and how much medication
the patient is taking
Environment
 Ask the patient if something in his or her
environment has changed
NIH National Asthma Education & Prevention Program, 1997
Community Pharmacy
Case Presentations
Get out your pocket cards!
Thought Process for
Case Studies
What types of questions would you ask
this patient?
 What is probably going on with this
patient?
 What information would you give this
patient?

Case: Urgent Care- New Albuterol

33YO Male from Urgent Care
 Albuterol MDI, 2 P q 4-6 h prn
 Z-Pak, UTD

Med profile is unremarkable. He notes a
bronchial infection every spring when
the trees bloom. Sees Dr q 2 years for
physical. Never used an inhaler before.
Case: Frequent Albuterol Refiller

17YO female comes to pick up her
albuterol refill. Insurance rejects for “Refill
Too Soon.” She has prn refills and says
“That’s fine, I’ll pay cash.”

You notice her refill history is q 3 weeks
for the past 3 months. Advair is on file but
not filled for 8 months.
Case: New Controller Prescription

9YO Male with parent with two new rxs
 Flovent 110 with Aerochamber, 2 P po bid
 Albuterol MDI with Aerochamber, 2 P 30 min before
exercise and q 4-6h prn

Mom states he has used nebulizer and albuterol MDI with
acute illness in the past with good success. Recently he
has been taken out of gym twice with trouble breathing
and has stopped playing saying his chest feels tight. Mom
is unclear of why he needs to use medicine regularly and
has safety concerns. He has never used a medicine daily.
Case: ER Steroid Burst

25YO Female comes to you with a new
ER rx
 Prednisone 30mg bid for 5 days
 Also requests an albuterol MDI refill

There are no other inhalers on her
profile
Case: OTC Cough Syrup

20YO male comes to you asking about
over-the-counter cough syrup for a
cough

He has albuterol on his profile but
hasn’t filled it for several months

He complains that he has had the
cough since spring. Nothing makes it
better, and it’s worse at night.
Summary: Counseling Questions

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Have you used an inhaler before?
 Or, how comfortable are you using an
inhaler?
Are you really using your inhaler this
frequently?
How often are you having trouble breathing?
Are you using any other medicines to control
your asthma?
Counseling Questions (cont.)



I see you have a prescription on file for
[controller inhaler]. Would you like a refill?
What are your concerns with using medicine
regularly?
Do you have a regular healthcare provider who
takes care of your breathing?
 When is the last time you saw that provider?
 Do you have plans to follow up with your provider?
 Have you and your provider developed an asthma
action plan?
How to Navigate the Health Plans


It can be challenging and confusing to navigate
our health plan system
Resources Available:
 Please refer to “Pharmacy Benefit Coverage for
Asthma-Related Products” in today’s packet
 The American Lung Association of Minnesota is
working with our health plans to remove
barriers to care and medication access
Becoming a
Certified Asthma Educator

Patient education remains a
critical component of achieving
asthma control.

By providing a certification
process, patients, providers, and
health care payers will be
assured that information
obtained from a certified asthma
educator is based upon
scientifically sound concepts of
disease management.
Want to Be More Involved?

American Lung Association of Minnesota
has many volunteer opportunities (see
the list of resources in today’s packet for
more information).

Make connections with other care
providers and improve the quality of
your care.
Acknowledgements

This is a product of the Minneapolis/St Paul Controlling
Asthma in American Cities Project Pharmacy Workgroup.

Primary authors: Molly Ekstrand, RPh, AE-C & Don Uden,
PharmD

Other contributors: Jean Moon, PharmD, Angie Carlson,
PhD

Development of this presentation was supported through
a cooperative agreement with the Centers for Disease
Control and Prevention, U.S. Department of Health and
Human Services, under program announcement 03030.