Transcript Step 3: Add-on therapy

Asthma Management
Fine Tuning
Maximum control with minimum medication
Start with mild asthma and work up the scale
(BTS/SIGN 2004)
Asthma Management
Fine Tuning
Asthma control means:
-Minimal symptoms during day and night
-Minimal need for reliever medication
-No exacerbations
-No limitation of physical activity
-Normal lung function (FEV1 and/or PEF >80% predicted or
best)
Asthma Management
Fine Tuning
Before initiating a new drug therapy:
-Check compliance with existing therapies
-Check inhaler technique ( Reconsider inhaler delivery system)
-Eliminate trigger factors
Asthma Management
Fine Tuning
Step-wise approach
Adults
5 steps
Children
5-12 Years
Children
< 5 Years
5 steps
4 steps
Asthma Management
Adults
Step 1:Mild intermittent asthma
Step 2:Introduction of regular preventer therapy
Step 3:Add-on therapy
Step 4:Poor control on moderate dose of inhaled steroids + Add on
Step 5:Use of oral steroids
Asthma Management
Preventers: Inhaled corticosteroids (ICS)
• 1st Choice
Moderate Dose:
Adults 
200-800 mcg/day
Children  200-400 mcg/day
•BDP= Becotide (Beclomethasone Dipropionate)
= Pulmicort (Budesonide)
•Flexotide (Fluticasone)
½ dose of BDP
High Dose ICS
 2000 mcg/day
 800 mcg/day
Adults
Children
Asthma Management
Add-On therapy
• 1st Choice
LABA
Adults/ Children 5-12 years
•LABA should not be used without ICS
• Others
•2nd choice:
•3rd choice:
•4rth choice:
LTRAs
SR Theophylline
Oral LABA ( SR Be agonists tab)
S.E
Asthma Management
Step 1: Mild intermittent asthma
-Prescribe inhaled short-acting 2 agonist as short term reliever
therapy for all patients with symptomatic asthma
-Review asthma management in patients with high usage of
inhaled short acting 2 agonists
Asthma Management
Step 2: Introduction of regular preventer
therapy when?
Recent exacerbations
Nocturnal asthma
Impaired lung function
Using inhaled B2 agonist >once a day
Using inhaled B2 agonists > 3 times per week
Asthma Management
Step 2: Introduction of regular preventer
therapy
 Inhaled steroids are the 1st line preventers
 Give inhaled steroids initially twice daily
 If good control, once a day inhaled steroids at the same
total daily dose
Asthma Management
Step 2: Introduction of regular preventer
therapy
Start patients at inhaled steroid dose appropriate to
disease severity
Adults: 400 mcg per day
Children 5-12 years: 200 mcg per day
Children under 5 years: higher doses may be required
to ensure consistent drug delivery
Use lowest dose at which effective control is maintained
Monitor children’s height on a regular basis
Asthma Management
Poor control
Still symptoms or
Sleep disturbance or
Restriction of activity
Despite use of regular inhaled steroid + PRN bronchodilator
Asthma Management
Poor control – Therapeutic options
1) check compliance
2) check inhaler technique
3) Add LABA 1st Choice: Adults/ children 5-12
(in children <5 years LTRAs preferred)
4) Suboptimal or no response : →  dose of
inhaled steroid (800 mcg adult, 400 mcg children via
spacer device
5) Poor control persist→ consider additional therapy:
LTRAs, SR Theophylline or SR oral B 2 agonist +
Increase Inhaled steroid to 2000 mcg/day
6) Oral steroids
Asthma Management
Step 3: Add-on therapy
Inadequate control on low dose inhaled steroids
Asthma Management
Step 3: Add-on therapy
Inadequate control on low dose inhaled steroids
Add inhaled long-acting ß2 agonist (LABA)
Asthma Management
Step 3: Add-on therapy
Inadequate control on low dose inhaled steroids
Add inhaled long-acting ß2 agonist (LABA)
Assess control of asthma
Asthma Management
Step 3: Add-on therapy
Inadequate control on low dose inhaled steroids
Add inhaled long-acting ß2 agonist (LABA)
Assess control of asthma
Good response to
LABA:
• Continue LABA
Benefit from LABA but control
still inadequate:
• Continue LABA
• Increase inhaled steroid dose to
800mcg/day (adults) and
400mcg/day (children 5-12 years)
No response to LABA:
• Stop LABA
• Increase inhaled steroid dose
to 800mcg/day (adults) and
400mcg/day (children
5-12 years)
Asthma Management
Inadequate control on low dose inhaled steroids
Step 3
Add inhaled long-acting ß2 agonist (LABA)
Assess control of asthma
Good response to
LABA:
• Continue LABA
Benefit from LABA but control
still inadequate:
• Continue LABA
• Increase inhaled steroid dose to
800mcg/day (adults) and
400mcg/day (children 5-12 years)
No response to LABA:
• Stop LABA
• Increase inhaled steroid dose
to 800mcg/day (adults) and
400mcg/day (children
5-12 years)
Control still inadequate:
• Trial of other add-on therapy,
e.g. leukotriene receptor
antagonist or theophylline
Asthma Management
Inadequate control on low dose inhaled steroids
Step 3
Add inhaled long-acting ß2 agonist (LABA)
Assess control of asthma
Good response to
LABA:
• Continue LABA
Benefit from LABA but control
still inadequate:
• Continue LABA and
• Increase inhaled steroid dose to
800mcg/day (adults) and
400mcg/day (children 5-12 years)
If control still inadequate
go to Step 4
No response to LABA:
• Stop LABA
• Increase inhaled steroid dose
to 800mcg/day (adults) and
400mcg/day (children
5-12 years)
Control still inadequate:
• Trial of other add-on therapy,
e.g. leukotriene receptor
antagonist or theophylline
If control still inadequate
go to Step 4
Asthma Management
Step 4: poor control on moderate dose of
inhaled steroids + Add on
 inhaled steroids to 2000 mcg/day (adult) or 800 mcg/day
(children)
LTRAs OR SR Theophylline OR Oral SR B2 agonist
Consider referring to specialist care before proceeding to step 5
Asthma Management
Step 5: Use of oral steroids
Maintenance course (long term)
Plus drugs in step 4
Stepwise management of
asthma in adults
Step 1: Mild intermittent asthma
Inhaled short acting ß2 agonist as required
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in adults
Step 2: Regular preventer therapy
Add inhaled steroid 200-800mcg/day *
400mcg is an appropriate starting dose for many patients
Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Step 1: Mild intermittent asthma
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in adults
Step 3: Add-on therapys
1. Add inhaled long-acting ß2 agonist (LABA)
2. Assess control of asthma:
• good response to LABA – continue LABA
• benefit from LABA but control still inadequate – continue LABA and
increase inhaled steroid dose to 800mcg/day * (if not already on this dose)
• no response to LABA – stop LABA and increase inhaled steroid to
800mcg/day *. If control still inadequate, institute trial of other therapies
(e.g. leukotriene receptor antagonist or SR theophylline)
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in adults
Step 4: Persistent poor control
Consider trials of:
• increasing inhaled steroid up to 2000mcg/day *
• addition of fourth drug (e.g. leukotriene receptor
antagonist, SR theophylline, ß2 agonist tablet)
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in adults
Step 5: Continuous or frequent use of oral steroids
Use daily steroid tablet in lowest dose providing adequate control
Maintain high dose inhaled steroid at 2000mcg/day *
Consider other treatments to minimise the use of steroid tablets
Refer patient for specialist care
Step 4: Persistent poor control
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in adults
Step 5: Continuous or frequent
use of oral steroids
Step 4: Persistent poor control
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in children aged 5-12 years
Step 1: Mild intermittent asthma
Inhaled short acting ß2 agonist as required
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in children aged 5-12 years
Step 2: Regular preventer therapy
Add inhaled steroid 200-400mcg/day *
(other preventer drug if inhaled steroid cannot be used)
200mcg is an appropriate starting dose for many patients
Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Step 1: Mild intermittent asthma
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in children aged 5-12 years
Step 3: Add-on therapy
1. Add inhaled long-acting ß2 agonist (LABA)
2. Assess control of asthma:
• good response to LABA – continue LABA.
• benefit from LABA but control still inadequate – continue LABA and
increase inhaled steroid dose to 400mcg/day * (if not already on this dose).
• no response to LABA – stop LABA and increase inhaled steroid to
400mcg/day *. If control still inadequate, institute trial of other therapies
(e.g. leukotriene receptor antagonist or SR theophylline).
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in children aged 5-12 years
Step 4: Persistent poor control
Increase inhaled steroid up to 800mcg/day *
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in children aged 5-12 years
Step 5: Continuous or frequent use of oral steroids
Use daily steroid tablet in lowest dose providing adequate control
Maintain high dose inhaled steroid at 800mcg/day *
Refer patient to respiratory paediatrician
Step 4: Persistent poor control
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in children aged 5-12 years
Step 5: Continuous or frequent
use of oral steroids
Step 4: Persistent poor control
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in children under 5 years
Step 1: Mild intermittent asthma
Inhaled short acting ß2 agonist as required
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in children under 5 years
Step 2: Regular preventer therapy
Add inhaled steroid 200-400mcg/day * †
(leukotriene receptor antagonist if inhaled steroid cannot be used)
Start at dose of inhaled steroid
appropriate to severity of disease.
* BDP or equivalent
† Higher nominal doses may be
required if drug delivery is difficult
Step 1: Mild intermittent asthma
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in children under 5 years
Step 3: Add-on therapy
In children aged 2-5 years consider addition of leukotriene
receptor antagonist
In children under 2 years consider proceeding to step 4
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in children under 5 years
Step 4: Persistent poor control
Refer to respiratory paediatrician
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Stepwise management of
asthma in children under 5 years
Step 4: Persistent poor control
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92
Asthma Management
Stepping down
Important to review patients regularly as they step down
Patients should be maintained at the lowest possible
dose of inhaled steroids
Reductions should be considered every 3 months
Reducing the dose by 25-50% each time
Asthma Management
Exercise Induced Asthma
Often indicates poorly controlled asthma
For patients taking inhaled steroids add:
LABA
LTRAs
Cromones
Oral B2 agonist
Theophylline
Inhaled short acting B2 agonists immediately before
exercise
Asthma Management
Seasonal asthma
Start prophylactic steroid therapy before season begin
Asthma Management
Exacerbations
Occasional attacks between period of good control which
can predicted by warning signs
Asthma Management
Exacerbations
warning signs
Increase symptoms
Sleep disturbance
Fall in exercise tolerance
Increase need for bronchodilator
Decrease effectiveness of bronchodilator
falling PEF
wide variations in PEF
inability to achieve optimum PEF after B agonist
Asthma Management
Exacerbations
Asthma Management
Management of exacerbations
Provide emergency supply oral steroids (Rescue
Course) → to take at the 1st warning sign
seek medical help
written action plan
Time spent with patient for “What to do and
When” will help prevent acute attack
Asthma Management
Rescue course oral steroid
20 mg
Children 2-5 years
30-40 mg
Children >5 y
↨3 days
*The dose should be repeated if child vomited
40-50 mg
Adult: 5 days or until recovery
Asthma Management
When do you stop medication?
Asthma Management
When do you stop medication?
Adult with stable asthma is possible to
reduce inhaled steroids without losing control
On average step down gradually by 25%
(Hawkins et al 2003)
Keep patient under regular review even
when well controlled
Asthma Management
How do you know if a child is growing out of well
controlled asthma if the prophylactic therapy is
never reduced for a trial period?
Often patients stops medications themselves when they
are better
Reducing treatment gradually to the minimum dose
possible before medication is stopped
No exacerbations
No symptoms
No B 2 use
If symptoms recur medications should be restarted.