Rx Prep Table Asthma

Inflammation and Bronchoconstriction

  • Inflammation and bronchoconstriction lead to:

    • Airway obstruction.

    • Reduced expiratory exhalation.

Characteristics of the Disease

  • Control Risk Factors:

    1. Symptoms:

    • Recurrent wheezing.

    • Breathlessness.

    • Chest tightness.

    • Coughing (frequently occurs at night and causes waking).

    1. Reversibility: Symptoms are reversible with medication.

    2. Exacerbations: Can range from mild to severe, potentially fatal.

    3. Triggers:

    • Environmental factors and inflammatory mediators such as:

      • Histamine

      • Leukotriene

      • Cytokines

      • Mast cells

      • Eosinophils

      • Genetics (IgE)

    • Specific triggers can include:
      a. Allergens, dust, smoke, chemicals, weather conditions.
      b. Lifestyle factors such as stress and exercise.
      c. Medications: Aspirin (ASA), Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), Beta-blockers (BBs).

    1. Comorbidities:

    • Allergy

    • Gastroesophageal reflux disease (GERD)

    • Obesity

    • Sleep apnea

    • Anxiety

    • Depression

Management and Control Strategies

  • Preventive Measures:

    1. Avoid smoking.

    2. Avoid known triggers.

    3. Maintain regular exercise, even with exercise-induced bronchoconstriction (EIB).

    4. Receive annual flu vaccinations.

    5. Receive PPSV23 vaccine for individuals aged 2 to 64 years.

    6. Receive PCV-13 vaccine for individuals aged 6 to 18 years.

Diagnosis and Classification

  • Assessment of Expiratory Volume:

    1. Spirometry:

    • Test Forced Vital Capacity (FVC) and Forced Expiratory Volume in 1 second (FEV1).

    1. Peak Expiratory Flow (PEF):

    • Use a Peak Flow Meter for daily measurement.

  • Impairment Criteria:

    • Types:

    • Intermittent

    • Mild-Persistent

    • Moderate-Persistent

    • Severe-Persistent

    • Criteria:

    • Daytime Symptoms:

      • Intermittent: ≤ 2 days/week

      • Mild-Persistent: > 2 days/week but not daily

      • Moderate-Persistent: daily

      • Severe-Persistent: throughout the day

    • Nighttime Awakenings:

      • Intermittent: ≤ 2 times/month

      • Mild-Persistent: 3-4 times/month

      • Moderate-Persistent: > 1 time/week but not nightly

      • Severe-Persistent: often, 7 times/week

    • Rescue Inhaler Use:

      • Intermittent: ≤ 2 days/week

      • Mild-Persistent: > 2 days/week or > 1 time/day

      • Moderate-Persistent: daily

      • Severe-Persistent: several times a day

    • Activity Limitations:

      • Intermittent: none

      • Mild-Persistent: minor limitations

      • Moderate-Persistent: some limitations

      • Severe-Persistent: extreme limitations

    • Lung Function - FEV1%:

      • Intermittent: > 80%

      • Mild-Persistent: > 80%

      • Moderate-Persistent: 60-80%

      • Severe-Persistent: < 60%

    • FEV1/FVC Ratio:

      • Intermittent: normal

      • Mild-Persistent: normal

      • Moderate-Persistent: 5% reduction

      • Severe-Persistent: 5% reduction

  • Risk Criteria:

    • Exacerbations requiring oral steroids:

    • Intermittent: 0-1 per year

    • Mild-Persistent: ≥2 per year

Steps for Initiation of Management

  • Stepwise Approach:

    • Step 1: SABA as needed - all patients must have SABA available.

    • Step 2: Low dose inhaled corticosteroids (ICS) or alternate treatments such as Cromolyn, Leukotriene Receptor Antagonist (LTRA), Theophylline.

    • Step 3: Low-dose ICS combined with LABA (Long-Acting Beta Agonist) or medium-dose ICS.

    • Step 4/5: Consider medium to high-dose ICS with LABA; oral steroids may need to be considered.

    • Step 6: High-dose ICS + LABA + oral steroid for severe cases.

Monitoring and Follow-Up

  • Follow-Up Strategy:

    1. Schedule follow-up in 2-6 weeks.

    2. Check patient adherence to medications.

    3. Provide counseling on inhaler technique and cleaning.

    4. Control triggers, risks, and comorbidities.

    5. Review the patient’s action plan.

    6. Determine if a step-up or step-down in treatment is needed.

    7. Further follow-ups every 1-6 months if asthma is controlled.

Assessment of Control

  • Well Controlled Indicators:

    1. Symptoms or SABA use ≤ 2 days/week.

    2. Nighttime awakenings ≤ 2 times per month.

    3. No limitations to activity.

  • Management: Maintain or step down treatment if controlled for 3 months.

Inhaler Technique

  • Use of Spacers:

    • Improves coordination of inhalation with metered-dose inhalers (MDIs) and helps prevent oral thrush.

    • Clean spacers once a week.

  • Nebulizers:

    • Converts liquid medications into a fine mist for inhalation.

    • If using more than one inhaler, patients must wait 60 seconds between each:

    • First: SABA

    • Any other bronchodilator

    • Last: ICS

Exercise-Induced Bronchospasm (EIB)

  • Management:

    • SABA is preferred to be taken 5-15 minutes prior to exercise.

    • Salmeterol (LABA) may be used unless it is being used for maintenance therapy.

    • Montelukast must be taken 2 hours before exercise.

    • Rescue inhalers should last for at least 12 months with good asthma control.

Poorly Controlled Indicators

  • Criteria:

    1. Symptoms or SABA use more than 2 days/week.

    2. Nighttime awakenings 1-3 times/week.

    3. Some limitations to activity.

    • Management: Step up by 1 step.

  • Criteria for Extremely Poor Control:

    1. Symptoms or SABA use several times a day.

    2. Nighttime awakenings ≥ 4 times/week.

    3. Extreme limitations to activity.

    • Management: Step up by 1-2 steps.

Pharmacotherapy Overview

  • Drug Classes Overview:

    β Agonists

    • Mechanism: Relax smooth muscle leading to bronchodilation.

    Drug Chart:

    Generic Name

    Brand Name

    Adverse Effects (ADRs)

    Black Box Warning (BBW)

    Contraindications/Cautions

    Notes

    Albuterol

    ProAir HFA, ProAir RespiClick, Ventolin HFA, Proventil HFA

    Nervousness, tremor, tachycardia, palpitations, hyperglycemia

    None

    Caution in CVD, glaucoma, hyperthyroidism, seizures, diabetes

    MDI's (HFA): Shake well before use. Albuterol inhalers = 200 puffs/inhaler. EIB: 2 inhalations 5 min. before exercise.

    Levalbuterol

    Xopenex

    N/A

    N/A

    N/A

    N/A

    Salmeterol

    Serevent Diskus

    Increased risk of asthma-related death

    ONLY used for patients on ICS when symptoms are not controlled

    Must be considered before increasing to high-dose ICS.

    N/A

    Racepinephrine

    N/A (Over-the-counter)

    N/A

    N/A

    N/A

    N/A

    Inhaled Corticosteroids (ICS)

    • Mechanism: Inhibits inflammation.

    Drug Chart:

    Generic Name

    Brand Name

    Adverse Effects (ADRs)

    Black Box Warning (BBW)

    Contraindications/Cautions

    Notes

    Beclomethasone

    QVAR

    Dysphonia, oral thrush, cough, URI

    None

    Not used as primary treatment for acute episodes

    First-line for all patients with persistent asthma. Rinse mouth with warm water or use a spacer to prevent thrush.

    Budesonide

    Pulmicort Flexhaler

    N/A

    N/A

    N/A

    N/A

    Fluticasone

    Flovent HFA, Arnuity Ellipta

    N/A

    N/A

    N/A

    N/A

    Mometasone

    Asmanex HFA (MDI), Asmanex Twisthaler (DPI)

    N/A

    N/A

    N/A

    N/A

    Ciclesonide

    Alvesco

    N/A

    N/A

    N/A

    N/A

    Flunisolide

    Aerospan

    N/A

    N/A

    N/A

    N/A

    Leukotriene Receptor Antagonists

    • Mechanism: Reduces airway inflammation.

    Drug Chart:

    Generic Name

    Brand Name

    Adverse Effects (ADRs)

    Black Box Warning (BBW)

    Contraindications/Cautions

    Notes

    Montelukast

    Singulair

    Headache, dizziness, abdominal pain, URI, liver function tests elevation

    Increased risk of neuropsychiatric events

    Mostly used in children. Dosage: 10 mg PO QHS. Granules must be used within 15 minutes.

    Zileuton

    Zyflo

    Hepatic impairment

    N/A

    N/A

    Taken with food.

    Zafirlukast

    Accolate

    N/A

    N/A

    N/A

    Taken on an empty stomach.

    Anticholinergic

    • Mechanism: Provides bronchodilation.

    • Drug: Tiotropium (Spiriva Respimat)

    • Indication: Approved for patients > 6 years old with a history of exacerbations despite ICS/LABA therapy.

    Xanthines

    • Mechanism: Blocks phosphodiesterase, increasing cAMP thus facilitating bronchodilation.

    Drug Chart:

    Generic Name

    Brand Name

    Adverse Effects (ADRs)

    Black Box Warning (BBW)

    Contraindications/Cautions

    Notes

    Theophylline

    Theo-24, Theo-Cron, Elixophyllin

    N/V, HA, increased heart rate, insomnia, tremor/nervous

    N/A

    Cautions for CVD, hyperthyroidism, PUD, seizures.

    Monitor serum concentration - target range 5-15 mcg/mL. Active metabolites: caffeine and 3-methylxanthine.

    Monoclonal Antibody Treatment

    • Mechanism: Inhibits IgE.

    • Drug: Omalizumab (Xolair)

      • Side Effects: Injection site reaction, arthralgias, dizziness, fatigue, Anaphylaxis.

      • Administration: Subcutaneously every 2-4 weeks under medical supervision for allergic asthma in patients > 6 years old with positive allergen skin test and inadequate control with ICS.

    • IL5 Antagonist:

      • Drugs: Mepolizumab (Nucala), Reslizumab (Cinqair)

      • Side Effects: Injection site reaction, arthralgias, dizziness, fatigue.

      • Mepolizumab indicated for eosinophilic asthma in patients >12 years old; given SC route.