Objectives. Asthma Management

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1 Objectives Asthma Management BREATHE Conference Allergy and Asthma Specialists PC Christine Malloy MD March 22, 2013 Review the role of inflammation in asthma Discuss the components of the EPR-3 management approach Review the concepts of severity, control, impairment, & risk Review age-based assessment & step therapy charts Review step-based medication options Interactions between CD4 T Cells and B Cells That Are Important in IgE Synthesis. INFLAMMAT ION Airway Hyperresponsiv eness Airway Obstructio n Clinical symptoms Busse WW, Lemanske RF Jr. N Engl J Med 2001;344:

2 RThe role of Eosinophils in Allergic Inflammation. The Lancet Volume 368, Issue Busse WW, Lemanske RF Jr. N Engl J Med 2001;344: The Importance of Establishing a Balance between Th1-Type and Th2-Type Cytokine Responses. Key Concepts for Understanding EPR-3 EPR-3 is built on the following key concepts: Severity and control Impairment and risk Therapy goals Four components of care Stepwise approach Busse WW, Lemanske RF Jr. N Engl J Med 2001;344:

3 Stepwise Approach to Asthma Control Severity and Control Severity Control Education Assessment & Monitoring Stepwise Approach Medications Control of Environmental Factors & Comorbid Conditions Intrinsic intensity of disease process Assessed to initiate therapy Degree to which: Signs and symptoms are minimized due to therapy Goals of therapy are met Assessed to monitor and adjust therapy Includes both Includes both Impairment and Risk Current Impairment Components are: Symptoms (day, night) Reliever therapy Activity Lung function Future Risk Components are: Exacerbation s Loss of lung function Medication side effects Goal of Therapy Asthma Control Reduce Impairment: Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the daytime, in the night, or after exertion) Require infrequent use ( 2 days per week) of inhaled SABA for quick relief of symptoms (not including prevention of exercise-induced bronchospasm (EIB)) Maintain (near) normal pulmonary function Maintain normal activity levels (including exercise and other physical activity and attendance at work or school) Meet patients' and families' expectations of and satisfaction with asthma care

4 Goal of Therapy Asthma Control Severity classification 0-4yrs Reduce Risk: Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations Prevent loss of lung function; for children, prevent reduced lung growth Provide optimal pharmacotherapy with minimal or no adverse effects of therapy Control 0-4years Step chart for 0-4years

5 Severity classification 5-11 years Control 5-11 yrs Step chart for 5-11 years DRUG Beclomethas one ( 5yr) Budesonide ( 6yr) Budesonide neb 0.25, 0.5, 1.0 ( 1yr) Fluticasone 44, 110, 220 Medications 0-11yrs LOW MEDIUM 0-4yr yr yr > > yr > > > HIGH 0-4yr >1.0 > yr >320 > >352

6 Medications 0-11yrs Severity classification 12yrs Drug Fluticason e/ Salmeterol Monteluka st Dose Forms : 100/ / /5 0 : 45/21 115/ /21 Typical dose 0-4yrs Typical dose 5-11yrs 1 puff BID () : 12yrs 4, Control 12yrs Step chart for 12yrs

7 DRUG Beclomethas one Budesonide Ciclesonide 80 Fluticasone 44, 110, 220 Fluticasone 50,100,250 Medications 12yrs LOW MEDIUM HIGH Adult Adult Adult > > > > > >480 >1200 >320 >440 >440 Mometason >400 DRUG Medications 12yrs Fluticasone/sal meterol Budesonide/fo rmoterol FORM TYPICAL 100/50 250/50 500/50 45/21m cg 115/21 230/21 mc 80/ /4.5 1puff BID 2puffs BID 2puffs BID DRUG Medications 12yrs FORM TYPICAL Zileuton QID *hepatic dysfx Theophylline Various 10/kg/day -> 300 max *levels Omalizumab Subcutaneo us injections mc q2-4wks Weight and IgE dependent dose Conclusions The goal for therapy is to control asthma by: Reducing impairment Reducing risk A stepwise approach to pharmacologic therapy is recommended to gain and maintain control of asthma in both the impairment and risk domains Monitoring and followup is essential

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