Ambulatory Asthma Management

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1 Ambulatory Asthma Management Summary of Recommendations Algorithm Patient presents with symptoms of asthma Establish diagnosis and determine level of severity by H and P and spirometry. (A) Consider alternative causes of airway obstruction. Previous diagnosis Acute Exacerbation Assess severity Does patient need E.D. assessment? E.D. Evaluation: H&P Use validated questionnaires (B) Assess asthma triggers Spirometry Consider consultation or allergy testing Manage with B2-agonists Corticosteroids Assess response to treatment Determine level of asthma control then manage via step care (see diagrams) Does patient need E.D. or inpatient management? Asthma education: Inhaler techniques Written action plan based on peak flow monitoring or symptom diary (B) Environmental control measures Schedule regular follow up

2 Age 12 and Above Ambulatory Asthma Management Children 5-11 Years of Age Step up if needed (first check inhaler technique, adherence, environmental control and co-morbid conditions) Assess control Adapted from the NAEPP guidelines and the Institute for Clinical Systems Improvement Step down if possible (and asthma is well controlled at least 3 months) Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if Step 3 care or higher is required. Consider consultation at Step 2. Step 6 Step 1 SABA PRN (A) Step 2 Low-dose ICS (A) LTRA, Cromolyn, Nedocromil or Theophylline (A) Step 3 Low-dose ICS LABA (B) OR (B) Low-dose ICS LTRA (A) or Theophylline (B) Step 4 LABA (E) Step 5 LABA (E) LABA Oral systemic corticosteroids (E) Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3. Step 6 Step 1 SABA PRN (A) Step 2 Low-dose ICS (A) LTRA, Cromolyn, Nedocromil or Theophylline (A) Step 3 Low-dose ICS LABA (A) OR (A) Low dose ICS either LTRA (A), Theophylline (B) or Zileuton (C) Step 4 LABA (B) Mediumdose ICS either LTRA (B), Theophylline (B), or Zileuton (C) Step 5 LABA (B) AND Consider Omalizumab for patients who have allergies (B) LABA Oral corticosteroids (B) AND Consider Omalizumab for patients who have allergies (B) Each step: Patient education, environmental control, and management of co-morbidities. Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes). (B) Quick-Relief Medication for All Patients ICS= SABA inhaled as corticosteroid, needed for symptoms LABA-inhaled and intensity long-acting of treatment B 2 -agonist, depends LTRA=Leukotriene-receptor on severity of symptoms: agonist, SABA=inhaled short-acting B 2 -agonist. Up to 3 Modified treatments from at 20-minute NAEPP guidelines. intervals as needed. Short course of oral systemic corticosteroids may be needed. Clinical Use Considerations of SABA >2 days\week and Evidence for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment. Eving system modified USPSTF protocol found on Evidence grading system modified USPSTF protocol found on ICS= inhaled corticosteroid, LABA-inhaled long-acting B 2 -agonist, LTRA=Leukotriene-receptor agonist, SABA=inhaled short-acting B 2 -agonist. Diagrams were modified from NAEPP guidelines.

3 Ambulatory Asthma Management Clinical Considerations and Evidence Goals of asthma control are to reduce impairment, reduce risk and to do periodic assessments to monitor for adjustments in prescription therapy. The severity of asthma is the intrinsic intensity of the disease process measured most easily and directly in a patient not receiving long-term control therapy and used as a guide to clinical decisions on appropriate medications and interventions. Control of asthma is the degree to which manifestations of asthma are minimized and the goals of therapy are met. In general, schedule visits at two to six week intervals for patients who are just starting therapy or require step up in therapy to achieve or regain asthma control. Schedule visits at one to six month intervals after asthma control has been achieved, to monitor whether asthma control is maintained. The interval will depend on factors such as the duration of asthma control or the level of treatment required. Consider scheduling visits at three month intervals if a step down in therapy is anticipated. Validated questionnaires to assess impairment are: the ATAQ (Asthma Therapy Assessment Questionnaire), the ACQ (Asthma Control Questionnaire), and the ACT (Asthma Control Test). The use of a LABA is contraindicated without the use of an asthma controller medication such as an ICS. LABAs should be used for the shortest duration of time required to achieve control of asthma symptoms. Step down therapy should be attempted once long-term control has been achieved. Immunotherapy for steps 2 4 is based on fair evidence for house dust mites, animal danders and pollens and weaker evidence for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults. Theophylline is a less desirable alternative in children due to the need to monitor serum concentration levels. Zileuton is a less desirable alternative in adults due to limited studies as adjunctive therapy and the need to monitor liver function tests. An acute asthma episode is characterized by breathlessness, cough, wheezing and chest tightness. An objective assessment reveals a decrease in expiratory flow based on spirometry or peak expiratory flow rate. Indications for emergency care include: 1) peak flow < 50% of predicted; 2) failure to respond to beta-agonists; 3) severe wheezing or coughing; 4) extreme anxiety due to breathlessness; and, 5) severe chest retractions, nasal flaring and a hunched forward posture. The treatment of acute asthma in pregnancy follows the guidelines for acute asthma care. Albuterol is the preferred SABA. Inhaled corticosteroids are the preferred long-term control medication. Budesonide is the preferred ICS because more data are available on using this medication in pregnant women than are available on the other ICSs. Recent data suggest that low-dose ICS LABA is the preferred therapy for step 3 in children ages Nedocromil is no longer available in the United States. This guideline does not address exercise-induced bronchospasm.

4 Abulatory Asthma Management DESCRIPTION APPLICABLE PATIENTS ELIGIBILITY ASTHMA: USE OF APPROPRIATE MEDICATION The percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period. Patients age 5-64 with a diagnosis of persistent asthma. Eligibility based on age at the end of the measurement period, continuous plan enrollment for 24 months prior to the end of reporting year and diagnosis of persistent asthma. Persistent asthma is defined by one or more of the following occurring during the 2 years prior to the measurement period (occurring at least once per year). at least 1 emergency department visit with asthma as the principal diagnosis at least 1 acute inpatient discharge with asthma as the principal diagnosis at least 4 outpatient asthma visits with asthma as one of the listed diagnoses and at least two asthma medication dispensing events at least 4 asthma medication dispensing events. See table below: Asthma Medications (dispensing events for denominator) Antiasthmatic combinations dyphylline-guaifenesin guaifenesin-theophylline potassium iodide-theophylline Antibody inhibitor omalizumab Inhaled steroid combinations budesonide-formoterol fluticasone-salmeterol Inhaled corticosteroids beclomethasone budesonide ciclesonide flunisolide fluticasone CFC free mometasone triamcinolone Leukotriene modifiers* montelukast zafirlukast zileuton Long-acting, inhaled beta-2 agonists aformoterol formoterol salmeterol Mast cell stabilizers cromolyn nedocromil Methylxanthines Short-acting, inhaled beta-2 agonists aminophylline dyphylline albuterol levalbuterol oxtriphylline theophylline metoproterenol pirbuterol * A patient identified as having persistent asthma because of at least four asthma medication dispensing events, where leukotriene modifiers were the sole asthma medication dispensed in that year, must also have at least one diagnosis of asthma, in any setting, in the same year as the leukotriene modifier (i.e., measurement year or year prior to the measurement year). Exclude patients with emphysema, COPD, cystic fibrosis or acute respiratory failure.

5 Abulatory Asthma Management ASTHMA: USE OF APPROPRIATE MEDICATION One or more dispensing events of a preferred asthma medication during the measurement period. COMPLIANCE INCLUDED PHYSICIANS Antiasthmatic combinations dyphylline-guaifenesin guaifenesin-theophylline potassium iodide-theophylline Antibody inhibitor omalizumab Inhaled steroid combinations budesonide-formoterol fluticasone-salmeterol Inhaled corticosteroids beclomethasone budesonide ciclesonide flunisolide fluticasone CFC free mometasone triamcinolone Leukotriene modifiers montelukast zafirlukast zileuton Mast cell stabilizers cromolyn nedocromil Methylxanthines aminophylline dyphylline oxtriphylline theophylline Eligible patients will be attributed to Allergists and Primary Care Physicians. In the event that multiple physicians within a specialty have claims with an eligible patient, assignment will be made to the physician with the most and/or most recent visits. *The supporting guideline is designed to assist clinicians by providing an analytical framework for evaluation and treatment of patients, and is not intended to replace a clinician s judgment or to establish a protocol for all patients with this particular condition. The supporting guideline is not intended to establish the only approach to this problem.

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