Asthma Guidelines: Stepwise Approach to Managing Asthma

Transcription

1 Asthma Guidelines: Stepwise Approach to Managing Asthma Karen Meyerson, MSN, RN, FNP-C, AE-C Asthma Network of West Michigan April 21, 2009 Acknowledgements: LeRoy M. Graham, MD, Atlanta, GA Allan T. Luskin, MD, Madison, WI

2 PREVIOUS NHLBI/GINA GUIDELINES Severity Symptoms Nocturnal Mild Intermittent < 1 x/week, asymptomatic between attacks Symptoms FEV 1 or PEF < 2 x / month > 80% predicted variability < 20% Mild Persistent > 1 x/week but not daily > 2 x / month > 80% predicted variability 20-30% Moderate Persistent Daily, affecting activity > 1 time / week 60-80% predicted variability > 30% Severe Persistent Continuous, limiting activity Frequent < 60% predicted variability > 30%

3 Asthma Severity Asthma severity is the intrinsic intensity of disease. Initial assessment of patients who have confirmed asthma begins with a severity classification because the therapy should then correspond to the level of asthma severity. This initial assessment of asthma severity is made immediately after diagnosis, or when the patient is first encountered, generally before the patient is taking some form of long-term control medication. Assessment is made on the basis of current spirometry and the patient s recall of symptoms over the previous 2 4 weeks, because detailed recall of symptoms decreases over time.

4 Asthma Severity Intermittent Mild Persistent Moderate Persistent Severe Persistent

5 CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN CHILDREN 0-4 YEARS OF AGE EPR-3, p72, 307 Components of Severity Symptoms Classification of Asthma Severity Intermittent Persistent Mild Moderate Severe <2 days/week >2 days/week not daily Daily Continuous Nighttime Awakenings 0 1-2x/month 3-4x/month >1x/week Impairment SABA use for sx control Interference with normal activity <2 days/week >2 days/week not daily Daily Several times daily none Minor limitation Some limitation Extremely limited Risk Exacerbations (consider frequency and severity) Recommended Step for Initiating Treatment 0-1/year >2 exacerbations in 6 months requiring oral steroids, or >4 wheezing episodes/ year lasting >1 day AND risk factors for persistent asthma Frequency and severity of may fluctuate over time Exacerbations of any severity may occur in patients in any category Step 1 Step 2 Step 3 Consider short course of oral steroids In 2-6 weeks, evaluate asthma control that is achieved and adjust therapy accordingly

6 Pulmonary Function Tests FEV 1 (Forced Expiratory Volume in 1 Second) this is the volume of air expired in the first second during maximal expiratory effort. The FEV 1 is reduced in both obstructive and restrictive lung disease. FVC (Forced Vital Capacity) this is the total volume of air expired after a full inspiration. FEV 1 /FVC this is the percentage of the vital capacity which is expired in the first second of maximal expiration.

7 CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN CHILDREN 5-11 YEARS OF AGE EPR-3, p73, 308 Components of Severity Impairment Risk Symptoms Nighttime Awakenings SABA use for sx control Interference with normal activity Lung Function Exacerbations (consider frequency and severity) Recommended Step for Initiating Treatment Intermittent Classification of Asthma Severity Persistent Mild Moderate Severe <2 days/week >2 days/week not daily Daily Continuous <2x/month 3-4x/month >1x/week not nightly Often nightly <2 days/week >2 days/week not daily Daily Several times daily none Minor limitation Some limitation Extremely limited Normal FEV 1 between exacerbations FEV 1 > 80% FEV 1 >80% FEV 1 /FVC> 80% FEV 1 =60% - 80% FEV 1 <60% FEV 1 /FVC < 75% FEV 1 /FVC=75% FEV 1 /FVC> 85% -80% 0-2/year > 2 /year Frequency and severity may vary over time for patients in any category Step 1 Relative annual risk of exacerbations may be related to FEV Step 2 Step3 mediumdose ICS option Step 3 or 4 Consider short course of oral steroids In 2-6 weeks, evaluate asthma control that is achieved and adjust therapy

8 CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS > 12 YEARS AND ADULTS EPR-3, p74, 344 Components of Severity Impairment Normal FEV 1 /FVC 8-19 yr 85% yr 80% yr 75% yr 70% Risk Symptoms Nighttime Awakenings SABA use for sx control Interference with normal activity Lung Function Exacerbations (consider frequency and severity) Recommended Step for Initiating Treatment Intermittent Classification of Asthma Severity 0-2/year Persistent Mild Moderate Severe <2 days/week >2 days/week not daily Daily Continuous <2x/month 3-4x/month > 2 /year >1x/week not nightly Frequency and severity may vary over time for patients in any category Relative annual risk of exacerbations may be related to FEV Often nightly <2 days/week >2 days/week not daily Daily Several times daily none Minor limitation Some limitation Extremely limited Normal FEV 1 between exacerbations FEV 1 > 80% FEV 1 /FVC normal FEV 1 >80% FEV 1 /FVC normal FEV 1 >60% but< 80% FEV 1 /FVC reduced 5% FEV 1 <60% FEV 1 /FVC reduced> 5% Step 1 Step 2 Step 3 Step 4 or 5 Consider short course of oral steroids In 2-6 weeks, evaluate asthma control that is achieved and adjust therapy accordingly

9 Asthma Control The purpose of periodic assessment and ongoing monitoring is to determine whether the goals of asthma therapy are being achieved and asthma is controlled. Well Controlled Not Well Controlled Very Poorly Controlled

10 Asthma Control Reducing Current Impairment Reducing Future Risk

11 ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 0-4 YEARS OF AGE EPR-3, p75, 309 Components of Control Symptoms Classification of Asthma Control Well Controlled Not Well Controlled Very Poorly Controlled < 2 days/week > 2 days/week Throughout the day IMPAIRMENT Nighttime awakenings Interference with normal activity SABA use < 1/month > 2 x/month >2x/week none Some limitation Extremely limited < 2 days/week > 2 days/week Several times/day RISK Recommended Action For Treatment Exacerbations Progressive loss of lung function Rx-related adverse effects 0-1 per year 2-3 per year > 3 per year Maintain current step REGULAR FOLLOW UP EVERY 3-6 MONTHS Consider step down if well controlled at least 3 months Evaluation requires long-term follow up care Consider in overall assessment of risk Step up 1 step Reevaluate in 2-6 weeks If no clear benefit in 4-6 weeks, consider alternative dx or adjust therapy Consider oral steroids Step up (1-2 steps) and reevaluate in 2 weeks If no clear benefit in 4-6 weeks, consider alternative dx or adjust therapy

12 ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 5-11 YEARS OF AGE EPR-3, p76, 310 Components of Control Symptoms Classification of Asthma Control Well Controlled Not Well Controlled Very Poorly Controlled < 2 days/week > 2 days/week Throughout the day Nighttime awakenings < 1/month > 2 x/month >2x/week IMPAIRMENT Interference with normal activity SABA use none Some limitation Extremely limited < 2 days/week > 2 days/week Several times/day FEV 1 or peak flow > 80% predicted/ personal best 60-80% predicted/ personal best <60% predicted/ personal best FEV 1 /FVC > 80% predicted 75-80% predicted <75% pre RISK Exacerbations Progressive loss of lung function Rx-related adverse effects 0-1 per year 2-3 per year > 3 per year Evaluation requires long-term follow up care Consider in overall assessment of risk Recommended Action For Treatment Maintain current step Consider step down if well controlled at least 3 months Step up 1 step Reevaluate in 2-6 weeks Consider oral steroids Step up 1-2 weeks and reevaluate in 2 weeks

13 ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTHS > 12 YEARS OF AGE AND ADULTS EPR-3, p77, 345 Components of Control Symptoms Classification of Asthma Control Well Controlled Not Well Controlled Very Poorly Controlled < 2 days/week > 2 days/week Throughout the day Nighttime awakenings < 2/month 1-3/week > 4/week IMPAIRMENT RISK Interference with normal activity SABA use FEV 1 or peak flow Validated questionnaires ATAQ/ACT Exacerbations Progressive loss of lung function Rx-related adverse effects none Some limitation Extremely limited < 2 days/week > 2 days/week Several times/day > 80% predicted/ personal best 60-80% predicted/ personal best 0-1 per year 2-3 per year > 3 per year Evaluation requires long-term follow up care Consider in overall assessment of risk <60% predicted/ personal best 0/> / /< 15 Recommended Action For Treatment Maintain current step Consider step down if well controlled at least 3 months Step up 1 step Reevaluate in 2-6 weeks Consider oral steroids Step up 1-2 weeks and reevaluate in 2 weeks

14 Asthma Control Test (ACT) for Patients 12 Years and Older 1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? Score 2. During the past 4 weeks, how often have you had shortness of breath? 3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night, or earlier than usual in the morning? 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 5. How would you rate your asthma control during the past 4 weeks? Copyright 2002, QualityMetric Incorporated. Asthma Control Test Is a Trademark of QualityMetric Incorporated. Patient Total Score

15 Childhood Asthma Control Test (ACT): Questions Completed by Child 1. How is your asthma today? SCORE Very bad Bad Good Very Good 2. How much of a problem is your asthma when you run, exercise or play sports? It s a big problem, I can t do what I want to do. It s a problem and I don t like it. It s a little problem but it s okay. It s not a problem 3. Do you cough because of your asthma? Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time 4. Do you wake up during the night because of your asthma? Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time

16 Childhood Asthma Control Test (ACT): Questions Completed by Parent/Caregiver 5. During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms? Not at all 1-3 days/mo 4-10 days/mo days/mo days/mo Everyday 6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma? Not at all 1-3 days/mo 4-10 days/mo days/mo days/mo Everyday 7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma? Not at all 1-3 days/mo 4-10 days/mo days/mo days/mo Everyday TOTAL

17 Monitoring Asthma Control EPR-3, Page 78 Ask the patient Has your asthma awakened you at night or early morning? Have you needed more rescue inhaler than usual? Have you needed urgent care for asthma? (office, ED, etc) Are you participating in your usual or desired activities? What are your triggers? (and how can we manage them?) Actions to consider Assess whether medications are being taken as prescribed Assess whether inhalation technique is correct Assess spirometry and compare to previous measurements Adjust medications, as needed to achieve best control with the lowest dose needed to maintain control Environmental mitigation strategy NAEPP Draft Report, ERP 2007

18 STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 0-4 YEARS OF AGE EPR-3, p Intermittent Asthma Step 1 Preferred: SABA prn Persistent Asthma: Daily Medication Consult with asthma specialist if step 3 or higher care is required Consider consultation at step 2 Step 2 Preferred: Low-dose ICS Alternative: LTRA Cromolyn Step 3 Preferred: Medium-dose ICS Step 4 Preferred: Medium-dose ICS AND either LTRA Or LABA Step 5 Preferred: High dose ICS AND either LTRA Or LABA Step 6 AND either LTRA Or LABA AND Oral Corticosteroid Step up if needed (check adherence, environmental control ) Assess Control Step down if possible (asthma well controlled for 3 months) Patient Education and Environmental Control at Each Step Intermittent Mild Persistent Moderate Persistent Severe Persistent

19 STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5-11 YEARS OF AGE EPR-3, p Intermittent Asthma Step 1 Preferred: SABA prn Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Step 2 Preferred: Low-dose ICS Alternative: LTRA Cromolyn Theophylline Step 3 Preferred: Medium-dose ICS OR Low-dose ICS+ either LABA, LTRA, or Theophylline Step 4 Preferred: Medium-dose ICS+LABA Alternative: Medium-dose ICS+either LTRA, or Theophlline Step 5 Preferred: High dose ICS + LABA Alternative: High-dose ICS+ either LTRA or Theophylline AND Consider Olamizumab for patients with allergies Step 6 Preferred: High-dose ICS + LABA + oral Corticosteroid Alternative: High-dose ICS +either LTRA or Theophylline + oral corticosteroid AND Consider Olamizumab for patients with allergies Step up if needed (check adherence, environmental control and comorbidities) Assess Control Step down if possible (asthma well controlled for 3 months) Patient Education and Environmental Control at Each Step

20 STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS > 12 YEARS AND ADULTS EPR-3, p Intermittent Asthma Step 1 Preferred: SABA prn Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Step 2 Preferred: Low-dose ICS Alternative: LTRA Cromolyn Theophylline Step 3 Preferred: Medium-dose ICS OR Low-dose ICS+ either LABA, LTRA, Theophylline Or Zileutin Step 4 Preferred: Medium-dose ICS+LABA Alternative: Medium-dose ICS+either LTRA, Theophlline Or Zileutin Step 5 Preferred: High dose ICS + LABA AND Consider Olamizumab for patients with allergies Step 6 Preferred: High-dose ICS + LABA + oral Corticosteroid AND Consider Olamizumab for patients with allergies Step up if needed (check adherence, environmental control and comorbidities) Assess Control Step down if possible (asthma well controlled for 3 months) Patient Education and Environmental Control at Each Step

21 EPR-3, Page 330 Recommended Action for Treatment Based on Assessment of Control Well Controlled Maintain current step Consider step down if well controlled for at least 3 months Not Well Controlled Step up 1 step and reevaluate in 2-6 weeks For side effects, consider alternative treatment options Very Poorly Controlled Consider short course of oral corticosteroids Step up 1-2 steps and reevaluate in 2 weeks For side effects, consider alternative treatment options Before stepping up check adherence and environmental control NAEPP Draft Report, ERP 2007

22 Treatment Strategies Gain Control!!! Aggressive, intensive initial therapy to suppress airway inflammation and gain prompt control Maintain Control Frequent follow-up, clinically and physiologically Therapeutic modifications depending on severity and clinical course Step down long-term control medications to maintain control with minimal side effects

23 Patients Are Candidates for Maintenance Therapy if The RULES OF TWO * Apply They are using a quick-relief inhaler more than 2 times per week They awaken at night due to asthma more than 2 times per month They refill a quick-relief inhaler Rx more than 2 times per year * RULES OF TWO is a trademark of the Baylor Health Care System.

24 Rules of Two TM Out of Control! If your patient can answer YES to ANY of these questions, his/her asthma is probably not under good control. These rules define persistent asthma.

25 Asthma Pharmacotherapy Quick-relief Short-acting betaagonists Inhaled anticholinergics Systemic corticosteroids Long-term control Corticosteroids Cromolyn sodium/nedocromil Long-acting inhaled beta-agonists Theophylline Leukotriene modifiers

26 Quick-Relief Medications Short-acting beta 2 -agonists (SABA): Albuterol, Ventolin, Proventil, Maxair, Xopenex, etc. Relax bronchial smooth muscles Short-acting Work within minutes Last 4-6 hours Side effects can include shakiness (tremors), tachycardia Danger of over-use

27 Short-acting β 2 -agonists Most effective medication for relief of acute symptoms RED FLAG more than 1 canister per month Regularly scheduled use not generally recommended May lower effectiveness May increase airway hyperresponsiveness

28 Anticholinergics Not specifically indicated for usual quickrelief medication in asthma contrast with COPD Now well-studied as adjunct to beta-agonists in emergency departments i.e., acute exacerbations

29 Long-term Control Medications Inhaled corticosteroids (ICS): Advair, Flovent, Azmacort, Q-Var, Pulmicort, Asmanex, Aerobid, Symbicort Non-steroidal anti-inflammatories: Intal, Tilade Leukotriene modifiers (LTM): Singulair, Accolate Theophylline: Theo-Dur, Slo-bid Long-acting beta 2 -agonists (LABA): Serevent, Foradil Taken daily and chronically to maintain control of persistent asthma and to prevent exacerbations: Soothes airway swelling Helps prevent asthma flares - very effective for longterm control but must be taken daily Often under-used

30 Inhaled Corticosteroids Actions: potentiate β-receptor responsiveness reduce mucus production and hypersecretion inhibit inflammatory response at all levels Best effects if started early after diagnosis Symptomatic and spirometric improvement within 2 weeks maximum effects within 4-8 weeks

31 Inhaled Corticosteroids (continued) Most effective long term control medication for persistent asthma Small risk for adverse events at usual doses Risk can be reduced even further by: Using spacer and rinsing mouth Using lowest effective dose Using with long-acting β 2 -agonist when appropriate Monitoring growth in children

32 Low dose ICS and the Prevention of Asthma Deaths ICS protects patients from asthma-related deaths Users of > 6 canisters/yr. had a death rate ~ 50% lower than non-users of ICS Death rate decreased by 21% for each additional ICS canister used during the previous year. Suissa et al. N Eng J Med 2000;343:

33 ICS May Help Prevent the Risk of Asthma Related Hospitalizations 8 Relative Risk of Hospitalization None β 2 -agonists Total Inhaled Steroids Total Short-acting B 2 prescriptions dispensed per person-year Adapted from Donahue et. al. JAMA 1997;277(11):

34 Inhaled Corticosteroids (continued) HPA Suppression no need to test in children receiving < 400 mcg/day (BEC), or adults < 1500 mcg/day (BEC) Cataracts Long bone growth growing understanding of this risk Osteoporosis/Bone Fractures some attention at high doses, high risk patients Candidiasis Dysphonia

35 Two mechanisms Leukotriene Modifiers 5-lipoxygenase inhibitors zileution (Zyflo) Cysteinyl leukotriene receptor antagonists zafirlukast (Accolate), montelukast (Singulair) Indications Generally, alternative therapy in mild persistent asthma or as add-on in higher stages Improve lung function Decrease short-acting β 2 -agonist use Prevent exacerbations

36 Methylxanthines (Theophylline) (continued) Places in therapy: primary therapy when inhaled corticosteroids not possible patient s who can t/won t use inhalers additive therapy at later Stages ADR s/serum Levels/Drug Interactions Therapeutic Range 5-15 mcg/ml, or mcg/ml levels > 20 mcg/ml: N/V/D, HA, irritability, insomnia, tachycardia levels > 30 mcg/ml: seizures, toxic encephalopathy, hyperthermia, brain damage ADR s/serum Levels/Drug Interactions Drug Interactions: PLENTY!!

37 Long-acting β 2 -agonists Not a substitute for anti-inflammatory therapy Not appropriate for monotherapy RED FLAG Literature supporting role in addition to inhaled corticosteroids Not for acute symptoms or exacerbations Salmeterol (Serevent) first of class in US Formoterol (Foradil) Newer long-acting beta-agonist Has rapid onset and long duration Available as dry powder inhaler and in combination with inhaled steroid (Symbicort)

38 Long-acting β 2 -agonists Salmeterol Multicenter Asthma Research Trial (SMART) A comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Nelson HS, Weiss ST, Bleecker ER, et al. Chest 2006; 129:15-26.

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40 Long-acting β 2 -agonists Patients > 12 years old with asthma Sought to evaluate the effects of salmeterol or placebo added to usual asthma care on respiratory and asthma related deaths life-threatening episodes Initial aim to enroll 30,000 patients; later changed with aim to enroll 60,000

41 Long-acting β 2 -agonists Two methods of recruitment Phase Recruited by advertising and assigned to study investigator by geography Phase Recruitment by study investigators and more investigators added

42 Long-acting β 2 -agonists Increase in adverse events in salmeterol group during SMART trial: Particularly in those recruited in Phase 1 Particularly among African-Americans who were noted to have markers of more severe asthma and less likely to be using ICS Increase in adverse events in salmeterol group Due to adverse effect of salmeterol? Due to inappropriate bronchodilator use? (affected patients were more severe at baseline and less likely to be using ICS)

43 FDA Advisory Panel Recommends Ban of Long-acting β 2 -agonists in Asthma A panel of outside advisers has told the FDA that two longacting asthma drugs -- Serevent and Foradil -- should be banned for use in asthma treatment because they are alleged to be more dangerous than they are helpful, particularly in children and adolescents. If the FDA takes this advice, it would remove the indication for asthma from the label for these drugs but they could still be prescribed for chronic obstructive pulmonary disease. But the advisers unanimously supported the continued use of the far more popular drugs Advair and Symbicort. Advisers overwhelmingly agreed these drugs provided great benefits to patients, though they expressed some concern about lack of information about how safe they are for adolescents and children. ~December 2008

44 Long-acting β 2 -agonists Conclusions: Black Box warning Do not use long-acting bronchodilators alone Always use with inhaled corticosteroids

45 Xolair Indication Xolair 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 Whose symptoms are inadequately controlled with inhaled corticosteroids Elevated serum IgE level ( IU/mL) Xolair has been shown to decrease the incidence of asthma exacerbations in these patients Safety and efficacy have not been established in other allergic conditions

46 Referral to an Asthma Specialist for Consultation and Co-Management Patient has had a life-threatening asthma exacerbation (hospitalization is a risk factor for mortality) Patient is not meeting the goals of therapy after 3-6 months Signs and symptoms are atypical; differential diagnosis? Co-morbid conditions complicate asthma (GERD, VCD etc) Additional diagnostic studies are indicated (allergy skin testing, pulmonary function studies, bronchoscopy) Patient requires additional education/guidance Patient has required more than two bursts of oral corticosteroids in 1 year Patient requires Step 4 care or higher ( Step 3 for children 0 4 years of age). Consider referral if patient requires step 3 care ( Step 2 for children 0 4 years of age) Expert Panel Report-3, Page 68

47 The Outpatient Asthma Visit EPR-3, p Assess severity and control (NAEPP Classification Criteria) Reduce current impairment Reduce future risk Address Inflammation vs. bronchoconstriction Differentiate controller vs. rescue medication Prescribe an inhaled steroid for all patients with persistent asthma Teach spacer device technique Write an Asthma Action Plan Daily management and recognizing early s/s of worsening Step-up Yellow Zone plan for home management Follow-up in 4-6 weeks: step-up/step-down & modify Action Plan Inhaler Law; Albuterol and spacer for school Annual Influenza vaccine, regardless of severity

48 What is Success: How do we measure it and how do we get there? Begin therapy based on Severity Monitor and adjust therapy based on Control and Risk and Responsiveness to Therapy Use routine standardized multifaceted measures The goal of therapy is to achieve control Individualize therapy based on likelihood of response and patient needs, desires, and goals

49 Inhaler Technique Metered-dose inhalers: Proper MDI technique Proper inhaler/spacer technique Care and cleaning Methods to determine amount of medication left in inhaler Dry-powder inhalers: Proper technique Care and cleaning Methods to determine amount of medication left in inhaler Nebulizers

50 Most Important: Six Key Messages 1. Inhaled corticosteroids are the most effective antiinflammatory medication for long term management of persistent asthma. All patients should receive: 2. Written asthma action plan 3. Initial assessment of asthma severity 4. Review of the level of asthma control (impairment and risk) at all follow up visits 5. Periodic, follow-up visits (at least every 6 months) 6. Assessment of exposure and sensitivity to allergens and irritants and recommendation to reduce relevant exposures.

51 Guidelines for the Diagnosis and Management of Asthma NAEPP/NHLBI Expert Panel Report-3 Case Scenarios

52 Case # 1 A 3-year old male currently not on any asthma medications has visited your outpatient clinic 3 times in the past 6 months for acute wheezing, each episode lasting 2-3 days. In between episodes, his mother reports nighttime cough about 4 nights per month. This patient s asthma severity can be BEST classified as: A. Mild Persistent Asthma (Step 2) B. Moderate Persistent Asthma (Step 3) C. Severe Persistent Asthma (Step 4) D. I would not diagnose this child with asthma

53 Case # 1 A 3-year old male currently not on any asthma medications has visited your outpatient clinic 3 times in the past 6 months for acute wheezing, each episode lasting 2-3 days. In between episodes, his mother reports nighttime cough about 4 nights per month. This patient s asthma severity can be BEST classified as: A. Mild Persistent Asthma (Step 2) B. Moderate Persistent Asthma (Step 3) C. Severe Persistent Asthma (Step 4) D. I would not diagnose this child with asthma

54 Case # 2 A 7-year old female with asthma reports nighttime awakenings about 2 times per week and requires albuterol about 3 times per week. She is currently taking fluticasone 44 mcg 2 puffs twice daily. The BEST next step in your step-up treatment plan would be to: A. Increase the dose of the inhaled steroid B. Add a leukotriene modifier C. Add a long-acting B-agonist D. Encourage albuterol more frequently, every 4 hours

55 ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 5-11 YEARS OF AGE EPR-3, p76, 310 Components of Control Symptoms Classification of Asthma Control Well Controlled Not Well Controlled Very Poorly Controlled < 2 days/week > 2 days/week Throughout the day Nighttime awakenings < 1/month > 2 x/month >2x/week IMPAIRMENT Interference with normal activity SABA use none Some limitation Extremely limited < 2 days/week > 2 days/week Several times/day FEV 1 or peak flow > 80% predicted/ personal best 60-80% predicted/ personal best <60% predicted/ personal best FEV 1 /FVC > 80% predicted 75-80% predicted <75% pre RISK Exacerbations Progressive loss of lung function Rx-related adverse effects 0-1 per year 2-3 per year > 3 per year Evaluation requires long-term follow up care Consider in overall assessment of risk Recommended Action For Treatment Maintain current step Consider step down if well controlled at least 3 months Step up 1 step Reevaluate in 2-6 weeks Consider oral steroids Step up 1-2 steps and reevaluate in 2 weeks

56 Recommended Action for Treatment Based on Assessment of Control Well Controlled Maintain current step Consider step down if well controlled for at least 3 months Not Well Controlled Step up 1 step and reevaluate in 2-6 weeks For side effects, consider alternative treatment options Very Poorly Controlled Consider short course of oral corticosteroids Step up 1-2 steps and reevaluate in 2 weeks For side effects, consider alternative treatment options Before stepping up check adherence and environmental control NAEPP Draft Report, ERP 2007

57 STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5-11 YEARS OF AGE EPR-3, p Intermittent Asthma Step 1 Preferred: SABA prn Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Step 2 Preferred: Low-dose ICS Alternative: LTRA Cromolyn Theophylline Step 3 Preferred: Medium-dose ICS OR Low-dose ICS+ either LABA, LTRA, or Theophylline Step 4 Preferred: Medium-dose ICS+LABA Alternative: Medium-dose ICS+either LTRA, or Theophlline Step 5 Preferred: High dose ICS + LABA Alternative: High-dose ICS+ either LTRA or Theophylline AND Consider Olamizumab for patients with allergies Step 6 Preferred: High-dose ICS + LABA + oral Corticosteroid Alternative: High-dose ICS +either LTRA or Theophylline + oral corticosteroid AND Consider Olamizumab for patients with allergies Step up if needed (check adherence, environmental control and comorbidities) Assess Control Step down if possible (asthma well controlled for 3 months) Patient Education and Environmental Control at Each Step

58 Case # 2 A 7-year old female with asthma reports nighttime awakenings about 2 times per week and requires albuterol about 3 times per week. She is currently taking fluticasone 44 mcg 2 puffs twice daily. The BEST next step in your step-up treatment plan would be to: A. Increase the dose of the inhaled steroid B. Add a leukotriene modifier C. Add a long-acting B-agonist D. Encourage albuterol more frequently, every 4 hours

59 Case # 3 Referral to an asthma specialist for consultation and co-management should be sought when a patient: A. Is hospitalized twice in the past year or once in the past month B. Requires more than two bursts of oral corticosteroids in one year C. Requires Step 3 care or higher or is not responding to a treatment plan that is appropriate for patient with Moderate Persistent Asthma D. Any of the above

60 Case # 3 Referral to an asthma specialist for consultation and co-management should be sought when a patient: A. Is hospitalized twice in the past year or once in the past month B. Requires more than two bursts of oral corticosteroids in one year C. Requires Step 3 care or higher or is not responding to a treatment plan that is appropriate for patient with Moderate Persistent Asthma D. Any of the above

61 Questions? Download the Guidelines at: Download the Summary Report at: