Adult Asthma Clinical Practice Guideline Summary · Indicators for a diagnosis of asthma •include...

© 2013 Kaiser Permanente Medical Care Program CMI020112-2For use within Kaiser Permanente only. — 1 — Last Reviewed/Revised: 4/2013

Key Points1.Anaccuratediagnosisisessentialtotreatment.2.Severityassessmentdeterminesinitialtherapy.3.Degreeofasthmacontroldeterminesongoingtherapy.4.Useastepwiseapproachforinitialandongoingtherapy.5.Effectivecontrolincludesmanagingspecialsituations.6.Managingexacerbationsisanimportantpartofcare.

Definition of AsthmaAsthmaisachronicinflammatorydisorderoftheairwaysinwhichmanycellsandcellularelementsplayarole.Insusceptibleindividuals,thisinflammationcausesrecurrentepisodesofcoughing(particularlyatnightorearlyinthemorning),wheezing,breathlessness,andchesttightness.Theseepisodesareusuallyassociatedwithwidespreadbutvariableairflowobstructionthatisoftenreversibleeitherspontaneouslyorwithtreatment.

Establishing the DiagnosisToestablishadiagnosisofasthma,useamedicalhistory,physicalexamandspirometrytodeterminethat:

• Episodicsymptomsofairflowobstructionorairwayhyperresponsivenessarepresent.

• Airflowobstructionisatleastpartiallyreversible,measuredbyspirometry.ReversibilityisdeterminedbyanincreaseinFEV1of>200mLand≥12%frombaselinemeasureafterinhalationofshort-actingbeta2-agonist(SABA).Somestudiesindicatethatanincreaseof≥10%ofthepredictedFEV1afterinhalationofaSABAmayhavehigherlikelihoodofseparatingpatientswhohaveasthmafromthosewhohavechronicobstructivepulmonarydisease(COPD).

• Alternativediagnoseshavebeenexcluded(e.g.,allergicrhinitisandsinusitis,congestiveheartfailure,pulmonaryembolism,chronicobstructivepulmonarydisease,drug-relatedcough,vocalcorddysfunction,andotherpulmonaryconditions).Indicatorsforadiagnosisofasthmaincludewheezing,cough,chesttightness,dyspnea,worseningofsymptomsinthepresenceofenvironmentalstimuli,andworseningofsymptomsatnight.

Adult Asthma Clinical Practice Guideline SummaryThe following evidence-based guideline was developed to assist Primary Care physicians and other clinicians in the management of asthma in adults. It was adapted from the National Heart, Lung and Blood Institute Expert Panel Review 3 (NHLBI EPR-3). It was reviewed and re-approved in 2013.

• Referraltoanasthmaspecialistisrecommendedifsignsandsymptomsareatypical,ifthereareproblemswithadifferentialdiagnosis,orifadditionaltestingisindicated.

Assessing Severity and ControlAfter establishing the diagnosis, assessment of asthma severity, control and responsiveness to medication typically guide the choice of therapy (see Figure 1 and Tables 1 to 3).

• Severity:theintrinsicintensityofthediseaseprocess.Severityismosteasilyanddirectlymeasuredinapatientwhoisnotreceivinglong-termcontroltherapy.Severitycanalsobemeasured,onceasthmacontrolisachieved,bythestepofcare(i.e.,theamountofmedication)requiredtomaintaincontrol.

• Control:thedegreetowhichthemanifestationsofasthmaareminimizedbytherapeuticinterventionandthegoalsoftherapyaremet.

• Responsiveness:theeasewithwhichasthmacontrolisachievedbytherapy.Asthmaseverityandasthmacontrolincludethedomainsofcurrentimpairmentandfuturerisk.

• Impairment:frequencyandintensityofsymptomsandfunctionallimitationsthepatientiscurrentlyexperiencingorhasrecentlyexperienced.

• Risk: the likelihood of either asthma exacerbations,

progressive decline in lung function, or risk of adverse

effects from medication.

Table 1: Components of Asthma Control

Components of Control Symptoms

IMPAIRMENT

• Nighttime awakenings

• Interference with normal activity

• Short-acting beta2-agonist use for symptom control

• Lung function

• Validated questionnaires*

RISK

• Exacerbations requiring oral systemic corticosteroids

• Progressive loss of lung function

• Treatement-related adverse effects

* Asthma Control Test (ACT).Derived from Figures 3-5b, 3-5c, Expert Panel Report 3; 75-77.


Initial and Ongoing TherapyMedications for asthma are categorized into two general classes: long-term control medication (inhaled corticosteroids) and quick-relief medication. Selection of medications includes consideration of the general mechanisms and role of the medication in therapy, delivery devices, and safety.• Long-termcontrolmedicationsareuseddailyto

achieveandmaintaincontrolofpersistentasthma.Themosteffectivearethosethatattenuatetheunderlyinginflammationcharacteristicofasthma.

• Quick-reliefmedicationsareusedtotreatacutesymptomsandexacerbations.

• Astepwiseapproachtotherapyisrecommended.See Tables 2 to 4 for therapy recommendations based on a step-wise approach.Thegoalofasthmatherapyistomaintainlong-termcontrolofasthmawiththeleastamountofmedication,therebyexposingthepatienttotheleastriskforadverseeffectsfrompharmacologictherapy.Accordingly,oncetherapyisinitiatedandthelevelofasthmacontrolisassessed,changescanbemadetotherapyaccordingtothisstepwiseapproach.Thisincludesstep-downtherapy,aswell.

• Forpatientsclassifiedwithintermittentasthma,treatmentwithshort-actingbronchodilatorsonanas-neededbasisisrecommended.

• Forpatientsclassifiedwithpersistentasthma,treatmentwiththelowest-steptherapythatwillcontrolsymptomsisrecommended.– Inhaledcorticosteroids(ICS)arethepreferredlong-

termcontroltherapy.Ingeneral,ICS’sarewelltoleratedandsafeattherecommendeddosages.

– TheadditionofLABA(salmeterolorformoterol)tothetreatmentofpatientswhorequiremorethanlow-doseICSalonetocontrolasthmaimproveslungfunction,decreasessymptoms,andreducesexacerbationsanduseofSABAforquickreliefinmostpatientstoagreaterextentthandoublingthedoseofICS’s.

– Instructpatientsintheuseofinhaledmedications,andreviewpatients’techniqueateverypatientvisit.

• TheAsthamaGuidelineDevelopmentTeam(GDT)stronglyendorsesthefollowing2010FDAstatements:

Useofalong-actingbeta-agonist(LABA)alonewithoutuseofalong-termasthmacontrolmedicationiscontra-indicatedinthetreatmentofasthma.

LABAsshouldnotbeusedinpatientswhoseasthmaisadequatelycontrolledonlow-ormedium-doseinhaledcorticosteroid(ICS).

LABAsshouldonlybeusedasadditionaltherapyforpatientswithasthmawhoarecurrentlytakingbutarenotadequatelycontrolledonalong-termasthmacontrolmedication,suchasanICS.

Onceasthmacontrolisachievedandmaintained,patientsshouldbeassessedatregularintervalsandstepdowntherapyshouldbegin(e.g.,discontinueLABA),ifpossiblewithoutlossofasthmacontrol,andthepatientshouldcontinuetobetreatedwithalong-termasthmacontrolmedication,suchasanICS.

AdditionallytheGDTrecommends:

Useforcedcombinationproductssuchasfluticasone/salmeterol(Advair),budesonide/formoterol(Symbicort),andmometasone/formoterol(Dulera)whenprescribingLABAsforallagegroupstoensuremedicationadherence.

ConsiderreferringpatientsofallageswhorequireLABAstoAllergyorPulmonologyforinitialandongoingevaluation.

ImmunotherapyConsidersubcutaneousallergenimmunotherapyforpatientswhohavepersistentasthmawhenthereisclearevidenceofarelationshipbetweensymptomsandexposuretoanallergentowhichthepatientissensitive.Evidenceisstrongestforuseofsubcutaneousimmunotherapyforsingleallergens,particularlyhousedustmites,animaldander,andpollen.Ifuseofallergenimmunotherapyiselected,itshouldbeadministeredonlyinaphysician’sofficewherefacilitiesandtrainedpersonnelareavailabletotreatanylife-threateningreactionthatcan,butrarelydoes,occur.


Comorbid ConditionsIdentify and treat comorbid conditions that may impede asthma management. If these conditions are treated appropriately, asthma control may improve. Comorbid conditions may include:

– AllergicBronchopulmonaryAspergillosis– GastroesophagealReflux– Obeseoroverweightpatients– ObstructiveSleepApnea– Rhinitisorsinusitis– Stressanddepression

Managing Special SituationsINTRODUCTIONPatientswhohaveasthmamayencountersituationsthatwillrequireadjustmentstotheirasthmamanagementtokeeptheirasthmaundercontrol.Specialsituationsdescribedinthissectioninclude:Exercise-InducedBronchospasm(EIB),Surgery,andPregnancy.

EXERCISE-INDUCEDBRONCHOSPASM(EIB)AnticipateEIBinallasthmapatients,especiallythosewithahistoryofcough,shortnessofbreath,chestpainortightness,wheezing,orenduranceproblemsduringexercise.Anexercisechallenge,inwhicha15%de-creaseinPEForFEV1(measuredbeforeandafterexerciseat5-minuteintervalsfor20to30minutes),willestablishthediagnosis.Animportantdimensionofadequateasthmacontrolisthepatient’sabilitytoparticipateinanyactivitywithoutexperiencingasthmasymptoms.Recommended treatments for EIB include:• Long-termcontroltherapy,ifappropriate.FrequentorsevereEIBmayindicatetheneedtoinitiateorstepuplong-termcontrolmedication.

• Pretreatmentbeforeexercise:

– Inhaledbeta2-agonistswillpreventEIBformorethan80%ofpatients.SABAusedshortlybeforeexercisemaybehelpfulfor2to3hours.LABAcanbeprotectiveupto12hours,butthereissomeshorteningofthedurationofprotectionwhenLABAisusedonadailybasis.FrequentorchronicuseofLABAaspretreatmentforEIBisdiscouraged,asitmaydisguisepoorlycontrolledpersistentasthma.

– LTRAs,withanonsetofactiongenerallyhoursafteradministration,canattenuateEIBinupto50%ofpatients.

– Awarm-upperiodbeforeexercisemayreducethedegreeofEIB.

– Amaskorscarfoverthemouthmayattenuatecold-inducedEIB.

SURGERYANDASTHMAPatientswhohaveasthmaareatriskforspecificcomplicationsduringandaftersurgery.Thesecomplicationsincludeacutebronchoconstrictiontriggeredbyintubation,hypoxemiaandpossiblehypercapnia,impairedeffectivenessofcough,atelectasis,andrespiratoryinfection,latex,andevensomeanestheticagents.Thelikelihoodofthesecomplicationsdependsontheseverityofthepatient’sairwayhyperresponsiveness,airflowobstruction,mucushypersecretions,latexsensitivity,andhistoryofpriorsurgeries,becausethelatterisariskfactorforbothlatexandanestheticagentsensitivities.

PREGNANCYANDASTHMAMaintainingadequatecontrolofasthmaduringpreg-nancyisimportantforthehealthandwell-beingofboththemotherandherbaby.Maternalasthmaincreasestheriskofperinatalmortality,preeclampsia,pretermbirth,andlow-birth-weightinfants.Moresevereasthmaisassociatedwithincreasedrisks,whilebetter-controlledasthmaisassociatedwithdecreasedrisks.Itissaferforpregnantwomenwhohaveasthmatobetreatedwithasthmamedicationsthantohaveasthmasymptomsandexacerbations.Monitoringandmakingappropriateadjustmentsintherapymayberequiredtomaintainlungfunctionand,hence,bloodoxygenationthatensuresoxygensupplytothefetus.

• Pregnantwomenwithasthmashouldbetreatedthesameasnon-pregnantasthmaticsexceptforthefollowingspecifications:– Budesonideisthepreferredinhaledcorticosteroid

(theonlycategoryBcorticosteroid).Ifthereisconcernaboutlosingasthmacontrolbyswitchinginhaledcorticosteroidsandapatient’sasthmaisalreadywellcontrolledonadifferentinhaledcorticosteroid,thereisnoneedtochangetobudesonide.

– Albuterolisthepreferredshort-actingbeta-agonist.

• Thereislittleexperiencewithleukotrienemodifiersinpregnancy.Ofthese,zileutonisnotrecommendedforuseinpregnancy;andzafirlukastandmontelukastshouldonlybeusedforotherwiserecalcitrantasthmathathasrespondedtothesemedicationspriortopregnancy.

Forpregnantwomendischargedafterhospitalizationforanacuteexacerbationoftheirasthma,aninhaledcorticosteroid,asneededinhaledshort-actingbeta-agonist,andanoralcorticosteroidarerecommended.


Managing ExacerbationsSevere exacerbations can be life threatening and can occur in patients at any level of asthma severity; i.e., intermittent, or mild, moderate, or severe persistent asthma (see Figure 2, 3).

Patientsathighriskofasthma-relateddeathrequirespecialattention—particularlyintensiveeducation,monitoring,andcare.Suchpatientsshouldbeadvisedtoseekmedicalcareearlyduringanexacerbation.

Riskfactorsforasthma-relateddeathinclude:– Previoussevereexacerbation

(e.g.,intubationorICUadmissionforasthma).– Twoormorehospitalizationsor>3EDvisitsinthe

pastyear.– Useof>2canistersofSABApermonth.– Difficultyperceivingairwayobstructionortheseverity

ofworseningasthma.– Lowsocioeconomicstatusorinner-cityresidence.– Illicitdruguse.– Majorpsychosocialproblemsorpsychiatricdisease.– Comorbidities,suchascardiovasculardiseaseor

otherchroniclungdisease.

HOME MANAGEMENT• Earlytreatmentbythepatientathomeisthebest

strategyformanagingasthmaexacerbations.Instructpatientsonthefollowing:– Useawrittenasthmaactionplanthatnoteswhen

andhowtotreatsignsofanexacerbation.Apeakflow-basedplanmaybeparticularlyusefulforpatientswhohavedifficultyperceivingairflowobstructionorhaveahistoryofsevereexacerbations.

– Recognizeearlyindicatorsofanexacerbation,includingworseningPEF.

– AdjusttheirmedicationsbyincreasingSABAand,insomecases,addingashortcourseoforalsystemiccorticosteroids.DoublingthedoseofICS’sisnoteffective.

– Removeorwithdrawfromallergensorirritantsintheenvironmentthatmaycontributetotheexacerbation.

– MonitorresponsetotreatmentandpromptlycommunicatewiththeclinicianaboutanyseriousdeteriorationinsymptomsorPEForaboutdecreasedresponsivenesstoSABAtreatment,includingdecreaseddurationofeffect.

– Thefollowinghomemanagementtechniquesarenotrecommendedbecausenostudiesdemonstratetheireffectivenessandtheymaydelaypatientsfromobtainingnecessarycare:drinkinglargevolumesofliquids;breathingwarm,moistair;orusingover-the-counterproducts,suchasantihistaminesorcoldremedies.Pursed-lipandotherformsofbreathingmayhelptomaintaincalm,butthesemethodsdonotimprovelungfunction.

Asthma Self-Management & Education• Ongoingpatienteducation,includingcomponentsof

clinicianfollow-up,monitoring,reinforcement,andadherencestrategiesisrecommendedforimprovingasthmacontrol.

• Continuingeducationforprovidersisrecommendedforimprovingasthmacontrol.

• Writtenactionplans(peakflowand/orsymptombased)aspartofanoverallefforttoeducatepatientsinself-managementarerecommended,especiallyforpatientswhoarenotcontrolledonlong-termcontrollermedicationandpatientswithahistoryofsevereexacerbations.

Thegoaloftheactionplanistoprovideinformationonthetimingandmethodofincreasingtreatment,thedurationandwhenandhowtoseekmedicalhelp.


Figure 1: SUMMARY OF RECOMMENDED KEY CLINICAL ACTIVITIES FOR THE DIAGNOSIS AND MANAGEMENT OF ASTHMA

CLINICALISSUE

KEYCLINICALACTIVITIES

ACTIONSTEPS

MANAGINGASTHMALONGTERM

GOALOFASTHMATHERAPYISASTHMACONTROL:

• Reduce impairment (prevent chronic symptoms, require infrequent use of short-acting beta2-agonist (SABA), maintain (near) normal lung function and normal activity levels).

• Reduce risk (prevent exacerbations, minimize need for emergency care or hospitalization, prevent loss of lung function, or for children, prevent reduced lung growth, have minimal or no adverse effects of therapy).

FOUR COMPONENTS OF CARE

ASSESSMENT AND MONITORING

Assess asthma severity to initiate therapy.

Assess asthma control to monitor and adjust therapy.

Use severity classification chart, assessing both domains of impairment and risk, to determine initial treatment.

Use asthma control chart, assessing both domains of impairment and risk, to determine if therapy should be maintained or adjusted (step up if necessary, step down if possible).

Use multiple measures of impairment and risk: different measures assess different manifestations of asthma; they may not correlate with each other; and they may respond differently to therapy. Obtain lung function measures by spirometry at least every 1 to 2 years, more frequently for not-well-controlled asthma.

Schedule follow-up care.

Asthma is highly variable over time, and periodic monitoring is essential. In general, consider scheduling patients at 2- to 6-week intervals while gaining control; at 1 to 6 month intervals, depending on step of care required or duration of control, to monitor if sufficient control is maintained; at 3-month intervals if a step down in therapy is anticipated.

Assess asthma control, medication technique, written asthma action plan, patient adherence and concerns at every visit.

EDUCATION Provide self-management education.

Teach and reinforce:• Self-monitoring to assess level of asthma control and signs of worsening

asthma (either symptom or peak flow monitoring shows similar benefits for most patients). Peak flow monitoring may be particularly helpful for patients who have difficulty perceiving symptoms, a history of severe exacerbations, or moderate or severe asthma.

• Using written asthma action plan (review differences between long-term control and quick-relief medication).

• Taking medication correctly (inhaler technique and use of devices).• Avoiding environmental factors that worsen asthma.

Tailor education to literacy level of patient. Appreciate the potential role of a patient’s cultural beliefs and practices in asthma management.

Develop a written asthma action plan in partnership with patient.

Integrate education into all points of care where health professionals interact with patients.

Agree on treatment goals and address patient concerns.

Provide instructions for (1) daily management (long-term control medication, if appropriate, and environmental control measures) and (2) managing worsening asthma (how to adjust medication, and know when to seek medical care).

Involve all members of the health care team in providing/reinforcing education, including physicians, nurses, pharmacists, respiratory therapists, and asthma educators.

Encourage education at all points of care: clinics (offering separate self-management education programs as well as incorporating education into every patient visit), Emergency Departments and hospitals, pharmacies, schools and other community settings, and patients’ homes.

Use a variety of educational strategies and methods.

Source: National Heart, Lung, and Blood Institute. Expert panel report 3: guidelines for the diagnosis and management of asthma—full report 2007. August 28, 2007. Available at: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed August 29, 2007.


Figure 2: CLASSIFYING SEVERITY OF ASTHMA EXACERBATIONS IN THE URGENT OR EMERGENCY CARE SETTING

Note: Patients are instructed to use quick-relief medications if symptoms occur or if PEF drops below 80% predicted or personal best. If PEF is 50% to 79%, the patient should monitor response to quick-relief medication carefully and consider contacting a clinician. If PEF is below 50%, immediate medical care is usually required. In the urgent or emergency care setting, the following parameters describe the severity and likely clinical course of an exacerbation.

SYMPTOMSANDSIGNS

INITIALPEF(ORFEV1) CLINICALCOURSE

MILD Dyspnea only with activity (assess tachypnea in young children)

PEF ≥ 70% predicted or personal best

• Usually cared for at home

• Prompt relief with inhaled SABA

• Possible short course of oral systemic corticosteroids

MODERATE Dyspnea interferes with or limits usual activity

PEF 40% to 69% predicted or personal best

• Usually requires office or ED visit

• Relief from frequent inhaled SABA

• Oral systemic corticosteroids; some symptoms last for 1 to 2 days after treatment is begun

SEVERE Dyspnea at rest; interferes with conversation

PEF < 40% predicted or personal best

• Usually requires ED visit and likely hospitalization

• Partial relief from frequent inhaled SABA

• Oral systemic corticosteroids; some symptoms last for > 3 days after treatment is begun

• Adjunctive therapies are helpful

SUBSET: LIFE

THREATENING

Too dyspnoeic to speak; perspiring

PEF < 25% predicted or personal best

• Requires ED/hospitalization; possible ICU

• Minimal or no relief from frequent inhaled SABA

• Intravenous corticosteroids

• Adjunctive therapies are helpful

KEY: ED, emergency department; FEV1, forced expiratory volume in 1 second; ICU, intensive care unit; PEF, peak expiratory flow; SABA, short-acting beta2-agonist


FIGURE 3: MANAGEMENT OF ASTHMA EXACERBATIONS: EMERGENCY DEPARTMENT AND HOSPITAL-BASED CARE


Table 2: CLASSIFYING ASTHMA SEVERITY AND INITIATING THERAPY IN ADULTS

COMPONENTSOFSEVERITY INTERMITTENTPERSISTENT

MILD MODERATE SEVERE

Impairment

Normal FEV1/FVC:

8-19 yr 85%20-39 yr 80%40-59 yr 75%60-80 yr 70%

Symptoms ≤ 2 days/week> 2 days/week but not daily

Daily Thoughout the day

Nighttime awakenings

≤ 2x/month 3-4x/month> 1x/week but not

nightlyOften 7x/week

Short-acting beta2-agonist use

for symptom control (not prevention of

EIB)

≤ 2 days/week> 2 days/week but not daily

DailySeveral times per

day

Interference with normal activity

None Minor limitation Some limitation Extremely limited

Lung Function

FEV1FEV1/FVC

Normal FEV1 between

exacerbations> 80%Normal

> 80%Normal

60% - 80%Reduced 5%

< 60%Reduced > 5%

Risk

Exacerbations requiring

oral systemic corticosteroids

0-1/year ≥ 2x/year

Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity class.

Recommended Step for Initiating Therapy

Step1 Step2 Step3 Step4or5

Re-evaluate control in 2 to 6 weeks and adjust therapy accordingly.

Table 3: ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN ADULTS

COMPONENTSOFCONTROLCLASSIFICATION OF ASTHMA CONTROL

WELL-CONTROLLED NOT WELL-CONTROLLED VERY POORLY CONTROLLED

Impairment

Normal FEV1/FVC:

8-19 yr 85%20-39 yr 80%40-59 yr 75%60-80 yr 70%

Symptoms ≤ 2 days/week > 2 days/week but not daily Throughout the day

Nighttime awakenings

≤ 2x/month 1-3x/week ≥ 4x/week

SABA Use for symptoms

≤ 2 days/week > 2 days/week Several times per day

Interference with normal activity

None Some limitation Extremely limited

FEV1 or peak flow > 80% 60% to 80% < 60%

ACT Questionnaire ≥ 20 16 to 19 ≤ 15

Risk

Exacerbations requiring oral steroids

0 to1/year ≥ 2/year

Progressive loss of lung function

Evaluation requires long-term follow-up care.

Treatment-related adverse effects

Intensity of medication side effects does not correlate to specific levels of control, but should be considered in the overall assessment of risk.

Recommended Action for Treatment

• Maintain current step.• Regular follow-up

every 1 to 6 months.• Consider step down

if well-controlled for ≥ 3 months.

• Step up 1 step.• Re-evaluate in 2 to 6

weeks.

• Consider oral steroids.• Step up 1 to 2 steps.• Re-evaluate in 2 weeks.

Source for both tables: National Heart, Lung, and Blood Institute. Expert panel report 3: guidelines for the diagnosis and management of asthma— full report 2007. August 28, 2007. Available at: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed August 29, 2007.


Table 4: STEPWISE APPROACH FOR MANAGING ASTHMA ADULTS

Quick Relief Medication for All Patients: SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20 minute intervals as needed. Short course of systemic oral corticosteroids may be needed. Use of SABA > 2 days a week for symptom control (but not prevention of EIB) indicates inadequate control and the need to step up treatment.

INTERMITTENTASTHMA

PERSISTENTASTHMA:DAILYMEDICATIONCONSULTWITHASTHMASPECIALISTIFSTEP4CAREORHIGHERISREQUIRED.

CONSIDERCONSULTATIONATSTEP3.

Step 6

Preferred:

Combinationtherapywith

Medium-doseICSplusoral

corticosteroidAND

ConsiderOmailzumabfor

patientswhohaveallergies

Step 5

Preferred:


Medium-doseICSAND

ConsiderOmailzumabfor

patientswhohaveallergies

CONSIDERCONSULTATIONATSTEP3.Step 4

Preferred:


Medium-doseICS

Alternative:Medium-doseICS

pluseitherLTRA,

Theophylline,orZileuton

Step 3

Preferred:

Low-doseICSplusLABA

ORCombinationtherapywith

Low-doseICSOR

Low-DoseICSplusLTRA

ORTheophyllineor

MediumDoseICS

Alternative:Low-doseICS

pluseitherLTRA,Theophylline,or

Zileuton

Step 2

Preferred:Low-doseICS

Alternative:Cromolyn,LTRA,Nedocromil,orTheophylline

Step 1

Preferred:

SABAPRN

Patient Education and Environmental Control at Each Step

Source: National Heart, Lung, and Blood Institute. Expert panel report 3: guidelines for the diagnosis and management of asthma—full report 2007. August 28, 2007. Available at: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed August 29, 2007.


TABLE 5: Estimated Comparative Daily Dosages for ICS (NHLBI)

Drug LowDailyDose MediumDailyDose HighDailyDoseBeclomethasoneHFA,40 or 80 mcg/puff 80 - 240 mcg >240 - 480 mcg >480 mcg

BudesonideDPI.(FG)180 mcg/inhalation 180 - 600 mcg >600 - 1,200 mcg >1,200 mcg

Flunisolide,(NF)80 mcg/puff 320 mcg >320 - 640 mcg >640 mcg

FluticasoneHFA,†44, 110, or 220 mcg/puff 88 - 264 mcg >264 - 440 mcg >440 mcg

Mometasone,(FG) 110, 220 mcg/inhalation 220 mcg 440 mcg >440 mcg

Ciclesonide MDI, (NF)80 and 160 mcg 80 - 160 mcg >160 - 320 mcg >320 mcg† 110 & 220 mcg/puff strengths of Fluticasone HFA are Non-Formulary. FG = Formulary with Guidelines; NF = Non-Formulary

Table 6: Usual Dosages for Quick-Relief Medications (NHLBI)

Medication AdultDose PotentialAdverseEffects Comments

InhaledShort-ActingBeta2-AgonistsAlbuterol

90 mcg/puff, 200 puffs/canister

2 puffs every 4 to 6 hours, as needed for

symptoms

• Tachycardia, skeletal muscle tremor, hypokalemia, increased lactic acid, headache, hyperglycemia.

• Inhaled route, in general, causes few systemic adverse effects.

• Patients with preexisting cardiovascular disease, especially the elderly, may have adverse cardiovascular reactions with inhaled therapy.

• Drugs of choice for acute bronchospasm.

• Differences in potencies exist, but all products are essentially comparable on a per puff basis.

• An increasing use or lack of expected effect indicates diminished control of asthma.

• Not recommended for long-term daily treatment. Regular use exceeding 2 days/week for symptom control (not prevention of EIB) indicates the need for additional long-term control therapy.

• May double usual dose for mild exacerbations.

• For HFA: periodically clean HFA actuator, as drug may plug orifice.

Nebulizer solution 2.5 mg/3 mL (0.083%)

2.5 mg 3 to 4 times

daily as needed

Levalbuterol HFA NF



symptoms

Nebulizer solution 0.31 mg/3 mL, 0.63 mg/3 mL 1.25 mg/3 mL

0.63 to 1.25 mg every 3 to 4

times daily as needed

Pirbuterol CFC†



symptoms

AnticholinergicsIpratropium17 mcg/puff,

200 puffs/canister

2 puffs 3 to 4 times

daily as needed for symptoms

• Drying of mouth and respiratory secretions, increased wheezing in some individuals, blurred vision if sprayed in eyes.

• If used in the ED, produces less cardiac stimulation than SABAs.

• Treatment of choice for bronchospasm due to beta-blocker medication.

• Does not block EIB.

• Reverses only cholinergically mediated bronchospasm; does not modify reaction to antigen.

• May be an alternative for patients who do not tolerate SABA.

• Has not proven to be efficacious as long-term control therapy for asthma.

Nebulizer solution500 mg/mL 2.5 mL

500 mg every 6 hours as needed for

symptoms

Ipratropium with albuterol18 mcg/puff of

ipratropium & 90 mcg/puff of

albuterol 200 puffs/canister

2 puffs 3 to 4 times

daily as needed for symptoms

NF=Non-Formulary;†Non-Formulary,oncommercialformularyinsomeregions.


Table 7: Usual Dosages for Long-Term Controller Medications (NHLBI)MEDICATION/DOSAGEFORM ADULTDOSE COMMENTS

SystemicCorticosteriodsMethylprednisolone2,4,8,16,32mgtablets

7.5to60mgpodailyinasingledoseina.m.orqodasneededforcontrol.

Short-course“burst”toachievecontrol,40to60mgpoperdayassingledoseor2divideddosesfor3to10days

• For long-term treatment of severe persistent asthma, administer single dose in a.m. either daily or on alternate days (alternate-day therapy may produce less adrenal suppression).

• Short courses or “bursts” are effective for establishing control when initiating therapy or during a period of gradual deterioration.

• There is no evidence that tapering the dose following improvement in symptom control and pulmonary function prevents relapse.

• For patients unable to tolerate the liquid preparations, dexamethasone syrup at 0.4 mg/kg/day may be an alternative. Studies are limited, however, and the longer duration of activity increases the risk of adrenal suppression.

Prednisolone5mgtablets,5mg/5mL,15mg/5mL

Prednisone1,2.5,5,10,20,50mgtablets;5mg/5mL*

Long-ActingInhaledBeta-Agonists(Shouldnotbeusedforacuterelieforexacerbations.Usewithcorticosteroids.)

Salmeterol(FG)

DPI50mcg/dose50 mcg INH q 12 hours

For both Salmeterol and Formoterol• Should not be used for acute symptom relief or exacerbations.

Use only with ICS’s. Consider prescribing Advair.• Decreased duration of protection against EIB may occur with regular use. • Do not blow into inhaler after dose is activated.For Formoterol only• Each capsule is for single use only; additional doses should not be administered

for at least 12 hours. • Capsules should be used only with the inhaler and should not be taken orally.

Formoterol(NF)

DPI12mcg/single-usecapsule

12 mcg INH q 12 hours

CombinedMedicationFluticasone/Salmeterol(FG)

DPI100/50,250/50,or500/50

MDI45/21,115/21,230/21(NF)

1inhalationbid;dosedependsonseverityofasthma

2puffsbid

• Do not blow into inhaler after dose is activated.• 100/50 DPI for patients who have asthma not controlled on low- to medium-dose ICS.• 250/50 DPI for patients who have asthma not controlled on medium- to high-

dose ICS.

Budesonide/Formoterol(NF)

MDI80/4.5or160/4.52puffsbid;dosedependsonseverityofasthma

• 80/4.5 for patients who have asthma not controlled on low- to medium-dose ICS.• 160/4.5 for patients who have asthma not controlled on medium- to high-dose ICS.

Mometasone/Formoterol(NF)

MDI100/5,200/52puffsbid;dosedependsonseverityofasthma

• 100/5 for patients who have asthma not controlled on low- to medium-dosed ICS.• 200/5 for patients who have asthma not controlled on high-dosed ICS.

LeukotrieneModifiers

Montelukast†(NF)

4mgor5mgchewabletablet,4mggranule packet,10mgtablet

10mgqhs • Montelukast exhibits a flat dose-response curve. Doses > 10 mg will not produce a greater response.

• As long-term therapy may attenuate exercise-induced bronchospasm in some patients, but less effective than ICS therapy.

Zafirlukast(NF)

10or20mgtablet20mgpobid • For zafirlukast, administration with meals decreases bioavailability; take at least

1 hour before or 2 hours after meals.• Zarfirlukast is a microsomal P450 enzyme inhibitor that can inhibit the

metabolism of warfarin. Doses of these drugs should be monitored accordingly.• Monitor hepatic enzymes (ALT). Warn patients to discontinue use if they

experience signs and symptoms of liver dysfunction.

Zileuton(NF)

600mgtablet1200mgpobid • Monitor hepatic enzymes (ALT).

• Zileuton is a microsomal P450 enzyme inhibitor that can inhibit the metabolism of warfarin and theophylline. Doses of these drugs should be monitored accordingly.

MethylxanthinesTheophyllineLiquids,sustained-releasetablets,andcapsules

Startingdose10mg/kg/day,upto300mgmax;usualmax800mg/day

• Adjust dosage to achieve serum concentration of 5 to 15 mcg/mL at steady state (at least 48 hours on same dosage).

• Due to wide interpatient variability in theophylline metabolic clearance, routine serum theophylline level monitoring is essential.

• Patients should be told to discontinue if they experience toxicity.• Various factors (diet, food, febrile illness, age, smoking, and other medications)

can affect serum concentrations. See EPR—3 Full Report 2007 and package inserts for details.

NF=Non-Formulary;FG=FormularywithGuidelines†Commercial:Non-FormularywithRestrictionsandGuidelines,MedicarePartD:Formulary

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