Asthma - Treatment

1. Asthma - Treatment UCI internal medicine mini-lecture series By Kevin Cook

2. Objectives • Understand severity scoring vs. control in guiding the treatment of asthma • Discuss the utility of the “asthma ladder” in step up and step down therapy • Introduce new therapies used in patients with refractory asthma

3. Asthma Severity vs. Control • Severity - the intrinsic intensity of the disease process • Dictates which step to initiate treatment • Intermittent symptoms require rescue medication • Persistent symptoms require controller medication • Control - the degree to which the goals of therapy are met • prevent symptoms/exacerbations, maintain normal lung function and activity levels

4. Assessing Severity All patients classified in a “persistent” asthma category will require initiation of controller medications

5. Assessing Control - The Asthma Ladder Step Up Therapy Persistent Asthma Step Down Therapy Intermittent Asthma

6. Assessing Control – Should I Step Up?

7. Case Study A 24 y/o patient with mild persistent asthma was initially well controlled with low dose inhaled corticosteroid. Today he returns for follow up.  He is now complaining of increasingly frequent episodes of shortness of breath, using his short-acting beta agonist 3 times per week.  Which of the following statements is correct regarding management of this patient?  a) continue current management as symptoms require beta agonist less than once daily b) add a long acting beta agonist c) increase to medium dose inhaled corticosteroid d) add tiotropium e) B or C

8. Assessing Control – Should I Step Up?

9. Assessing Control - The Asthma Ladder Step Up Therapy Persistent Asthma Step Down Therapy Intermittent Asthma

10. Case Study A 24 y/o patient with mild persistent asthma was initially well controlled with low dose inhaled corticosteroid. Today he returns for follow up.  He is now complaining of increased shortness of breath and using his short-acting beta agonist 3 times per week.  Which of the following statements is correct regarding management of this patient?  a) continue current management as symptoms require beta agonist less than once daily b) add a long acting beta agonist c) increase to medium dose inhaled corticosteroid d) add tiotropium e) B or C

11. On step 6 and still not well controlled? • Alternative diagnoses such as COPD, left ventricular failure, localized obstruction, cystic fibrosis and/or vocal cord dysfunction should be ruled out • Omalizumab - anti-IgE therapy in patients with allergic asthma (works by binding IgE so that it cannot complex with allergens to stimulate immune cells • Bronchial thermoplasty – heat applied directly to the airways by bronchoscopy to reduce the airway smooth muscle mass and attenuate bronchoconstriction

12. Summary • Initial treatment of asthma requires assessment of severity • Longitudinal treatment requires assessment of control with the use of the “asthma ladder” for step up and step down therapy • Persistent symptoms require controller medication: start with ICS and add LABA if still not controlled • Seek consultation if high dose ICS are required

13. References • National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug.Available from: http://www.ncbi.nlm.nih.gov/books/NBK7232/ • Scialla, Timothy. “Asthma Summary 2013”. Hopkins Modules.