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Use of Medications in Asthma

Use of Medications in Asthma. Cyril Grum, M.D. Department of Internal Medicine. *Based on the University of Michigan Guidelines for Clinic Care and the National Asthma Education and Prevention Progam (NAEPP) 2002 Update. Recommended therapies are based on clinical severity.

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Use of Medications in Asthma

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  1. Use of Medications in Asthma Cyril Grum, M.D. Department of Internal Medicine *Based on the University of Michigan Guidelines for Clinic Care and the National Asthma Education and Prevention Progam (NAEPP) 2002 Update

  2. Recommended therapies are based on clinical severity • See Powerpoint presentation on “Diagnosing and Staging Asthma” for background

  3. Regimens for long-term control of asthma

  4. Children 5 years and under-1 • Step 1 (mild, intermittent) • No daily medications indicated • Step 2 (mild, persistent) • Preferred treatment: Low-dose inhaled corticosteroids (with nebulizer or MDI with holding chamber with or without face mask or DPI). • Alternative treatment (listed alphabetically): • Cromolyn (nebulizer is preferred or MDI with holding chamber) • Leukotriene receptor antagonist.

  5. Children 5 years and under-2 • Step 3 (moderate persistent) • Preferred treatments: • Low-dose inhaled corticosteroids AND long-acting inhaled b2-agonists • Medium-dose inhaled corticosteroids. • Alternative treatment: • Low-dose inhaled corticosteroids AND either leukotriene receptor antagonist or theophylline. • In patients with recurring severe exacerbations: • Medium-dose inhaled corticosteroids AND • long-acting b2-agonists (preferred), OR • leukotriene receptor antagonist (alternate) OR • theophylline (alternate)

  6. Children 5 years and under-3 • Step 4 (severe, persistent), preferred treatment: • High-dose inhaled corticosteroids PLUS • Long-acting inhaled b2-agonists AND if needed, • Corticosteroid tablets or syrup long term (2 mg/kg/day, but not >60 mg/day, with repeat attempts to reduce systemic corticosteroids

  7. Adults and Children >5 years - 1 • Step 1 (mild, intermittent) • No medications are recommended • If severe exacerbations occur infrequently, separated by asymptomatic intervals --> oral corticosteroids • Step 2 (mild, persistent) • Preferred treatment: Low-dose inhaled corticosteroids. • Alternative treatments (listed alphabetically) • cromolyn or nedocromil, OR • leukotriene modifier, OR • sustained release theophylline to serum conc. of 5–15 mcg/mL.

  8. Adults and Children >5 years - 2 • Step 3 (moderate, persistent) • Preferred treatment: • Low-to-medium dose inhaled corticosteroids AND long-acting inhaled b2-agonists • Alternative treatments (listed alphabetically): • Increase inhaled corticosteroids within medium-dose range • Low-to-medium dose inhaled corticosteroids AND either leukotriene modifier OR theophylline. • In patients with recurring severe exacerbations: • Add long-acting b2-agonists (preferred), OR • Increase inhaled corticosteroid to medium-dose range (alternate), OR • leukotriene receptor antagonist (alternate) OR • theophylline (alternate)

  9. Adults and Children >5 years - 3 • Step 4 (severe, persistent) • High-dose inhaled corticosteroids AND • Long-acting inhaled b2-agonists AND (if needed) • Oral corticosteroids 2 mg/kg/day, up to 60 mg per day, with repeated attempts to reduce systemic corticosteroids.

  10. Medications and dosing: selected corticosteroid inhalers

  11. Medications and dosing: Bronchodilators and mast cell stabilizers

  12. Medications and dosing: Oral medications

  13. Regimens for quick relief of acute symptoms

  14. Quick relief of acute symptoms in children age 5 and under • Bronchodilator prn. Intensity of rx depends on severity. • Preferred rx: Short-acting, inhaled b2-agonist, by nebulizer or face mask and space/holding chamber • Alternative rx: Oral b2-agonist • With viral respiratory infection • Bronchodilator q4–6 hours up to 24 hours (longer with physician consult); do not repeat < q6 weeks • Consider systemic corticosteroid if severe or patient has hx of previous severe exacerbations

  15. Quick relief of acute symptoms in adults and children > age 5 • Short-acting bronchodilator: 2–4 puffs short-acting inhaled b2-agonists as needed for symptoms. • Intensity of treatment depends on severity; up to 3 treatments at 20-minute intervals or a single nebulizer treatment as needed. • A course of systemic corticosteroids may be needed.

  16. A note on intensity of treatment for acute symptoms in all age groups • Excessive use of short-acting b2-agonists may indicate a need to increase long-term-control therapy • Defined as: • >2 times a week in intermittent asthma • daily or increasingly in persistent asthma

  17. Emergency room or in-hospital treatment

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