CLINICAL PRACTICE GUIDELINE

Guideline Number: DHMP_DHMC_CG1007 Effective Date: 7/2014

Guideline Subject: Management of Asthma in Adults and Children Revision Date: 7/2016

Pages: 1 of 2 Obsoletes: 1/99, 3/01, 3/04, 7/04, 9/05, 9/06, 09/07, 12/09, 12/11, 02/12

___________________________________________________ Quality Management Committee Chair Date

NOTE: This guideline is designed to assist providers by providing an analytical framework for the evaluation and treatment of patients, and is not intended either to replace a clinicians judgment or to establish a protocol for all patients with a particular condition.

Rationale: Asthma, which can lead to COPD, is among the 10 leading chronic conditions in the United States (U.S.), which restrict activity and contribute to illness in children. Presently, asthma continues to remain a rapidly growing health problem, with more than 22 million persons in the U.S. diagnosed with the condition. Annually, asthma contributes to a significant number of hospitalizations and deaths as well as frequent emergency department visits. An important aspect of management of asthma includes the use of inhaled anti-inflammatory agents, smoking cessation among patients and their families and proper education about self-management, long-term control medications and rescue drugs.

I. PURPOSE: To define the care for management of Asthma in Adults and Children. The long-term goals of asthma management are to achieve good symptom control, minimize future risk of exacerbations, maintain normal lung function and sustain normal activity levels.

II. POPULATION:

All currently enrolled Denver Health Medical Plan, Inc. (DHMP) and Denver Health Medicaid Choice (DHMC) members. DHMP and DHMC, for the rest of the guideline, will be represented as the Company.

III. GUIDELINE:

The Company supports the National Heart, Lung and Blood Institute (NHLBI), Denver Health Ambulatory Care Services (ACS) and Health TeamWorks nationally-defined protocols and algorithms for the appropriate tiere management and strategies for members with sustained reactive airways disease or asthma. The use of specific medications will be in accord with Company formulary. Each patient should be assessed to establish his/her current treatment regimen, adherence to the current regimen, and level of asthma control:

a) Conduct interval evaluations of asthma including medical history and physical examination,

assessment of asthma triggers and allergens, measurement of pulmonary function, and consideration of consultation and/or allergy testing.

b) Assess control using objective measures and a validated asthma control tool. c) Match therapy with asthma control. d) Provide asthma education to patients and parents of pediatric patients. Education should include

basic facts about asthma, how medications work, inhaler technique, a written action plan including home peak flow rate monitoring or a symptom diary, environmental control measures, and emphasis on the need for regular follow-up visits. (Clinical highlights ICSI, July 2012)

CLINICAL PRACTICE GUIDELINE

Guideline Number: DHMP_DHMC_CG1007 Effective Date: 7/2014

Guideline Subject: Management of Asthma in Adults and Children Revision Date: 7/2016

Pages: 2 of 2 Obsoletes: 1/99, 3/01, 3/04, 7/04, 9/05, 9/06, 09/07, 12/09, 12/11, 02/12

___________________________________________________ Quality Management Committee Chair Date

NOTE: This guideline is designed to assist providers by providing an analytical framework for the evaluation and treatment of patients, and is not intended either to replace a clinicians judgment or to establish a protocol for all patients with a particular condition.

e) Develop a Doctor-Patient Partnership to achieve guided self-management of asthma Giving people the ability to control their own asthma is associated with improved clinical outcomes. Key components include:

• Joint goal setting by provider and patient • Education - teaching by health care team with frequent reinforcement. Key components

include: o Recognition of early signs of worsening asthma and a prompt symptom response plan o Medications (actions, benefits, side effects, difference between “relievers” and

“controllers”) o Proper use of inhalers o Home allergen control

• Self-monitoring (regular use of either symptom-based or peak flow monitoring are effective) • Regular health care visits to review asthma control, treatment, and self-management skills • Written action plan that integrates self-monitoring with evidence-based management for both

long-term control of asthma and treatment of acute exacerbations. (NHLBI)

IV. ATTACHMENTS: A. Health TeamWorks Asthma Guideline: Asthma Management for Children and Adults (age 5+ yrs) March 2013 B. Denver Health CHS Adult Asthma Care Guideline CCG-26.016, 2013

V. REFERENCES:

A. National Heart Lung and Blood Institute NAEPP. Expert Panel Report 3 (EPR-3): Guidelines for the diagnosis and management of asthma. In: Services USDoHH, ed. Bethesda 2007. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

B. Health TeamWorks Asthma Guidelines: http://www.healthteamworks.org/guidelines/asthma.html

i. (Most current information) C. Denver Health CHS Adult Asthma Care Guideline CCG-26.016, 2013

Sveum R et al. Institute for Clinical Systems Improvement (ICSI). Diagnosis and Management of Asthma. Updated July 2012. Available at: https://www.icsi.org/_asset/rsjvnd/Asthma.pdf

1. Consider the diagnosis of asthma if symptoms include: recurrent coughing, wheezing or shortness of breath relieved by a bronchodilator.

2. Spirometry: ≥12% increase of FEV1 post-bronchodilator.

3. Consider co-morbidities or alternate diagnosis, especially if poor control: GERD, aspiration, airway anomaly, foreign body, cystic fibrosis, vocal cord dysfunction, tobacco/secondhand smoke exposure, or COPD. GERD is a common co-morbidity.

4. If diagnosis in doubt, consult with an asthma specialist.

Asthma Management for Children and Adults (age 5+ yrs)Good asthma control reduces the risk of exacerbations and long-term pulmonary damage.page 1 of 2

Make the Diagnosis

Criterion Well-Controlled Not Well-Controlled Very Poorly ControlledDaytime symptoms ≤2 days/week >2 days/week Throughout the day

Nighttime awakenings ≤2 times/month 1-3 times/week ≥4 times/night

Limitation of activities None Some limitation Extremely limited

Short-acting beta2-agonist use for symptom control (not prevention of EIB)

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

Asthma Control Test (ACT)† Score of ≥20 Score of 16-19 Score of ≤15

Courses of prednisone in last year <2 ≥2 ≥2

Spirometry ‡FEV1

% predicted >80% predicted or personal best 60-80% predicted or personal best <60% predicted or personal best

FEV1/FVC ratio Normal ratio for age ≤5% decrease in ratio for age >5% decrease in ratio for age

FEV1/FVC:

5-19 yrs ≥ 85%

20-39 yrs ≥ 80%

40-59 yrs ≥ 75%

60-80 yrs ≥ 70%

Follow the Stepwise Approach Guideline (see page 2).

Consider step down if well-controlled for 3 consecutive months.

Re-assess every 1 to 6 months.

If Well-Controlled:Follow the Stepwise Approach Guideline. If initial visit, start at

Step 2. Step up until well-controlled. Re-assess in 2 to 6 weeks. For

side effects, consider alternative treatment.

If Not Well-Controlled:

Consider course of prednisone (1-2 mg/kg, daily max 60 kg). If initial visit, start at Step 2. Step up 1-2

steps using Stepwise Approach Guideline. Re-assess in 2 weeks.

If Very Poorly Controlled:

Assess Asthma Control (determination of level of control is dictated by the criterion at the lowest level of control)

••

• Check adherence and address possible poor adherence to medication.• Review environmental factors: e.g., pets, cigarette smoke, perfume, allergy

season, respiratory infection.• Provide self-management education.• Develop and review a written asthma control plan in partnership with the

patient.

• Integrate education into all points of care where healthcare professionals interact with patient.

• Review inhaler technique. Encourage use of spacers with all MDIs.• Treat co-morbid conditions: rhinitis and sinusitis, obesity, gastroesophageal

reflux, obstructive sleep apnea, stress, depression or anxiety, allergic bronchopulmonary aspergillosis.

Other Things to Consider at Every Visit

†For the full ACT go to www.healthteamworks.org/guidelines/asthma.html‡ Spirometry is suggested annually and/or any time the clinical picture changes or does not make sense.

1. Asthma is a variable disease and needs to be assessed at every visit.

2. Use the Assess Asthma Control box to guide your assessment and make treatment decisions.

3. The goal of asthma therapy is to keep the patient in control as much as possible with the least amount of medication.

4. If at the first visit the patient is not well-controlled (see below), begin controller therapy. A patient should be diagnosed with Persistent Asthma if he/she needs a daily controller medication to stay in control.

Key Points of Assessment and Treatment

• If symptoms resolve without treatment after 5 minutes of rest, it is more likely poor conditioning.

• If EIB is unresponsive to albuterol and the patient has allergies, consider starting an inhaled steroid (see Stepwise Treatment table on page 2).

• If still unresponsive after starting inhaled steroid, refer to specialist.

Exercise-Induced Bronchospasm

(EIB)

If not well-controlled within 3-6 months using stepwise approach OR if 2 or more ED visits or hospitalizations for asthma in a year.

Consider Referral to a Specialist

Based on the NAEPP-EPR-3 (http://www.nhlbi.nih.gov/guidelines/asthma/) with some modifications. This guideline is designed to assist the clinician in the management of asthma. This guideline is not intended to replace the clinician’s judgment or establish a protocol for all patients with a particular condition. For references, additional copies of the guideline, or patient documents go to www.healthteamworks.org or call (303) 446-7200 or 866-401-2092. Revised 10/17/2012.

See page 2 for treatment.

Based on the NAEPP-EPR-3 (http://www.nhlbi.nih.gov/guidelines/asthma/) with some modifications. This guideline is designed to assist the clinician in the management of asthma. This guideline is not intended to replace the clinician’s judgment or establish a protocol for all patients with a particular condition. For references, additional copies of the guideline, or patient documents go to www.healthteamworks.org or call (303) 446-7200 or 866-401-2092. Revised 10/17/2012.

Asthma Stepwise ApproachGood asthma control reduces the risk of exacerbations and long-term pulmonary damage.

Step 1

Age 5+ years

Short-actingbeta-agonist (e.g.,

albuterol) PRN

If used more than 2 days per week (other

than for exercise) consider

inadequate controland the need to

step up treatment.

Step 2

Age 5+ years

Preferred:Low-dose inhaled

steroid

Alternative:Leukotriene blocker

or cromolyn

Step 3

Age 5+ years

Preferred:Low-dose inhaled

steroid + LABA

Alternative:Medium-doseinhaled steroid

-or-Low-dose

inhaled steroid +leukotriene blocker

Step 4

Age 5+ years

Preferred:Medium-dose

inhaled steroid +LABA

Alternative:Medium-dose

inhaled steroid + leukotriene blocker

Step 5

Age 5-11 years

Preferred:High-dose inhaled

steroid + LABA

Alternative:High-dose

inhaled steroid +leukotriene blocker

Age 12+ years

High-dose inhaledsteroid + LABA

-and-Consider

omalizumab ifallergies

Step 6

Age 5-11 years

Preferred:High-dose inhaled

steroid + LABA+

oral steroid

Alternative:High-dose

inhaled steroid + leukotriene blocker

+ oral steroid

Age 12+ years

High-dose inhaledsteroid + LABA+ oral steroid

-and-Consider

omalizumab ifallergies

IntermittentAsthma Persistent Asthma: Daily Medication

Consider immunotherapy if allergic asthma.

All ages Steps 4 through 6: Consider consult with an asthma specialist.

Step up as indicated, although address possible poor adherence to medication. Re-assess in 2 to 6 weeks.

Step down if well-controlled and re-assess in 3 months. If patient remains well-controlled then assess control every 1 to 6 months.

All long-acting beta-agonists (LABAs) and combination agents containing LABAs have a black-box warning.

page 2 of 2

Frequency of follow-up visits based on severity:• Step 1-2: 1-2x per year• Step 3-4: Every 6 months• Step 5-6: Every 3 months

Schedule Follow-Up Care

All ages Steps 3 through 6: Consider alternative therapy within step before stepping up.

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TITLE: OBSOLETES

NO: Dated:

CHS Adult Asthma Care Guideline --- ---

APPROVED: EFFECTIVE DATE:

01/11/2013

REVIEW DATE:

Philip S. Mehler, MD, Medical Director 01/11/2016

I. PURPOSE

Guidelines to control asthma are provided by the National Asthma Education and Prevention Program

Expert Panel Report 3 (EPR-3).B This document provides a framework to incorporate EPR-3 guidelines

into standard work for adult patients with asthma in Community Health Services (CHS).

II. INCLUSION / EXCLUSION CRITERIA

A. Inclusion: All patients 18 years of age and older who receive primary care services in a CHS

clinic at Denver Health (DH).

B. Exclusion: None

III. RESPONSIBILITY

CHS Primary Care Providers

CHS primary care clinic RNs

Pharmacists

IV. GUIDELINE

A. Diagnosis:

Asthma can be difficult to diagnose in the adult population as there are several conditions that

masquerade as asthma. Refer to Attachment A - Algorithm: CHS Asthma Care Clinical Process,

for an overview of the recommended process for approaching the patient with suspected or

known asthma.

Recommended methods to establish a diagnosis of asthma (per EPR-3) include the following:

1. Detailed medical history:

a. History of the Present Illness (HPI) – Assess for:

1) Episodic symptoms of airflow obstruction or airway responsiveness (e.g., episodic

wheezing, cough, shortness of breath).

2) Duration of symptoms

3) Associated symptoms

4) Triggers or alleviating factors

5) Medication trials and outcomes

b. Past Medical History (PMH):

1) History of childhood asthma is suggestive

2) Allergies (seasonal, food, perennial)

3) Other diagnoses that can masquerade as asthma (see Section B, item 3b of this

guideline).

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c. Social History (SH):

1) Current or former tobacco use, marijuana use, etc.

2) Exposure to second hand smoke

3) Animals in home

4) Molds

5) Pests

d. Family History (FH):

1) Asthma

2) Allergy

3) Atopy

2. Physical exam focusing on:

a. HEENT – nasal polyps, pale boggy turbinates

b. Lung – wheezes, prolonged inspiration to expiration (I:E) ratio

c. Skin – eczema

3. Spirometry:

Although asthma is typically associated with an obstructive impairment that is reversible,

these findings are not adequate to diagnose asthma. Many diseases are associated with this

pattern of abnormality. The patient’s pattern of symptoms (along with other information

from the patient’s medical history) and exclusion of other possible diagnoses also are needed

to establish a diagnosis of asthma. Note that spirometry can be normal in asthma as asthma

is an intermittent disease and sometimes patients have predominately nocturnal symptoms.

a. Provider should send any adult patient with suspected asthma and no prior documented

spirometry testing to the pulmonary function lab for the first pre- and post-bronchodilator

spirometry.

b. Reversibility is determined by an increase in FEV1 of ≥ 12 percent and ≥ 200 cc from

baseline after inhalation of a short-acting beta agonist (SABA).

c. Spirometry should meet American Thoracic Society (ATS) standards.C

d. When spirometry shows severe abnormalities the patient should be referred for formal

pulmonary function testing.

e. Spirometry measures should include:

1) FEV1

2) FVC

3) FEV1/FVC

4. Additional studies as necessary to exclude alternate diagnoses/support asthma diagnosis

(e.g., full pulmonary function testing, methacholine challenge testing).

5. Classification of asthma severity and disease risk:

All adult asthma patients should have asthma severity classified using impairment and

risk domains. Refer to Attachment B - Classifying Asthma Severity in Adults.

B. Management:

There are four components to asthma management as outlined by EPR-3: 1) Measures of

assessment and monitoring, 2) Education for partnership in asthma care, 3) Control of

environmental factors and comorbid conditions that affect asthma, and 4) Medications.

1. Measures of assessment and monitoring to diagnose and assess characteristics of asthma and

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to monitor whether asthma control is achieved and maintained.

a. All adult asthma patients should be monitored for symptom control (Attachment C:

Assessing Asthma Control in Adults).

1) Impairment:

a) Several tools are available to assess impairment from asthma. The Asthma

Control Test (ACT) (Attachment D) is recommended. If patient’s total point

value is 19 or below, his/her asthma may not be well-controlled.

b) Symptoms:

i. Nighttime awakenings

ii. Need for SABA for quick relief of symptoms

iii. Work or school days missed

iv. Ability to engage in normal activity

v. Quality of life assessments

c) Spirometry may be performed annually or more often as determined by the provider.

d) Delineate persistent from intermittent disease. Persistent baseline/untreated

asthma is suggested by any of the following:

i. Symptoms > 2 days/week OR

ii. Night awakenings from asthma ≥ 2 times/month OR

iii. Limitation of activities, despite pre-treatment for exercise induced asthma OR

iv. More than two steroid bursts in one year OR

v. FEV1 < 80% predicted, or lower than expected for age, or low FEV1/FVC

ratio OR.

vi. Short-acting beta agonist use > 2 times/week (not for exercise induced

bronchospasm).

2) Risk: Determine the patient’s overall risk:

a) Exacerbation frequency

b) ED visits or other unannounced care

c) Decline in lung function greater than expected as a result of normal aging

d) Side effects of medications.

b. In general, patients who have intermittent or mild persistent asthma that has been under

control for at least three months should be seen by a clinician approximately every six

months, and patients who have uncontrolled and/or severe persistent asthma and those

who need additional supervision to help them follow their treatment plan need to be seen

more often.

2. Education for a partnership in asthma care:

a. Providers of adult asthmatic patients should discuss the following questions with patients

when first diagnosed and on an ongoing basis. Providers include physicians, NPs, PAs,

RNs and pharmacists. Educational handouts are available on the DH Pulse

(http://dhpulse.hosp.dhha.org/EducationTraining/pafe/Pages/GeneralTopicRespiratorySy

stems.aspx).

1) What is asthma?

2) What is good asthma control?

3) What medications are used for asthma?

4) What is the role of medication in asthma care? (controller/rescuer paradigm)

5) What is proper metered dose inhaler (MDI) technique? This should include an

assessment of technique in the clinic or pharmacy.

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b. Patients, in partnership with providers, should develop a self-management goal regarding

their asthma.

3. Control of environmental factors and comorbid conditions that affect asthma:

a. Advise patients to eliminate or reduce exposure to following allergens/irritants

1) Tobacco

2) Indoor:

a) Pests (house dust mites, cockroaches)

b) Animal dander

c) Mold

d) Wood burning stove

e) Unvented gas stove

f) Volatile organic compounds (VOCs; e.g., paint, cleaning fluids)

g) Perfumes

h) NSAIDs and aspirin in some adults

3) Outdoor: Pollens

b. When patient’s asthma cannot be well controlled, evaluate for a complicating comorbid

condition, for example:

1) Allergic bronchopulmonary aspergillosis

2) Gastroesophageal reflux disease (GERD)

3) Obesity

4) Obstructive sleep apnea (OSA)

5) Rhinitis/sinusitis

6) Stress/depression

7) Vocal cord dysfunction (VCD)

8) Upper airway cough syndrome

4. Pharmacologic therapy:

A stepwise approach to pharmacologic therapy is recommended to gain and maintain control

of asthma in both the impairment and risk domains (Attachment E - Stepwise Approach for

Managing Asthma in Adults). When initiating therapy, the type, amount, and scheduling of

medication is dictated by asthma severity. The level of control is considered when adjusting

therapy. Step down therapy is essential to identify the minimum medication necessary to

maintain control. (See EPR-3)

a. Patients with persistent asthma should be on long-term controller medication to be taken

daily. Inhaled corticosteroids (ICS) are the most potent and consistently effective long-

term single control medication for asthma.

b. Regularly scheduled daily chronic use of SABA is not recommended and generally

indicates inadequate control of asthma and the need for initiating or intensifying anti-

inflammatory therapy (e.g., ICS).

c. Step up therapy if needed to gain control patient medication use and technique should

first be reviewed, as well as environmental control.

d. Spacers should be used with MDIs to optimize appropriate drug delivery.

1) Long-term controller medication (Attachment F: Inhaled Corticosteroids for Asthma

on DH Formulary):

a) ICS

b) ICS/long-acting beta agonist (LABA) combination

c) LABA

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d) Leukotriene modifier

e) Methylxanthines

f) Antibody inhibitor.

2) Quick relief medication (Attachment F - Inhaled Corticosteroids for Asthma on DH

Formulary):

a) SABA

b) Anticholinergics (for exacerbations only)

C. Referrals:

Consider referral to Pulmonary Clinic when the diagnosis is uncertain or patients are on Step

3 through Step 6 therapies as per EPR-3 (Attachment E - Stepwise Approach for Managing

Asthma in Adults).

D. Goals of therapy:

Patients should:

a. Have no chronic symptoms day or night.

b. Have minimal or no exacerbations (i.e., AUCC visits, ED visits, hospitalizations).

c. Experience no activity limitations (i.e., no missed work).

d. Have minimal use of quick relief agents (one canister of SABA should last longer than

one month).

e. Experience minimal or no adverse effects from medications.

V. REFERENCES

A. Li C, Balluz LS, Okoro CA, et al. Surveillance of certain health behaviors and conditions

among states and selected local areas --- Behavioral Risk Factor Surveillance System, United

States, 2009. MMWR Surveill Summ. Aug 19 2011;60(9): 1-250.

B. National Heart Lung and Blood Institute NAEPP. Expert Panel Report 3 (EPR-3): Guidelines

for the diagnosis and management of asthma. In: Services USDoHH, ed. Bethesda 2007.

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

C. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J.

Aug 2005;26(2):319-338.

VI. ATTACHMENTS

Attachment A - Algorithm: CHS Asthma Care Clinical Process, 2012-12-28.

Attachment B - Classifying Asthma Severity in Adults, 2012-11-15.

Attachment C - Assessing Asthma Control in Adults, 2012-03-01.

Attachment D - Asthma Control Test (ACT), 12yrs+, 2012-07-16.

Attachment E - Stepwise Approach for Managing Asthma in Adults, 2012-10-24.

Attachment F - Inhaled Corticosteroids for Asthma on DH Formulary, 2012-10-24.

Start Registration & Check-In

If patient currently

using asthma medications, ask if he/she has asthma

If asthmatic

give patient

ACT form

History & Physical

STD WORKHCP Potential

Asthma Recognition

& ACT Administration

STD WORKCHS Adult

Asthma Care

Guideline –H & P

Patient has prior

assessment for asthma?

N

Y

Differential diagnosis includes asthma?

Alternate Diagnosis

End

N

Y

Refer to PFT lab for pre-and post-

bronchodilator (BD)

spirometry

Do you stillthink this is asthma e.g. nocturnal or

exerciseinduced?

Is there obstruction?

Does FEV1 increase ≥12% from baseline and ≥200 cc change

post-BD?

Clinical presentation and

medical hx consistent with

asthma?

N

Y

N

Y

Consider methacholine challenge

Classify asthma as intermittent or

persistent

STD WORKCHS Adult Asthma Care Guideline –

Attachment B (Classifying

Asthma Severity)

Initial Asthma Assessment

Follow Up Asthma Assessment

STD WORKCHS Adult

Asthma Care Guideline –

Attachment F (Inhaled

Corticosteroids for Asthma )

STD WORKCHS Adult

Asthma Care Guideline

Step down treatment

No change in treatment

Step Up treatment

STD WORKCHS Adult

Asthma Care Guideline –

Attachment E (Stepwise Approach)

Consider spirometry by

PFT lab

Document & evaluate ACT, H&P; review spirometry if

done

Asthma controlled?

Y

N

Y

Opportunity to Step Down?

Y

N

Educate patient how to use

medications & assess need for

further education

Determine follow-up & track patient

Document plan of care and self management goal on the encounter

N

CCG-26.016: CHS Adult Asthma Care Guideline – Attachment A: Asthma Care Clinical Process

Alternate Diagnosis

End

STD WORKCHS Adult

Asthma Care Guideline –

Attachment C (Assessing

Asthma Control)

Version Date: 2012-12-28

CCG-26.016: CHS Adult Asthma Care Guideline - Attachment B

Adapted from Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma (2007) 2012-11-15

Classifying Asthma Severity in Adults

SEVERITY is determined by assessing both IMPAIRMENT and RISK in patients who are not currently taking long-term controller medications.

Assign severity to the highest category in which any feature occurs (e.g., patients with multiple exacerbations requiring oral corticosteroids may be considered to have persistent asthma even in the absence of matching impairment levels).

INTERMITTENT PERSISTENT

Mild Moderate Severe

IMPAIRMENT

Recall of previous 2-4 weeks

Spirometry Normal FEV1/FVC

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

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

Daily Throughout the day

Nocturnal Symptoms ≤ 2 times/month 3 – 4 times/month > 1 time/week but

not nightly Often (nightly)

Short-acting beta agonist use*

≤ 2 days/week

> 2 days/week but not daily, and not

more than once on any given day

Daily Several times/day

Interference with normal activity

None Minor limitation Some limitation Extreme limitation

Lung function

Normal FEV1 between exacerbations

FEV1 > 80% predicted FEV1/FVC normal

FEV1 > 80% predicted

FEV1/FVC normal

FEV1 > 60% but <80% predicted

FEV1/FVC reduced 5%

FEV1 < 60% predicted

FEV1/FVC reduced > 5%

RISK Exacerbations requiring oral corticosteroids

0-1/year ≥ 2/year

RECOMMENDED STEP FOR INITIATING TREATMENT**

Step 1 Step 2 Step 3 Step 4 or 5

*not for the prevention of exercise-induced bronchospasm **Refer to Guideline Attachment E for step treatments

CCG-26.016: CHS Adult Asthma Care Guideline – Attachment C

Adapted from Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma (2007) 2012-03-01

Assessing Asthma Control in Adults

WELL CONTROLLED NOT WELL CONTROLLED VERY POORLY CONTROLLED

IMPAIRMENT

Recall of previous 2-4 weeks

Spirometry

Days with Symptoms ≤ 2 days/week > 2 days/week Throughout the day

Nocturnal Symptoms ≤ 2 times /month 1-3 times/week ≥ 4 times/week

Short-acting beta agonist use*

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

Interference with normal activity

None Some limitation Extreme limitation

FEV1 > 80% predicted 60% - 80% predicted < 60% predicted

Asthma Control Test (ACT) Score

≥ 20 16-19 ≤ 15

RISK

≥ 2 exacerbations in the past year requiring oral corticosteroids indicates asthma is not well controlled, even in the absence of corresponding impairment levels

Medication side effects should be assessed and considered in the overall assessment of risk. Evaluate continually for loss of lung function.

RECOMMENTATIONS

Maintain current Step Regular follow-up every 1-6

months Consider Step Down if well

controlled ≥ 3 months

Step up 1 step and re-evaluate in 2-6 weeks

For side effects, consider alternative treatment options

Consider short course of oral corticosteroids

Step up 1-2 steps and re-evaluate in 2 weeks

For side effects, consider alternative treatment options

*not for prevention of exercise-induced bronchospasm

Copyright 2002 by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated. ACT 12yrs+ ENG 2012-07-06

ASTHMA CONTROL TESTTM (ACT) for people 12 years and older

Step 1: Write the number of each answer in the score box provided. Step 2: Add the score boxes for your total. Step 3: Take the test to your Care Provider to talk about your score. 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?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

2. During the past 4 weeks, how often have you had shortness of breath?

More than once a day Once a day 3 to 6 times

a week Once or twice a week Not at all

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 or more nights a week

2 or 3 nights a week Once a week Once

or twice Not at all

4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication

(such as albuterol)?

3 or more times per day

1 or 2 times per day

2 or 3 times per week

Once a week or less Not at all

5. How would you rate your asthma control during the past 4 weeks?

Not controlled at all

Poorly controlled

Somewhat controlled

Well controlled

Completely controlled

If your Total score is 19 or less, your asthma may not be controlled as well as it could be. Talk to your Care Provider.

4 1 2 3 5

SCORE

TOTAL

4 1 2 3 5

4 1 2 3 5

4 1 2 3 5

4 1 2 3 5

Copyright 2002 by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated. ACT 12yrs+ SP 2012-07-06

LA PRUEBA DE CONTROL DEL ASMA (ASTHMA CONTROL TESTTM – ACT) para personas de 12 años de edad en adelante

Paso 1: Anote el número correspondiente a cada respuesta en el cuadro de la derecha. Paso 2: Sume todos los puntos en los cuadros para obtener el total. Paso 3: Llévele la prueba a su doctor para hablar sobre su puntaje total. 1. En las últimas 4 semanas, ¿cuánto tiempo le ha impedido su asma hacer todo lo que quería

en el trabajo, en la escuela o en la casa?

Siempre La mayoría del tiempo

Algo del tiempo

Un poco del tiempo Nunca

2. Durante las últimas 4 semanas, ¿con qué frecuencia le ha faltado aire?

Más de una vez al día

Una vez por día

De 3 a 6 veces por semana

Una o dos veces por semana Nunca

3. Durante las últimas 4 semanas, ¿con qué frecuencia sus síntomas del asma (respiración sibilante o

un silbido en el pecho, tos, falta de aire, opresión en el pecho o dolor) lo/la despertaron durante la noche o más temprano de lo usual en la mañana?

4 o más noches por semana

2 ó 3 veces por semana

Una vez por semana

Una o dos veces Nunca

4. Durante las últimas 4 semanas, ¿con qué frecuencia ha usado su inhalador de rescate o medicamento en

nebulizador (como albuterol)?

3 o más veces al día

1 ó 2 veces al día

2 ó 3 veces por semana

Una vez por semana o menos Nunca

5. ¿Cómo evaluaría el control de su asma durante las últimas 4 semanas?

No controlada, en absoluto

Mal controlada

Algo controlada

Bien controlada

Completamente controlada

Si obtuvo 19 puntos o menos, es posible que su asma no esté tan bien controlada como podría. Hable con su médico.

4 1 2 3 5

PUNTAJE

TOTAL

4 1 2 3 5

4 1 2 3 5

4 1 2 3 5

4 1 2 3 5

CCG-26.016: CHS Adult Asthma Care Guideline – Attachment E

Adapted from Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma (2007). 2012-10-24

Stepwise Approach for Managing Asthma in Adults

STEP 1

Preferred:

albuterol PRN

STEP 2

Preferred: beclomethasone 80 mcg

1–3 puffs BID

Alternative:

zafirlukast 20 mg BID

STEP 3

Preferred: fluticasone-salmeterol 45 mcg/21 mcg MDI

1-2 puffs BID OR fluticasone-salmeterol 100 mcg/50 mcg DPI

1 inhalation BID

OR

beclomethasone 80 mcg 3–6 puffs BID

Alternative:

beclomethasone 80 mcg 1–3 puffs BID

+ zafirlukast 20 mg BID

STEP 4

Preferred: fluticasone-salmeterol 115 mcg/21 mcg MDI

2 puffs BID OR

fluticasone-salmeterol 250 mcg/50 mcg DPI 1-2 inhalations BID

Alternative: fluticasone 220 mcg MDI

2 puffs BID or fluticasone 250 mcg DPI

2 inhalations BID

+ zafirlukast 20 mg BID

STEP 5

Preferred: fluticasone-salmeterol 230 mcg/21 mcg MDI

1 puff BID OR

fluticasone-salmeterol 500 mcg/50 mcg DPI

1 inhalation BID

STEP 6

Preferred: fluticasone-salmeterol 230 mcg/21 mcg MDI

2 puffs BID OR

fluticasone-salmeterol 500 mcg/50 mcg DPI

1 inhalation BID +

oral corticosteroid

Step Up if needed

Step Down

if possible

INTERMITTENT ASTHMA

PERSISTENT ASTHMA

Steps 3-5: Consider short course of oral corticosteroids

Steps 3-6: Consider referral to Pulmonary Clinic

Each step: Quick relief for all patients: albuterol prn; use of albuterol > 2 days/week (excluding use for EIB) may indicate inadequate control and the need to

Step Up treatment Use of a spacer is recommended with all MDI Assess for medication adherence, MDI technique, self-management support, environmental control, and management of comorbid conditions

EIB, exercise-induced bronchospasm; MDI, metered dose inhaler; DPI, diskus powder inhaler; BID, twice daily; PRN, as needed

CCG-26.016: CHS Adult Asthma Care Guideline – Attachment F

2012-10-24 **DH - Internal** Confidential

Denver Health - Inhaled Corticosteroids and Steroid Combinations for Managing Asthma in Adults Brand Name Generic Name - Strength Low Medium High

Inhaled Corticosteroids

Qvar Inhaler beclomethasone 40 mcg 2-6 puffs BID

Qvar Inhaler beclomethasone 80 mcg 1-3 puffs BID 3-6 puffs BID >6 puffs BID

Flovent Diskus fluticasone 50 mcg 2-6 puffs BID

Flovent Diskus fluticasone 100 mcg 1-3 puffs BID 3-5 puffs BID >5 puffs BID

Flovent Diskus fluticasone 250 mcg 1 puffs BID 2 puffs BID >2 puffs BID

Flovent HFA Inhaler fluticasone 44 mcg 2-6 puffs BID

Flovent HFA Inhaler fluticasone 110 mcg 1-2 puffs BID 2-4 puffs BID >4 puffs BID

Flovent HFA Inhaler fluticasone 220 mcg 1 puff BID 2 puffs BID >2 puffs BID

Inhaled Steroid Combinations

Advair Diskus fluticasone-salmeterol 100 mcg-50 mcg 1 puff Daily to BID 1 puff Daily to BID

Advair Diskus fluticasone-salmeterol 250 mcg-50 mcg

1 puff Daily to BID 1 puff BID

Advair Diskus* fluticasone-salmeterol 500 mcg-50 mcg

1 puff Daily to BID

Advair HFA Inhaler fluticasone-salmeterol 45 mcg-21 mcg 2 puffs Daily to BID

Advair HFA Inhaler fluticasone-salmeterol 115 mcg-21 mcg

2 puffs Daily to BID

Advair HFA Inhaler† fluticasone-salmeterol 230 mcg-21 mcg

1 puff Daily to BID 2 puffs BID * The maximum recommended dosage is 1 inhalation of ADVAIR DISKUS 500/50 mcg twice daily

† The maximum recommended dosage is 2 inhalations of ADVAIR HFA 230/21 mcg twice daily.

References: 1. NHBLI, NAEPP. Expert Panel 3: Guidelines for the Diagnosis and Management of Asthma 2007 2. Jonas DE, Wines R, DelMonte M, et al. Drug class review: Controller medications for asthma. Final update 1 report. 3. Kelly HW. Comparison of Inhaled Corticosteroids: An Update. Ann Pharmacother 2009;43:519-27.