Component 3:Component 3:Pharmacologic TherapyPharmacologic Therapy

Asthma is a chronic inflammatory disorderAsthma is a chronic inflammatory disorderof the airways.of the airways.

A key principle of therapy is regulation of A key principle of therapy is regulation of chronic airway inflammation.chronic airway inflammation.

Component 3: Component 3: Pharmacologic TherapyPharmacologic Therapy

Environmental risk factors (causes)Environmental risk factors (causes)

INFLAMMATIONINFLAMMATION

AirwayAirway Airflow Airflow hyperresponsivenesshyperresponsiveness limitation limitation

PrecipitantsPrecipitants

Adapted with permission from Stephen T. Holgate, M.D., D.Sc.Adapted with permission from Stephen T. Holgate, M.D., D.Sc. Symptoms Symptoms

Asthma is a chronic inflammatory disorder of the airways.Asthma is a chronic inflammatory disorder of the airways. A key principle of therapy is regulation of chronic airway inflammation.A key principle of therapy is regulation of chronic airway inflammation.

Inhaled MedicationInhaled Medication Delivery Devices Delivery Devices

Metered-dose inhaler (MDI)Metered-dose inhaler (MDI) Dry powder inhaler (DPI)Dry powder inhaler (DPI) Spacer/holding chamberSpacer/holding chamber Spacer/holding chamber and face maskSpacer/holding chamber and face mask NebulizerNebulizer

Transition to Transition to Non-CFC InhalersNon-CFC Inhalers

Most currently available MDIs use chlorofluorocarbonsMost currently available MDIs use chlorofluorocarbons(CFCs) as propellants.(CFCs) as propellants.

CFCs are being phased out globally to protectCFCs are being phased out globally to protectthe earth’s ozone layer.the earth’s ozone layer.

CFC MDIs have a temporary medical exemptionCFC MDIs have a temporary medical exemptionto the phaseout.to the phaseout.

Over the next several years, CFC MDIs will be gradually Over the next several years, CFC MDIs will be gradually replaced by non-CFC alternatives.replaced by non-CFC alternatives.

Non-CFC alternatives will include HFA MDIs, DPIs,Non-CFC alternatives will include HFA MDIs, DPIs,and other new devicesand other new devices..

CFC Transition: What PatientsCFC Transition: What Patientsand Practitioners Should Knowand Practitioners Should Know

Non-CFC products/devices are being developed and Non-CFC products/devices are being developed and introduced into the US market.introduced into the US market.

Non-CFC alternatives must be shown to be safe andNon-CFC alternatives must be shown to be safe andeffective prior to FDA approval.effective prior to FDA approval.

FDA will not phase out CFC MDIs until an adequateFDA will not phase out CFC MDIs until an adequatenumber of safe, effective, and acceptable non-CFC number of safe, effective, and acceptable non-CFC alternatives are available.alternatives are available.

As non-CFC alternatives become available, patients and As non-CFC alternatives become available, patients and practitioners should try them.practitioners should try them.

Patients may notice differences in taste and feel of thePatients may notice differences in taste and feel of thenew products.new products.

Overview ofOverview ofAsthma MedicationsAsthma Medications

Daily: Long-Term ControlDaily: Long-Term Control– Corticosteroids (inhaled and systemic)Corticosteroids (inhaled and systemic)– Cromolyn/nedocromilCromolyn/nedocromil– Long-acting betaLong-acting beta22-agonists-agonists

– MethylxanthinesMethylxanthines– Leukotriene modifiersLeukotriene modifiers

Overview of Overview of Asthma Medications Asthma Medications (continued)(continued)

As-needed: Quick ReliefAs-needed: Quick Relief– Short-acting betaShort-acting beta22-agonists-agonists

– AnticholinergicsAnticholinergics– Systemic corticosteroidsSystemic corticosteroids

Inhaled CorticosteroidsInhaled Corticosteroids

Most effective long-term-control therapy for Most effective long-term-control therapy for persistent asthmapersistent asthma

Small risk for adverse events at Small risk for adverse events at recommended dosagerecommended dosage

Reduce potential for adverse events by:Reduce potential for adverse events by:– Using spacer and rinsing mouthUsing spacer and rinsing mouth– Using lowest dose possibleUsing lowest dose possible– Using in combination with long-acting Using in combination with long-acting

betabeta22-agonists-agonists– Monitoring growth in childrenMonitoring growth in children

Inhaled CorticosteroidsInhaled Corticosteroids(continued)(continued)

Benefit of daily use:Benefit of daily use:– Fewer symptomsFewer symptoms– Fewer severe exacerbationsFewer severe exacerbations– Reduced use of quick-relief medicineReduced use of quick-relief medicine– Improved lung functionImproved lung function– Reduced airway inflammationReduced airway inflammation

Inhaled Corticosteroids Inhaled Corticosteroids and Linear Growth in Childrenand Linear Growth in Children

Potential risks are well balanced by benefits.Potential risks are well balanced by benefits. Growth rates in children are highly variable. Growth rates in children are highly variable.

Short-term evaluations may not be predictive of attaining Short-term evaluations may not be predictive of attaining final adult height.final adult height.

Poorly controlled asthma may delay growth.Poorly controlled asthma may delay growth. Children with asthma tend to have longerChildren with asthma tend to have longer

periods of reduced growth rates prior to puberty (males > periods of reduced growth rates prior to puberty (males > females).females).

Inhaled Corticosteroids and Inhaled Corticosteroids and Possible Effect onPossible Effect on

Linear GrowthLinear Growth Most studies show no effect with low-to-medium doses,Most studies show no effect with low-to-medium doses,

but some short-term studies show growth delay. but some short-term studies show growth delay. Potential risk appears to be dose dependent:Potential risk appears to be dose dependent:

Medium doses may be associated with possible, but notMedium doses may be associated with possible, but notpredictable, effect on linear growth. The clinical significancepredictable, effect on linear growth. The clinical significancehas not yet been determined.has not yet been determined.

High doses have greater potential for growth delay or suppression.High doses have greater potential for growth delay or suppression.

For severe persistent asthma, high doses of inhaled For severe persistent asthma, high doses of inhaled corticosteroids have less risk than oral corticosteroids.corticosteroids have less risk than oral corticosteroids.

Inhaled Corticosteroids and Inhaled Corticosteroids and Possible Effect onPossible Effect on

Linear Growth Linear Growth (continued)(continued)

Some caution is suggested while studies continue:Some caution is suggested while studies continue:– Monitor growthMonitor growth– Use the lowest dose necessary to maintain controlUse the lowest dose necessary to maintain control

(step down therapy when possible)(step down therapy when possible)– Administer with spacers/holding chambersAdminister with spacers/holding chambers– Advise patients to “rinse and spit” following inhalationAdvise patients to “rinse and spit” following inhalation– Consider adding a long-acting inhaled betaConsider adding a long-acting inhaled beta22-agonist to a-agonist to a

low-to-medium dose of inhaled corticosteroids (vs. using a low-to-medium dose of inhaled corticosteroids (vs. using a higher dose of the corticosteroid)higher dose of the corticosteroid)

Estimated ComparativeEstimated ComparativeDosages ofDosages of

Inhaled CorticosteroidsInhaled Corticosteroids Preparations are not equivalent per puff or per Preparations are not equivalent per puff or per

microgram.microgram. Comparative doses are Comparative doses are estimated.estimated.

– Few data directly compare preparations.Few data directly compare preparations.

Most important determinant of dosingMost important determinant of dosingis clinician judgment.is clinician judgment.– Monitor patient’s clinical response to therapy.Monitor patient’s clinical response to therapy.– Adjust dose accordingly.Adjust dose accordingly.

Estimated Comparative Daily Estimated Comparative Daily Dosages of InhaledDosages of Inhaled

Corticosteroids for AdultsCorticosteroids for Adults

DrugDrug Low Dose Medium Dose High Dose Low Dose Medium Dose High Dose

Beclomethasone 168 - 504 mcg 504 - 840 mcg > 840 mcgBeclomethasone 168 - 504 mcg 504 - 840 mcg > 840 mcg

Budesonide DPI 200 - 400 mcg 400 - 600 mcgBudesonide DPI 200 - 400 mcg 400 - 600 mcg > 600 mcg > 600 mcg

FlunisolideFlunisolide 500 - 1,000 mcg 1,000 - 2,000 mcg >2,000 mcg 500 - 1,000 mcg 1,000 - 2,000 mcg >2,000 mcg

FluticasoneFluticasone 88 - 264 mcg 264 - 660 mcg > 660 mcg 88 - 264 mcg 264 - 660 mcg > 660 mcg

Triamcinolone Triamcinolone 400 - 1,000 mcg 1,000 - 2,000 mcg >2,000 mcg 400 - 1,000 mcg 1,000 - 2,000 mcg >2,000 mcg

Estimated Comparative DailyEstimated Comparative DailyDosages of Inhaled CorticosteroidsDosages of Inhaled Corticosteroids

for Children for Children <<12 Years12 Years

DrugDrug Low Dose Medium Dose High Low Dose Medium Dose High DoseDose

Beclomethasone 84 - 336 mcg 336 - 672 mcg > 672 mcgBeclomethasone 84 - 336 mcg 336 - 672 mcg > 672 mcg

Budesonide DPI 100 - 200 mcg 200 - 400 mcg > 400 mcgBudesonide DPI 100 - 200 mcg 200 - 400 mcg > 400 mcg

FlunisolideFlunisolide 500 - 750 mcg 1,000 - 1,250 mcg >1,250 mcg 500 - 750 mcg 1,000 - 1,250 mcg >1,250 mcg

FluticasoneFluticasone 88 - 176 mcg 176 - 440 mcg > 440 mcg 88 - 176 mcg 176 - 440 mcg > 440 mcg

Triamcinolone Triamcinolone 400 - 800 mcg 800 - 1,200 mcg >1,200 mcg 400 - 800 mcg 800 - 1,200 mcg >1,200 mcg

Long-Acting BetaLong-Acting Beta22-Agonists-Agonists

Not a substitute for anti-inflammatory therapyNot a substitute for anti-inflammatory therapy

Not appropriate for monotherapyNot appropriate for monotherapy

Beneficial when added to inhaled Beneficial when added to inhaled corticosteroidscorticosteroids

Not for acute symptoms or exacerbationsNot for acute symptoms or exacerbations

Short-Acting BetaShort-Acting Beta22-Agonists-Agonists

Most effective medication for relief of Most effective medication for relief of

acute bronchospasmacute bronchospasm More than one canister per month suggests More than one canister per month suggests

inadequate asthma controlinadequate asthma control Regularly scheduled use is not generally Regularly scheduled use is not generally

recommendedrecommended May lower effectivenessMay lower effectiveness May increase airway hyperresponsivenessMay increase airway hyperresponsiveness

Leukotriene ModifiersLeukotriene Modifiers

MechanismsMechanisms– 5-LO inhibitors5-LO inhibitors– Cysteinyl leukotriene receptor antagonistsCysteinyl leukotriene receptor antagonists

IndicationsIndications– Long-term-control therapy in mildLong-term-control therapy in mild

persistent asthmapersistent asthma Improve lung functionImprove lung function Prevent need for short-acting betaPrevent need for short-acting beta22-agonists-agonists Prevent exacerbationsPrevent exacerbations

– Further experience and research neededFurther experience and research needed

Stepwise Approach to Stepwise Approach to Therapy: Gaining ControlTherapy: Gaining Control

STEP 4STEP 4Severe PersistentSevere Persistent

STEP 3STEP 3Moderate Moderate PersistentPersistent

STEP 2STEP 2Mild PersistentMild Persistent

STEP 1STEP 1Mild IntermittentMild Intermittent

11 22

1. Start high and 1. Start high and step down. step down.

2. Start at initial2. Start at initiallevel of severity; level of severity;

gradually step gradually step up.up.

Stepwise Approach to Therapy for Stepwise Approach to Therapy for Adults and Children >Age 5: Adults and Children >Age 5:

Maintaining ControlMaintaining Control Step down if Step down if

possiblepossible Step up if Step up if

necessarynecessary Patient education Patient education

and environmental and environmental control at every control at every stepstep

Recommend Recommend referral to referral to specialist atspecialist atStep 4; consider Step 4; consider referral at Step 3referral at Step 3

STEP 4STEP 4Multiple long-term-control Multiple long-term-control

medications, includemedications, includeoral corticosteroidsoral corticosteroids

STEP 3STEP 3 >> 1 Long-term-control medications 1 Long-term-control medications

STEP 2STEP 21 Long-term-control medication:1 Long-term-control medication: anti-inflammatory anti-inflammatory

STEP 1STEP 1

Quick-relief medication: PRNQuick-relief medication: PRN

Indicators of PoorIndicators of PoorAsthma ControlAsthma Control

Step up therapy if patient:Step up therapy if patient:

– Awakens at night with symptomsAwakens at night with symptoms

– Has an urgent care visitHas an urgent care visit

– Has increased need for short-acting Has increased need for short-acting inhaled betainhaled beta22-agonists-agonists

– Uses more than one canister of short-acting Uses more than one canister of short-acting betabeta22-agonist in 1 month-agonist in 1 month

Indicators of PoorIndicators of Poor Asthma Control Asthma Control (continued)(continued)

Before increasing medications, check:Before increasing medications, check:

– Inhaler techniqueInhaler technique

– Adherence to prescribed regimenAdherence to prescribed regimen

– Environmental changesEnvironmental changes

– Also consider alternative diagnosesAlso consider alternative diagnoses

Daily Long-Term ControlDaily Long-Term Control– Not neededNot needed

Quick ReliefQuick Relief– Short-acting inhaledShort-acting inhaled

betabeta22-agonist PRN-agonist PRN

– Increasing use, or use more Increasing use, or use more than 2x/week, may than 2x/week, may indicate indicate need for long-need for long- term-control term-control therapytherapy

– Intensity of treatmentIntensity of treatmentdepends on severity of depends on severity of exacerbationexacerbation

Step 1 Treatment for Adults and Step 1 Treatment for Adults and Children >5: Mild IntermittentChildren >5: Mild Intermittent

STEP 1STEP 1

Step 2 Treatment for Adults and Step 2 Treatment for Adults and Children >5: Mild PersistentChildren >5: Mild Persistent

Daily Long-Term ControlDaily Long-Term Control– Anti-inflammatoryAnti-inflammatory

Inhaled corticosteroid (low Inhaled corticosteroid (low dose) ordose) or

Cromolyn or nedocromilCromolyn or nedocromil

OROR– Sustained-release Sustained-release

theophylline (to serum theophylline (to serum concentration 5-15 concentration 5-15

mcg/mL) mcg/mL) is an is an alternative but not preferredalternative but not preferred

– Leukotriene modifier may be Leukotriene modifier may be consideredconsidered

STEP 2STEP 2

Step 2 Treatment for Adults and Step 2 Treatment for Adults and Children >5: Mild PersistentChildren >5: Mild Persistent (continued)(continued)

Quick ReliefQuick Relief Short-acting inhaledShort-acting inhaled

betabeta22-agonist PRN-agonist PRN Daily or increasing use indicates Daily or increasing use indicates

need forneed for long-long- term-control term-control therapy therapy

Intensity of treatment depends Intensity of treatment depends on severity of exacerbationon severity of exacerbation

STEP 2STEP 2

Step 3 Treatment for Adults andStep 3 Treatment for Adults andChildren >5: Moderate PersistentChildren >5: Moderate Persistent

Daily Long-Term ControlDaily Long-Term Control Inhaled corticosteroid (medium dose)Inhaled corticosteroid (medium dose)OROR Inhaled corticosteroidInhaled corticosteroid

(low-to-medium dose) (low-to-medium dose) ANDAND Long-acting bronchodilator Long-acting bronchodilator

(long-acting beta (long-acting beta22-agonist -agonist

or sustained-release theophylline)or sustained-release theophylline)IF NEEDED, increase to:IF NEEDED, increase to: Inhaled corticosteroid Inhaled corticosteroid

(medium-to-high dose) and(medium-to-high dose) andlong-acting bronchodilatorlong-acting bronchodilator

Consider referral to a specialistConsider referral to a specialist

STEP 3STEP 3

Step 3 Treatment for Adults andStep 3 Treatment for Adults andChildren >5: Moderate PersistentChildren >5: Moderate Persistent

(continued)(continued)

Quick ReliefQuick Relief Short-acting inhaled betaShort-acting inhaled beta22-agonist -agonist

PRNPRN Daily or increasing use indicatesDaily or increasing use indicates

need for long-term-control need for long-term-control

therapytherapy Intensity of treatment depends on Intensity of treatment depends on severity of exacerbationseverity of exacerbation

STEP 3STEP 3

Step 4 Treatment for Adults andStep 4 Treatment for Adults andChildren >5: Severe PersistentChildren >5: Severe Persistent

Daily Long-Term ControlDaily Long-Term Control Inhaled corticosteroid (high dose) Inhaled corticosteroid (high dose) ANDAND Long-acting bronchodilatorLong-acting bronchodilator

– Long-acting inhaledLong-acting inhaledbetabeta22-agonist -agonist OROR

– Sustained-release theophylline Sustained-release theophylline OROR– Long-acting betaLong-acting beta22-agonist -agonist

tablets tablets ANDAND Oral corticosteroid, long termOral corticosteroid, long term

Recommend referral to a specialistRecommend referral to a specialist

STEP 4STEP 4

Step 4 Treatment for Adults andStep 4 Treatment for Adults andChildren >5: Severe PersistentChildren >5: Severe Persistent

(continued)(continued)

Quick ReliefQuick Relief Short-acting inhaled betaShort-acting inhaled beta22-agonist -agonist

PRNPRN Daily or increasing use indicatesDaily or increasing use indicates

need for long-term control need for long-term control

therapytherapy Intensity of treatment depends onIntensity of treatment depends on

severity of exacerbationseverity of exacerbation

STEP 4STEP 4

Stepwise Approach to Therapy for Stepwise Approach to Therapy for Infants and Young ChildrenInfants and Young Children

STEP 4STEP 4Multiple long-term-control Multiple long-term-control medications; include oral medications; include oral corticosteroidscorticosteroids

STEP 3STEP 3>> 1 Long-term-control medications 1 Long-term-control medications

STEP 2STEP 21 Long-term-control medication:1 Long-term-control medication:anti-inflammatoryanti-inflammatory

STEP 1STEP 1

Quick-relief medication: PRNQuick-relief medication: PRN

Step down if Step down if possiblepossible

Step up if Step up if necessarynecessary

Patient education Patient education and environmental and environmental control at every stepcontrol at every step

Recommend referral Recommend referral to specialist atto specialist atSteps 3 and 4; Steps 3 and 4; consider referral at consider referral at Step 2.Step 2.

Step 1 Treatment for InfantsStep 1 Treatment for Infantsand Young Children and Young Children <<5:5:

Mild IntermittentMild Intermittent Daily Long-Term ControlDaily Long-Term Control

– Not neededNot needed Quick ReliefQuick Relief

– Bronchodilator PRN. Either:Bronchodilator PRN. Either: Inhaled short-acting betaInhaled short-acting beta22-agonist by -agonist by

nebulizer or by face mask and spacernebulizer or by face mask and spacerOROR– Oral betaOral beta22-agonist-agonist

Use more than 2x/week or increasing Use more than 2x/week or increasing use may indicate need for long-term use may indicate need for long-term control therapycontrol therapy

Intensity of treatment depends on Intensity of treatment depends on severity of exacerbationseverity of exacerbation

STEP 1STEP 1

Treatment for Infants and Treatment for Infants and Young Children With Viral Young Children With Viral

Respiratory InfectionRespiratory Infection

Short-acting inhaled betaShort-acting inhaled beta22-agonist q 4 to 6 hours up to 24 hours (longer -agonist q 4 to 6 hours up to 24 hours (longer

with physician consult)with physician consult) Consider step up if repeated more than once every 6 weeksConsider step up if repeated more than once every 6 weeks Consider systemic corticosteroid if:Consider systemic corticosteroid if:

– Current exacerbation is severeCurrent exacerbation is severe OROR

– Patient has history of previous severe exacerbationsPatient has history of previous severe exacerbations

Step 2 Treatment for Infants and Step 2 Treatment for Infants and Young Children Young Children <<5: Mild Persistent5: Mild Persistent

Daily Long-Term ControlDaily Long-Term Control Anti-inflammatoryAnti-inflammatory

– Cromolyn (nebulizer Cromolyn (nebulizer

preferred) or nedocromilpreferred) or nedocromil

OROR Low-dose inhaled Low-dose inhaled

corticosteroid (spacer/face corticosteroid (spacer/face mask)mask)

Consider referral to specialistConsider referral to specialist

STEP 2STEP 2

Quick ReliefQuick Relief Brochodilator PRN. Either:Brochodilator PRN. Either:

– Inhaled short-acting betaInhaled short-acting beta22-agonist by -agonist by

nebulizer or face mask and spacernebulizer or face mask and spacerOROR– Oral betaOral beta22-agonist -agonist

Increasing use, daily use, or use >3 or Increasing use, daily use, or use >3 or 4x/day indicate need for long-term-4x/day indicate need for long-term-control therapycontrol therapy

Intensity of treatmentIntensity of treatmentdepends on severitydepends on severityof exacerbationof exacerbation

Step 2 Treatment for Infants and Step 2 Treatment for Infants and Young Children Young Children <<5: Mild Persistent5: Mild Persistent

(continued(continued)

STEP 2STEP 2

Step 3 Treatment for Infants and Step 3 Treatment for Infants and Young Children Young Children <<5: Moderate 5: Moderate

PersistentPersistent

Daily Long-Term Control Anti-inflammatory

– Medium-dose inhaledcorticosteroid (spacer/face mask)

Or, once control is established

– Lower medium-dose inhaled corticosteroid AND nedocromil or theophylline

Recommend referral to specialist

STEP 3

Quick ReliefQuick Relief Brochodilator PRN. Either:Brochodilator PRN. Either:

– Inhaled short-acting betaInhaled short-acting beta22-agonist by-agonist by

nebulizer or face mask and spacernebulizer or face mask and spacerOROR

– Oral betaOral beta22-agonist -agonist Increasing use, daily use, or use >3 or Increasing use, daily use, or use >3 or

4x/day indicate need for long-term-4x/day indicate need for long-term-control therapycontrol therapy

Intensity of treatmentIntensity of treatmentdepends on severitydepends on severityof exacerbationof exacerbation

Step 3 Treatment for Infants and Step 3 Treatment for Infants and Young Children Young Children << 5: 5:

Moderate PersistentModerate Persistent (continued)(continued)

STEP 3

Step 4 Treatment for Infants and Step 4 Treatment for Infants and Young Children Young Children <<5:5:Severe PersistentSevere Persistent

Daily Long-Term ControlDaily Long-Term Control High-dose inhaled corticosteroid High-dose inhaled corticosteroid

(spacer/face mask)(spacer/face mask)

If needed, add oral corticosteroid and If needed, add oral corticosteroid and reduce to lowest daily or alternate-day reduce to lowest daily or alternate-day dose that stabilizes symptomsdose that stabilizes symptoms

STEP 4STEP 4

Step 4 Treatment for Infants and Step 4 Treatment for Infants and Young Children Young Children <<5:5:

Severe PersistentSevere Persistent (continued)(continued)

STEP 4STEP 4

Quick ReliefQuick Relief Brochodilator PRN. Either:Brochodilator PRN. Either:

– Inhaled short-acting betaInhaled short-acting beta22-agonist by -agonist by

nebulizer or face mask and spacernebulizer or face mask and spacerOROR– Oral betaOral beta22-agonist -agonist

Increasing use, daily use, or use >3 or Increasing use, daily use, or use >3 or 4x/day indicate need for long-term-4x/day indicate need for long-term-control therapycontrol therapy

Intensity of treatmentIntensity of treatmentdepends on severitydepends on severityof exacerbationof exacerbation

School-Age Children: School-Age Children: Special Considerations Special Considerations

In addition to following adult management principles:In addition to following adult management principles:– Give special consideration to school andGive special consideration to school and

developmental issuesdevelopmental issues– Monitor growth in children receiving corticosteroidsMonitor growth in children receiving corticosteroids– Consider use of cromolyn or nedocromil first forConsider use of cromolyn or nedocromil first for

Step 2 careStep 2 care– Encourage active participation in physical activityEncourage active participation in physical activity– Provide written asthma management planProvide written asthma management plan

for home and schoolfor home and school– Involve children in developing planInvolve children in developing plan

Older Adults:Older Adults: Special Considerations Special Considerations

High prevalence of coexisting obstructive lung High prevalence of coexisting obstructive lung

diseasedisease– Determine the extent of reversible airflow Determine the extent of reversible airflow

obstructionobstruction

– Use 2- to 3-week trial of systemic corticosteroidsUse 2- to 3-week trial of systemic corticosteroids

Essential to review patient technique in using Essential to review patient technique in using

medications and devicesmedications and devices

Older Adults:Older Adults: Special Considerations Special Considerations (continued)(continued)

Asthma medications may have increased Asthma medications may have increased adverse effectsadverse effects– BronchodilatorsBronchodilators

Airway response to bronchodilators may changeAirway response to bronchodilators may changewith agewith age

Patients with pre-existing ischemic heart disease may Patients with pre-existing ischemic heart disease may experience tremor and tachycardiaexperience tremor and tachycardia

Concomitant use of anticholinergics and betaConcomitant use of anticholinergics and beta22-agonists -agonists

may be beneficialmay be beneficial

Older Adults:Older Adults: Special Considerations Special Considerations (continued)(continued)

– TheophyllineTheophylline Theophylline clearance is reduced, causing increased Theophylline clearance is reduced, causing increased

blood levelsblood levels

Age is independent factor for developingAge is independent factor for developinglife-threatening events from iatrogenic chronic life-threatening events from iatrogenic chronic theophylline overdosetheophylline overdose

Potential for drug interactions (e.g., with epinephrine, Potential for drug interactions (e.g., with epinephrine, antibiotics, Hantibiotics, H22-histamine antagonists)-histamine antagonists)

Older Adults:Older Adults: Special Considerations Special Considerations (continued)(continued)

– Systemic corticosteroids can provoke confusion, Systemic corticosteroids can provoke confusion, agitation, changes in glucose metabolismagitation, changes in glucose metabolism

– Inhaled corticosteroidsInhaled corticosteroids May be associated with dose-dependent reduction in May be associated with dose-dependent reduction in

bone mineral contentbone mineral content Treat concurrently with:Treat concurrently with:

– Calcium supplements andCalcium supplements and– Vitamind D and, when appropriate,Vitamind D and, when appropriate,– Estrogen replacementEstrogen replacement

Older Adults:Older Adults: Special Considerations Special Considerations (continued)(continued)

Medications for other diseases may Medications for other diseases may exacerbate asthmaexacerbate asthma– NSAIDsNSAIDs– Nonselective beta-blockersNonselective beta-blockers– Beta-blockers found in some eye dropsBeta-blockers found in some eye drops

Managing Exercise-Induced Managing Exercise-Induced Bronchospasm (EIB)Bronchospasm (EIB)

Anticipate EIB in all patientsAnticipate EIB in all patients Teachers and coaches need to be notifiedTeachers and coaches need to be notified DiagnosisDiagnosis

– History of cough, shortness of breath, chest pain or History of cough, shortness of breath, chest pain or tightness, wheezing, or endurance problemstightness, wheezing, or endurance problemsduring exerciseduring exercise

– Conduct exercise challenge Conduct exercise challenge OROR have patient have patientundertake task that provoked the symptomsundertake task that provoked the symptoms

– 15% decrease in PEF or FEV15% decrease in PEF or FEV11 is compatible with EIB is compatible with EIB

Managing Exercise-Induced Managing Exercise-Induced Bronchospasm (EIB) Bronchospasm (EIB) (continued)(continued)

Management StrategiesManagement Strategies– Short-acting inhaled betaShort-acting inhaled beta22-agonists used shortly before -agonists used shortly before

exercise last 2 to 3 hoursexercise last 2 to 3 hours– Salmeterol may prevent EIB for 10 to 12 hoursSalmeterol may prevent EIB for 10 to 12 hours– Cromolyn and nedcromil are also acceptableCromolyn and nedcromil are also acceptable– A lengthy warmup period before exercise may preclude A lengthy warmup period before exercise may preclude

medications for patients who can tolerate itmedications for patients who can tolerate it– Long-term-control therapy, if appropriateLong-term-control therapy, if appropriate

Managing Seasonal Managing Seasonal Asthma SymptomsAsthma Symptoms

Medical history is usually sufficient to determine Medical history is usually sufficient to determine sensitivity to seasonal allergens.sensitivity to seasonal allergens.

Just before allergy season:Just before allergy season:

– Start daily anti-inflammatory therapyStart daily anti-inflammatory therapy

During allergy season:During allergy season:

– Continue anti-inflammatory therapyContinue anti-inflammatory therapy

– Use stepwise approach to control symptomsUse stepwise approach to control symptoms