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National Panel Updates Its Asthma Guidelines

Tzippora Halpert, PharmD Candidate; Dean Pham, PharmD; Roger A. Santos, PharmD; and David Q. Pham, PharmD, BCPS
Published Online: Tuesday, April 1, 2008   [ Request Print ]

The National Asthma Education and Prevention Program recently updated its Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma (EPR 3). In addition to recommendations on appropriate diagnosis and management, the guidelines provide structure for classifying asthma severity?based on objective and subjective symptoms?and detailed recommendations for pharmacotherapy.

Asthma Zones
? Red Zone?PEF <50% of personal best
  • Alerts patient that asthma is worse
  • Patient should take rescue medication and notify physician if PEF does not return to yellow or green zone
? Yellow Zone?PEF 50%-80% of personal best
  • Signals caution
  • Patient should follow acute asthma exacerbation plan
? Green Zone?PEF 80%-100% of personal best
  • Good control
  • Patient should follow routine therapeutic plan

PEF = peak expiratory flow.
*Patients' personal bests are determined by using their peak flow meters twice a day?in the morning just after waking up and in the early afternoon?for 2 weeks during an exacerbation-free period.


Pharmacologic Therapy

A variety of different agents are available for the treatment of asthma. The treatment of choice depends on the stage at which the patient presents.

Intermittent Asthma

According to the EPR 3,1 adults and children >12 years who are diagnosed with intermittent asthma, or step 1, do not require daily medications. They are, however, in need of a short-acting inhaled beta2 agonist to relieve acute bronchospasms. The agents currently available include albuterol, levalbuterol, and pirbuterol. Some adverse effects seen with these agents include nervousness, restlessness, tremor, chest pain, palpitations, electrolyte imbalance, and hyperglycemia.

Mild Persistent Asthma

For patients diagnosed with step 2, or mild persistent asthma, low-dose inhaled corticosteroids should be added. The agents currently available are be-clomethasone, budesonide, flunisolide, fluticasone, mometasone, and triamcinolone acetonide. Some of the common adverse reactions include dysphonia, hoarseness, and oropharyngeal fungal infections. To reduce the incidence of these adverse effects, patients should rinse their mouths and spit after the use of inhaled corticosteroids.

Some alternate treatments include mast cell stabilizers, leukotriene modifiers, or sustained-release theophylline (serum levels 5-15 mcg/mL).The current mast cell stabilizers available are cromolyn and nedocromil. Some adverse effects seen with these agents include irritation of the nose, throat, and trachea, unpleasant taste, and cough.

Moderate Persistent Asthma

The preferred treatment for moderate persistent asthma, or step 3, involves the addition of low-dose inhaled corticosteroids in conjunction with a long-acting beta2 agonist, or medium-dose inhaled corticosteroids only. At present, 2 long-acting beta2 agonists are available, salmeterol and formoterol. It is recommended that long-acting beta2 agonists not be used as monotherapy, because these medicines may increase the chances of a severe asthma episode.2 Common adverse effects of these agents include nervousness, restlessness, tremor, chest pain, headache, abdominal pain, palpitations, and tachycardia. To aid patient adherence, 1 combination agent with fluticasone and salmeterol is available.

Some alternative treatments are using a low-dose corticosteroid in conjunction with a leukotriene modifier or theophylline. Available leukotriene modifiers include montelukast, zafirlukast, and zileuton. Adverse effects seen when taking these agents include fatigue, headache, weakness, cough, abdominal pain, nausea, and dyspepsia. In addition, a short course of oral systemic corticosteroids may be considered. The agents available are methylprednisolone, prednisolone, and prednisone.

Severe Persistent Asthma

In severe persistent asthma, step 4 or 5, the preferred treatment is a medium or a high-dose inhaled corticosteroid, respectively, in conjunction with a long-acting beta2 agonist. If needed, oral systemic corticosteroids may be added. Some adverse effects seen include growth retardation, muscle wasting, osteoporosis, hypertension, depression, acne, hirsutism, and cushingoid appearance. Because of the severity of adverse reactions, every attempt should be made to taper the dose of the systemic corticosteroid and to manage the patient on high-dose inhaled corticosteroids.

An alternative treatment to step 4 therapy is the use of medium-dose inhaled corticosteroids in conjunction with a leukotriene modifier or theophylline. As a supplement to step 5 therapy, omalizumab may be considered for patients who have allergic asthma. This treatment may cause pain and bruising at the site of injection and anaphylaxis reaction.

Patients who are not controlled on step 5 therapy may be required to move up to step 6 therapy, which includes high-dose inhaled corticosteroids, long-acting beta2 agonists, and oral corticosteroids.

Any patient diagnosed with asthma, regardless of the stage, should have a short-acting beta2 agonist available to treat an acute exacerbation. The use of >1 canister/month indicates that a patient?s asthma is not well-controlled and that treatment must be adjusted accordingly.

Peak Flow Monitoring

Daily monitoring of peak flow is critical in the management of asthma. A patient who is feeling well and falls into the green zone (Table above) has asthma that is being well-managed, and the patient should be advised to continue the regular regimen. A patient who enters the yellow zone, however, needs a short-acting beta2 agonist. A patient could receive 2 to 4 puffs every 20 minutes for up to 1 hour or a single nebulizer treatment. If the patient is then in the green zone, the patient may continue with a short-acting beta2 agonist every 3 to 4 hours for 24 to 48 hours. Patients who are treated with inhaled corticosteroids may double their dose for 7 to 10 days.

If a patient stays in the yellow zone after using an inhaled beta2 agonist for 1 hour, a systemic corticosteroid should be added. For a patient who is experiencing a severe exacerbation and is in the red zone, a systemic corticosteroid should be administered in addition to a short-acting beta2 agonist. The patient should then call 911 and proceed to the emergency department (ED).

When a patient is brought to the ED due to an acute asthma exacerbation, the patient is started on oxygen, a short-acting beta2 agonist given via a metered dose inhaler (MDI) or a nebulizer, and a systemic corticosteroid. The dose and frequency of these agents are dependent on the severity of the exacerbation.

Asthma Management Devices

The vast majority of asthma medications come in the form of inhalers, making it crucial to instruct patients on the proper inhaler technique to ensure proper administration. (A table listing the steps for appropriate use MDIs can be found below.)

In recent years, dry powder inhalers (DPIs) have been gaining acceptance. DPIs offer some advantages over the traditional MDIs in that they require less coordination than MDIs, and many of them offer a dose counter.

Peak flow meters (PFMs) monitor declining lung function and asthma exacerbations in patients with moderate to severe asthma.

How to Use a Metered Dose Inhaler (MDI): Method 1


  1. Use the MDI in an upright position.
  2. Shake the inhaler 3 or 4 times, remove the cover, and exhale normally.
  3. Hold the MDI between the thumb and index fingers, and place it 2 in (~2 finger widths) in front of an open mouth.
  4. Slowly inhale through the mouth while depressing the MDI to get a dose; continue inhaling until the lungs are full.
  5. Hold your breath for 10 seconds or as long as possible; then exhale slowly.
  6. If a second dose is needed, wait 1 to 2 minutes, then repeat steps 3 to 5.
  7. If the MDI contains a corticosteroid, rinse the mouth after use.

How to Use a Metered Dose Inhaler (MDI): Method 2


  1. Use the MDI in an upright position.
  2. Shake the inhaler 3 or 4 times, then remove the cover.
  3. Hold the left index, middle, and ring fingers horizontal, with the side of the index finger between the upper lip and the nostrils. Place the MDI's mouthpiece just below the ring finger. With this method, the fingers help to maintain the proper distance between the MDI and the mouth, as well as preventing any inadvertent sprays into the nostrils and/or the eyes.
  4. Exhale normally.
  5. Slowly inhale through the mouth while depressing the MDI with the right thumb and index finger to administer a dose; continue inhaling until the lungs are full.
  6. Hold your breath for 10 seconds or as long as possible, then exhale slowly.
  7. If a second dose is needed, wait 1 to 2 minutes, then repeat steps 3 to 6.
  8. If the MDI contains a corticosteroid, rinse the mouth after use.

How to Use a Peak Flow Meter (PFM)


  1. Hold the PFM by the handle without blocking the needle or the airhole in the back.
  2. Reset the needle to 0 before each use.
  3. Use a PFM in the standing position.
  4. Take a deep breath to fill the lungs completely.
  5. Place your mouth around the mouthpiece, making a seal with the lips; be sure that the tongue is not blocking the mouthpiece.
  6. Exhale quickly in 1 forceful expiration to completely empty the lungs.
  7. Note this reading, and repeat steps 1 to 6 twice more, recording the highest of the 3 readings in an asthma diary.

How to Use a Dry Powder Inhaler (DPI)


  1. Use the DPI in an upright position.
  2. Load the dose of the DPI; this dose varies, depending on the type of DPI.
  3. Exhale normally away from the DPI so as not to blow the powder.
  4. Place the DPI into the mouth, making a seal with the lips.
  5. Inhale normally through the mouth until the lungs are full.
  6. Hold your breath for 10 seconds or as long as possible, then exhale slowly.
  7. Repeat steps 3 to 6 if another dose is needed.
  8. If the DPI contains a corticosteroid, rinse the mouth after use.

Choosing Medications for a Formulary

Pharmacy directors and clinicians need to fully comprehend the pharmaco-therapeutic agents that are used in the treatment of asthma for children and adults to streamline their medication formulary. Many medications that are used in asthma also are used for patients with other respiratory disorders, such as chronic obstructive pulmonary disease.

It is vital to differentiate chronic medications for asthma from those that are used in asthma exacerbation. Nebulizer treatments with ipratropium, a beta2 agonist, and systemic corticosteroids usually are required in the ED. Chronic medications, which include inhaler devices and spacers, should be readily available for patients to reconcile if they are admitted to the hospital for a nonrespiratory ailment.

A New Direction for Asthma Treatment

Susan Sloane, RPh, CDE, CPT

Ms. Sloane is a freelance writer based in Jamesville, New York.

The National Asthma Education and Prevention Program?s (NAEPP) updated Guidelines for the Diagnosis and Management of Asthma include 4 components for effective asthma control: assessment and monitoring; patient education; control of environmental factors and comorbid conditions that may affect asthma; and medications. It is hoped that, by implementing all 4 components in an individualized disease management plan, morbidity and mortality will be reduced.

1. Assessment and Monitoring

First, a practitioner needs to assess a patient?s current and future asthma risk. This includes checking frequency of exacerbations of symptoms and assessing current lung function. The clinician also will look at future risk, such as possible progressive loss of lung function, and adverse side effects from current medications that may affect lung function or breathing.

2. Patient Education

Patient education is of paramount importance in treating a chronic illness such as asthma. This training is best accomplished with a team approach, utilizing the physician, nursing staff, and pharmacist to educate patients properly on the disease itself, as well as proper use of medications?especially proper technique for inhaler use. (A table listing the steps for appropriate use of metered dose inhalers can be found above.)

Proper patient education should increase adherence to the treatment plan. In addition, a family support system for the continued proper management of the disease is crucial; the patient?s family needs to be educated so that family members may help the patient keep to the prescribed treatment regimen.

3. Environmental Factors and Comorbid Conditions

An important part of asthma treatment is the control of environmental factors and other conditions that can affect management of the disease. This includes assessing a patient?s home and work environment for possible exposure to allergens or irritants that can affect lung function, such as exposure to cigarette smoke or pollutants. Underlying health conditions that may affect asthma control also are considered, as well as any medications that may interact with asthma medications or impair breathing. For example, if a patient is obese, asthma symptoms are more difficult to manage; therefore, if the obesity is addressed with a proper weight-management program, asthma control will be improved.

4. Medications

The fourth component in this treatment modality is medication management. The goal of medication management is to eliminate symptoms as much as possible by using the minimum amount of medication, while still maintaining a high quality of life. This is accomplished by a stepwise approach to treatment. Patients are evaluated using testing such as spirometry; in some cases, oxygen levels are measured in the blood. One standard of how asthma treatment is determined is to assess how often breathing problems occur. If problems occur more than twice a week during the daytime or more than twice a month during the night, a patient is generally a candidate for long-term preventive treatment options.

The updated NAEPP guidelines are necessary because asthma remains poorly controlled in many patients. They address previously unrecognized or understated treatment factors, such as the treatment of asthma in young children and infants, and point out that reducing early childhood exposure to allergens and tobacco smoke may prevent the development of asthma later in life.

If followed correctly, these guidelines could help make significant strides in keeping asthma patients healthy and improving their overall quality of life. If a patient?s primary care physician adheres to the new guidelines, asthma patients will receive not only a more complete analysis of their disease, but will, in turn, receive more personalized treatment. Doctors will use a host of methods to discern how well patients are doing other than just asking them. It is a bold step forward in asthma management.


References

  1. National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung, and Blood Institute Web site. www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
  2. FDA Public Health Advisory: Serevent Diskus, Advair Diskus, and Foradil Aerolizer. www.fda.gov/cder/drug/advisory/LABA.htm.
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