Tzippora Halpert, PharmD Candidate

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.

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

Patient should follow acute asthma exacerbation plan

? Green Zone?PEF 80%-100% of personal best

Patient should follow routine therapeutic plan

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

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.

 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 beta

 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.

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.

The preferred treatment for moderate persistent asthma, or step 3, involves the addition of low-dose inhaled corticosteroids in conjunction with a long-acting beta

 agonist, or medium-dose inhaled corticosteroids only. At present, 2 long-acting beta

 agonists are available, salmeterol and formoterol. It is recommended that long-acting beta

 agonists not be used as monotherapy, because these medicines may increase the chances of a severe asthma episode.

 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.

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 beta

 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 beta

Any patient diagnosed with asthma, regardless of the stage, should have a short-acting beta

 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.

Daily monitoring of peak flow is critical in the management of asthma. A patient who is feeling well and falls into the green zone (

) 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 beta

 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 beta

 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 beta

 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 beta

 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 beta

 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.

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

Shake the inhaler 3 or 4 times, remove the cover, and exhale normally.

Hold the MDI between the thumb and index fingers, and place it 2 in (~2 finger widths) in front of an open mouth.

Slowly inhale through the mouth while depressing the MDI to get a dose; continue inhaling until the lungs are full.

Hold your breath for 10 seconds or as long as possible; then exhale slowly.

If a second dose is needed, wait 1 to 2 minutes, then repeat steps 3 to 5.

If the MDI contains a corticosteroid, rinse the mouth after use.

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

Shake the inhaler 3 or 4 times, then remove the cover.

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.

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.

Hold your breath for 10 seconds or as long as possible, then exhale slowly.

If a second dose is needed, wait 1 to 2 minutes, then repeat steps 3 to 6.

Articles

The National Asthma Education and Prevention Program's Expert Panel has issued revised guidelines for treating asthma in children and adults.