UCI INTERNAL MEDICINE MINI-LECTURE SERIES

BY KEVIN COOK

Asthma - Treatment

Objectives

Understand severity scoring vs. control in guiding the treatment of asthma

Discuss the utility of the “asthma ladder” in step up and step down therapy

Introduce new therapies used in patients with refractory asthma

Asthma Severity vs. Control

Severity - the intrinsic intensity of the disease process Dictates which step to initiate treatment Intermittent symptoms require rescue medication Persistent symptoms require controller medication

Control - the degree to which the goals of therapy are met prevent symptoms/exacerbations, maintain normal

lung function and activity levels

Assessing Severity

Class Daytime symptoms

Nocturnal symptoms

Intermittent 2x or less per week

2x or less per mo

Mild Persistent >2x per week >2x per mo

Moderate Persistent

Daily >1x per week

Severe Persistent

Continual Frequent

All patients classified in a “persistent” asthma category will require initiation of controller medications

Assessing Control - The Asthma Ladder

Asthma Step Ladder

Step 6 High dose ICS + LABAAND oral corticosteroid

Step 5 High dose ICS + LABA

Step 4 Medium dose ICS + LABA

Step 3 Low dose ICS + LABAOR Medium dose ICS

Step 2 Low dose ICS

Step 1 SABA as needed

Per

sist

ent

Ast

hma

Inte

rmitt

ent

Ast

hma

Ste

p U

p T

hera

py

Ste

p D

own

The

rapy

Assessing Control – Should I Step Up?

Well controlled

Not well controlled

Poorly controlled

Daytime symptoms

2x or less per week

>2x per week daily

Night awakenings 2x or less per month

>2x per month >3x per week

SABA use 2x or less per week

>2x per week daily

FEV1 or peak flow >80% 60-80% <60%

Recommendation Maintain current step

Step up 1, reevaluate 2-6 weeks

Step up 1-2, Consider short course of oral steroids, reevaluate in 2 weeks

Case Study

A 24 y/o patient with mild persistent asthma was initially well controlled with low dose inhaled corticosteroid. Today he returns for follow up.  He is now complaining of increasingly frequent episodes of shortness of breath, using his short-acting beta agonist 3 times per week.  Which of the following statements is correct regarding management of this patient? 

a) continue current management as symptoms require beta agonist less than once daily

b) add a long acting beta agonist

c) increase to medium dose inhaled corticosteroid

d) add tiotropium

e) B or C

Assessing Control – Should I Step Up?

Well controlled

Not well controlled

Poorly controlled

Daytime symptoms

2x or less per week

>2x per week daily

Night awakenings 2x or less per month

>2x per month >3x per week

SABA use 2x or less per week

>2x per week daily

FEV1 or peak flow >80% 60-80% <60%

Recommendation Maintain current step

Step up 1, reevaluate 2-6 weeks

Step up 1-2, Consider short course of oral steroids, reevaluate in 2 weeks

Assessing Control - The Asthma Ladder

Asthma Step Ladder

Step 6 High dose ICS + LABAAND oral corticosteroid

Step 5 High dose ICS + LABA

Step 4 Medium dose ICS + LABA

Step 3 Low dose ICS + LABAOR Medium dose ICS

Step 2 Low dose ICS

Step 1 SABA as needed

Per

sist

ent

Ast

hma

Inte

rmitt

ent

Ast

hma

Ste

p U

p T

hera

py

Ste

p D

own

The

rapy

Case Study

A 24 y/o patient with mild persistent asthma was initially well controlled with low dose inhaled corticosteroid. Today he returns for follow up.  He is now complaining of increased shortness of breath and using his short-acting beta agonist 3 times per week.  Which of the following statements is correct regarding management of this patient? 

a) continue current management as symptoms require beta agonist less than once daily

b) add a long acting beta agonist

c) increase to medium dose inhaled corticosteroid

d) add tiotropium

e) B or C

On step 6 and still not well controlled?

Alternative diagnoses such as COPD, left ventricular failure, localized obstruction, cystic fibrosis and/or vocal cord dysfunction should be ruled out

Omalizumab - anti-IgE therapy in patients with allergic asthma (works by binding IgE so that it cannot complex with allergens to stimulate immune cells

Bronchial thermoplasty – heat applied directly to the airways by bronchoscopy to reduce the airway smooth muscle mass and attenuate bronchoconstriction

Summary

Initial treatment of asthma requires assessment of severity

Longitudinal treatment requires assessment of control with the use of the “asthma ladder” for step up and step down therapy

Persistent symptoms require controller medication: start with ICS and add LABA if still not controlled

Seek consultation if high dose ICS are required

References

National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug.Available from: http://www.ncbi.nlm.nih.gov/books/NBK7232/

Scialla, Timothy. “Asthma Summary 2013”. Hopkins Modules.