6) Seroflo Traning Module-Asthma Management (6).pptx

Seroflo Medical Training Asthma Management Section Objective You need to know from this section • What is the therapy options for asthma? • How to manage asthma. • What is the best therapy option • What is the key features to control asthma. • What is the asthma management guidelines. Asthma...

Seroflo Medical Training Asthma Management Section Objective You need to know from this section • What is the therapy options for asthma? • How to manage asthma. • What is the best therapy option • What is the key features to control asthma. • What is the asthma management guidelines. Asthma Management There is a wide range of medications used in the treatment of asthma. These can be grouped into six classes: • • • • • • Corticosteroids (cornerstone for asthma management)  2 -agonists (short-acting or long-acting) Cromones Theophylline leukotriene receptor antagonists Anticholinergics. The two most important, and widely used, treatments are  2- agonists and corticosteroids Corticosteroids (Local Or Systemic) • Corticosteroids are used as Prophylactic therapy for controlling the underlying airways inflammation that is present in asthma. • That is, they are used to Prevent the symptoms of asthma (coughing, wheezing, chest tightness, breathlessness) from occurring. • They are also known as “Preventers”. • Oral corticosteroids (such as prednisolone) are also used in severe asthma, as well as in a number of other conditions that have an inflammatory element, such as arthritis. • Corticosteroids can also be given by injection during acute severe asthma attacks. • Local Corticosteroids (Inhaled or Topical): Fluticasone Propionate (Flohale & Flixotide) and Budesonide (Pulmicort) Corticosteroids • Corticosteroids act to decrease the inflammatory process. At therapeutic doses, inhaled corticosteroids help to prevent the consequences of inflammatory mediator activity. • This effect manifests itself by:  A reduction in the number of inflammatory cells in the bronchial epithelium and submucosa A reduction in mucus secretion and oedema Suppression of smooth muscle hyperreactivity. • Inhaled corticosteroid also demonstrated:  an increase in FEV1 and other measures of lung function  a reduction in symptoms  a reduction in exacerbations  an increase in ciliated epithelial cells, and improvement in the structure of the bronchial epithelium  a reduction in bronchial hyperreactivity compared to before therapy Corticosteroids Onset of Action and Duration of Effect • Inhaled steroids need to be taken regularly every day to have maximum effect. • It may take up to 1 week for the patient to notice a difference, so it is important that they persevere with treatment. • Most presentations are taken 2 day, but occasionally may be taken three or four times a day or once only. Corticosteroids Local Side-effects • With inhaled therapies, local side-effects may occur in the mouth and throat. • These are the most common local side-effects:  Fungal infection of the mouth – thrush (oral candidiasis).  Sore throat/hoarseness (dysphonia). • These side-effects appear to increase with higher doses, but can be reduced by simple measures such as taking the daily dose in two, as opposed to four, divided doses and brushing the teeth or rinsing the mouth after each dose. • The use of a large-volume spacer may also reduce local side-effects, since less drug impacts on the back of the throat. Corticosteroids Systemic Side-effects • When considering the possible systemic side-effects of inhaled corticosteroids, the five main areas for concern are: • Adrenal function (HPA axis) suppression  The body is unable to differentiate between naturally occurring (endogenous) cortisol and medically administered (exogenous) corticosteroids. Therefore, if sufficient exogenous corticosteroids are present in the systemic circulation they can trigger this negative feedback mechanism, decreasing the production of the body's own cortisol.  Acute adrenal insufficiency results in a serious and, if untreated, fatal condition known as Addisonian crisis.  Addison’s disease is a rare, chronic endocrine disorder in which the adrenal glands do not produce sufficient steroid hormones. It is characterized by a number of relatively nonspecific symptoms, such as abdominal pain and weakness, but under certain circumstances, these may progress to Addisonian crisis, a severe illness which may include very low blood pressure and coma. Corticosteroids Adrenal function (HPA axis) suppression CRH=Corticotropin releasing hormone ACTH= Adrenocorticotropic hormone Corticosteroids Systemic Side-effects • In extreme cases, such as in overdose or with prolonged use, actions of corticosteroids may be exaggerated, leading to side-effects. • These may include : diabetes, osteoporosis, mental disturbances, peptic ulceration, Cushing syndrome (moon face, buffalo hump, striae or stretch marks on the skin, acne, skin bruising), reduced resistance to infections, or adrenal atrophy. • Reduction in bone mineral density (or osteoporosis) • Growth retardation: Corticosteroids affect androgen secretion and inhibit the release of growth hormone as well as inhibition of osteoblasts. • Glaucoma (or ocular hypertension) is a condition where the pressure in the eye is increased. This can be seen when corticosteroid eye drops are used or with oral steroid use • Cataract: cataract is an opacity in the lens of the eye which occurs most commonly in the elderly. Cataracts can cause a gradual loss of vision, if left untreated, but surgical treatment is available. Systemic corticosteroids can cause cataracts Asthma Management-  2 -agonists  2 –agonists •  2 -agonists (beta 2 -adrenergic agonists) are medications that stimulate the  2 –adrenergic receptors, which relaxes the airway smooth muscle thereby relieving or preventing bronchospasm. • There are two main types of  2 -agonist:  Short-acting  2 -agonists are  Long-acting  2 -agonists, are  2 –agonist usually used on an “as required” bronchodilators with a longer duration basis for the rapid relief of of action (12 hours compared with asthma symptoms.  They are commonly referred to 4–6 hours for short-acting  2 -agonists). as “relievers”.  Example: Salbutamol (Ventolin)  Long-acting  2 agonists are generally used to protect patients from symptoms. They are sometimes referred to as “protectors”.  Example: Salmeterol (Servent) & Formoterol (Foradil)  2 -agonists Routes of Administration  Inhalation = Direct Administration • To relieve bronchoconstriction, the  2 -agonist must reach the  2 -receptors on the airway smooth muscle. Inhaling medication directly into the lungs is an effective method of delivering drug directly to the site of action and not stimulating other  -receptors in the body. • It also allows a lower dose to be administered than with oral therapy, and reduces the potential for systemic sideeffects. Inhaled therapy is therefore the preferred method of beta-agonist drug delivery in asthma.  2 -agonists Role of Short-acting  2 -agonists in Asthma Therapy • “As required” relief of asthma symptoms. When given by inhalation, short-acting  2 -agonists have a rapid onset of action – within 20-45 seconds – providing rapid relief of bronchoconstriction. • Inhaled short-acting  2 -agonists can also be given 10–15 minutes prior to exercise or exposure to an allergen or other trigger factor, to help prevent symptoms occurring. • Inhaled short-acting  2 -agonists can be given up to four times a day. However, Frequent use (more than once daily) suggests that the underlying inflammation of asthma is not being adequately controlled, and an over-reliance on relief medication may delay appropriate treatment with anti-inflammatory agents (i.e. corticosteroids).  2 -agonists Role of Long-acting  2 -agonists in Asthma Therapy • The onset can vary from within 3 minutes (formoterol) to 10–20 minutes (salmeterol). • Both of these agents have a duration of action of 12 hours. • Unlike short-acting  2 –agonists, long-acting  2–agonists should be used regularly to produce long-lasting bronchodilatation • Salmeterol has much higher  2/  1 selectivity than formoterol (85000/400)  2 -agonists Side-effects • The side-effects of  -receptors in the body, other than in the lung. 2 -agonists usually stem from their action on  • While  2 -receptors, some stimulation of the  2 -agonists used in asthma treatment today are “selective” for the  1 -receptors in the heart muscle may still occur. • This can cause cardiovascular side-effects, such as rapid or irregular heart beats (cardiac palpitations, arrhythmias or tachycardia). • While  2 -receptors are found predominantly in the lung, they are also situated elsewhere in the body, such as in skeletal muscle. Stimulation of  2–receptors in these sites may cause tremor, usually in the hands. • This is unusual with inhaled therapy at standard doses, but may happen when  2 -agonists are given orally or nebulized at high doses.  2 -agonists Side-effects • Hypokalemia, which is a lowering of the potassium level in the blood. Again, this is a dose-dependent effect and usually only occurs at high doses. • Mechanism: not clear, however, it is thought that: Salbutamol increases Insulin release and Insulin causes a shift of potassium into the cells, i.e.: decreased extracellularly  hypokalemia • As with any inhaled product, local side-effects, such as mouth or throat irritation, may also occur following use of an inhaled  2 -agonist. Chromones • Chromones are anti-inflammatory drugs that act in a different manner to steroids. • The two main drugs in this group are sodium cromoglicate and nedocromil sodium. • Sodium cromoglicate and nedocromil sodium are substances that do not cross cell membranes and are poorly absorbed from the gastrointestinal tract. • They must therefore be given by the inhaled route. • These drugs were originally regarded as being specific anti-allergic compounds because they are able to stabilize mast cells to prevent degranulation in response to an allergen trigger. • The mechanism of mast cell ‘stabilization’ is poorly understood and this may not be their sole method of action. • Chromones are mostly used in children because of their relative lack of adverse events. • Example: Cromoglicic acid Leukotriene Receptor Antagonists • Various mediators of inflammation are significant in asthma, including histamine, various cytokines and leukotrienes. • Intervention in the action of these mediators is proposed to offer therapeutic benefit. • Recent developments in drug therapy have centered around leukotriene receptor antagonists (LTRAs). • Role of Leukotrienes: constrict bronchial smooth muscle, increase mucus production and promote vascular permeability and oedema formation. • These are all properties that may be relevant to the pathogenesis of asthma. • Example: Singulair Leukotriene Receptor Antagonists Mode of Action • The extent to which blockade of one set of inflammatory mediators can attenuate the asthmatic response may be difficult to predict. • This is reflected in the clinical profile of LTRAs, which are less effective than low-dose inhaled corticosteroids in the management of mild asthma. • Inhaled corticosteroids block the inflammatory cascade earlier than LTRAs and are established as the cornerstone of management. • Montelukast is indicated as add-on therapy to inhaled. Side Effects • Experience is limited with these relatively new drugs. • The most commonly reported adverse effects following treatment with LTRAs are headache and gastrointestinal disturbances. Theophylline • There are 3 types of oral theophylline drugs currently in use in asthma treatment .  Theophylline – Nuelin, Slo-Phyllin, Theo-dur, Uniphyllin Continus  Choline theophyllinate – Choledyl  Aminophylline - Phyllocontin. • Aminophylline is also available as an injection for acute, severe asthma. • Theophylline exert a direct action on airway smooth muscle. • Theophylline may work by inhibiting the enzyme (phosphodiesterase) responsible for breaking down adenosine triphosphate (ATP). This is a process that releases the energy to allow a muscle cell to contract. • There is limited evidence that theophylline may have an anti inflammatory action at sub-bronchodilator doses, but the clinical relevance of this is unclear. • Example: Quibron-T. Theophylline Onset of Action and Duration of Effect / Side Effects • Theophylline are too irritant for intramuscular or inhaled use. One theophylline (aminophylline) can be given intravenously; in this case the onset of action is rapid, and for this reason they are used as emergency relief in acute bronchospasm. • In other situations, theophylline's may be given orally; in this case the onset of action depends on the formulation. • Ordinary tablets, soluble tablets and syrup act more quickly and have a shorter duration of effect than slow release (SR) tablets, which may last for 8–12 hours • Theophylline's may cause vasodilatation resulting in flushing, headache & hypotension. • Stimulation of the central nervous system may result in restlessness, insomnia, nausea, vomiting and, in severe cases, convulsions, coma and death. • Theophylline's also stimulate the heart causing palpitations, tachycardia, arrhythmias and, in severe cases, cardiac arrest and death. Theophylline Side Effects • Theophylline have a very narrow therapeutic window, a small increase in dose can result in toxic effects, while a small decrease may result in loss of therapeutic effect. • Many factors can affect the metabolism of theophylline, for example age, sex, body weight and smoking. • Individual dose titration, using blood samples, is therefore desirable. Numerous drug interactions can also increase or decrease plasma theophylline levels. Anticholinergics There are two anticholinergic dugs in current use as bronchodilators: ipratropium bromide (Atrovent) oxitropium bromide (Oxivent). Mechanism of Action: • Anticholinergic drugs act on the parasympathetic pathway of the autonomic nervous system. • Anticholinergic drugs antagonize, or block, the action of acetylcholine at cholinergic receptor sites on smooth muscle cells. • Cholinergic receptors have many functions in the respiratory system including mucus secretion and smooth muscle contraction. • Anticholinergics are not widely used in asthma, and are usually prescribed to patients already on high-dose inhaled steroids. • Anticholinergics are mostly used in patients with COPD. Anticholinergics Mechanism of Action: Side Effects: • Significant anticholinergic side-effects are rarely seen except at high doses but, when they do occur, they include dry mouth, urinary retention and constipation. Asthma Management • The aim of asthma management is to achieve the maximum Control of symptoms using the minimum amount of drug therapy, thereby reducing the risk of side-effects. • There is no permanent cure for asthma but appropriate use of medication can control symptoms for the majority of patients, enabling them to lead normal active lives. • It is important to note that patients should start treatment at the step most appropriate to the severity of their disease. • Patients do not have to be started at step 1 and work their way up the steps until their asthma is controlled. • For example, a patient with severe asthma may be started at step 4 or 5, and subsequently reviewed. • The aim of therapy is to achieve control of asthma as quickly as possible and then to reduce treatment. Asthma Management Stepping Down • An important, and sometimes overlooked, part of asthma management is the regular review of patients and stepping down of therapy. • Patients with chronic asthma should be reviewed every 3 to 6 months and, if control is achieved, a step-wise reduction in treatment tried. • Let’s have a look at the previous guidelines: Goals of asthma treatment § Few asthma symptoms § No sleep disturbance § No exercise limitation Symptom control (e.g. ACT, ACQ) § Maintain normal lung function § Prevent flare-ups (exacerbations) § Prevent asthma deaths § Minimize medication side-effects (including OCS) Risk reduction § The patient’s goals may be different § Symptom control and risk may be discordant § Patients with few symptoms can still have severe exacerbations ACQ: Asthma Control Questionnaire; ACT: Asthma Control Test; OCS: oral corticosteroids © Global Initiative for Asthma, www.ginasthma.org GINA 2023 Box 3-2 © Global Initiative for Asthma, www.ginasthma.org *Anti-inflammatory reliever (AIR) Box 3-12 © Global Initiative for Asthma, www.ginasthma.org GINA 2023 – Adults and adolescents Track 1 Maintenance and reliever therapy (MART) with ICS-formoterol As-needed-only ICS-formoterol (‘AIR-only’) *An anti-inflammatory reliever (AIR) Box 3-12 (2/4) Track 1 © Global Initiative for Asthma, www.ginasthma.org GINA 2023 – Adults and adolescents Track 2 *An anti-inflammatory reliever (Steps 3–5) Box 3-12 (3/4) Track 2 © Global Initiative for Asthma, www.ginasthma.org GINA 2023 – Adults and adolescents Box 3-12 4/4) © Global Initiative for Asthma, www.ginasthma.org Classification Of Asthma Control Asthma Management Follow Up • It is very important that any patient who has had an asthma attack should receive follow up care. • Patients who have had a severe attack and were admitted to hospital, should be discharged only if they have been on their discharge medications for 24 hours and their inhaler technique is correct. • An asthma self-management plan is in place and the patient has their own PEF meter. • GP or asthma nurse follow-up appointment arranged within 1 week • Follow-up appointment in hospital clinic arranged within 4 weeks. Thank You