Describe the rescue inhaler (salbutamol) for asthma
- Every patient should have this as rescue when experiencing sx
- Shouldn’t use more than 4 times per week
- Monotherapy only appropriate in very mild asthma
- Strongly encourage aerochamber
- AE = increased nervousness, HR, and headache
Describe the maintenance inhaler (corticosteroid) for asthma
- Every patient should be on this for maintenance
- Always start at lowest possible dose
- Can increase dose if asthma not controlled in 6-11 year olds
- AE = thrush and hoarseness; sx decreased w/ spacer and rinsing mouth after use
Describe the use of LABA for asthma
- Add on to steroid for those 12 years and older w/ uncontrolled asthma
- Steroid/LABA combination inhaler (ex: Symbicort, Advair, Breo) preferred for adherence
- If using Symbicort, can increase to 8 puffs/day as reliever and controller during flare
- AE = same as SABA
Describe the use of LTRAs (montelukast) for asthma
- Help w/ allergic component
- Prevent further inflammation (better for prevention than tx)
- AE = headache, rash
Describe asthma exacerbation management
- Exacerbation = acute worsening of sx from baseline
- Repetitive administration of rapid-acting beta 2 agonist -> 4-10 puffs every 20 mins for 1 hour, then if stable 2-4 puffs PRN (ex: every 1-4 hours)
- Early introduction of systemic corticosteroids (kids = prednisone 1-2 mg/kg/day * 3-5 days; adults = prednisone 50 mg daily * 5-7 days)
- Short term AE = hyperglycemia, increased appetite, fluid retention, mood alteration
- Oxygen supplementation
Describe asthma post-exacerbation management
- May continue SABA 2-4 puffs every 1-4 hours until sx resolve
- Step up tx (increase ICS dose or add LABA) and monitor over 1-3 months, then may consider reducing ICS to lowest effective dose
Describe exercise-induced bronchoconstriction
- Develops 5-10 mins after completing exercise and resolves spontaneously w/in 30-45 mins
- If underlying asthma, may indicate poor control -> step-up controller therapy
- If no underlying asthma, yet require SABA prior to exercise -> get a spirometry
- If pt needs SABA more than 3 times/week (including for exercise) -> need an ICS (poor control)
Drug interactions w/ asthma meds
- ICS -> 3A4 inhibitors may increase fluticasone and budesonide serum concentrations
- LABA -> 3A4 inhibitors may increase AE of salmeterol
Asthma red flags
- Any child under 6 y/o (refer to specialist)
- Unable to speak
- SOB at rest
- Reliever not working
- Peak flow < 60% predicted best
- Pt knows from past experience they are having a serious attack
Case specific assessment questions for asthma
Adherence, triggers, technique!!
- How do you use your inhalers?
- Do you know what triggers an asthma attack for you? Do you try to avoid it as much as possible?
- How many days in the week do you have symptoms? (want less than 4)
- How many nights in the week do you have symptoms? (want less than 1)
- How often do you use your rescue inhaler in a week? (want less than 4 including exercise)
- How often do you have exacerbations?
- Do you miss any school or work due to your asthma? (want none)
- How is your physical activity? (want it to be normal)
- Do you have an action plan?
- How often do you measure your breathing? (should be twice a day)
- Have you had a spirometry? (only way to diagnose)
- Do you use an aerochamber?
Yellow zone recommendations for asthma (based on age)
- For 11 years and younger -> prednisone 1 mg/kg * 3-5 days
- For 12 years and older -> quadruple ICS for 7-14 days
Non-pharms for asthma
- Avoid triggers
- Annual flu shot
- Healthy diet
- Encourage physical activity
- Breathing exercises
GENERAL follow-up for asthma
- Always assess adherence, triggers, and technique
- Follow up at every visit and reassess if asthma is still controlled
- Follow-up in 1-3 months for every dose increase or addition of new inhaler
- Maximum sx improvement w/ steroids in 4-8 weeks; follow-up 1-3 months after starting tx
Describe monitoring for post-asthma exacerbation
- Monitor for signs & sx of exacerbation daily/weekly & for SE of the drug
- Should be scheduling the SABA to 4-10 puffs every 20 minutes for 1 hour, then if stable 2-4 puffs PRN (q1-4h)
- SABA SE -> headache, increased HR, increased excitability
- Should be prescribed prednisone if doesn’t respond to SABA in 6-8 hrs. Depending on how long the steroids are prescribed (3-5 days), sx should be improving within 1-2 days and should be almost completely gone by the time the course is finished
- Prednisone SE -> “most of the side effects of this drug only occur after long-term use of the drug, however when you take it for only a short period of time you may experience insomnia or GI upset”
When to go to a doctor post-asthma exacerbation
Go to doctor if sx have not improved at all or only minimally after full tx course
When to go to emergency post-asthma exacerbation
Go to emergency if any sx get worse, you can’t breathe, you are unable to speak, or the rescue inhaler is not working
Describe non-pharms for post-asthma exacerbation
- Find out your triggers and avoid as much as possible
- Ensure you are using the proper technique; always use an aerochamber w/ MDI
- Make sure you use your controller meds every day and shouldn’t be using SABA more than 4 times/week, so shouldn’t be using more than 2-3 inhalers per year (b/c if they use 2 puffs/dose & if they have 1-2 exacerbations/year then they’ll need > 1 inhaler/year)
- Immunizations, exercise, good nutrition
Describe follow-up for post-asthma exacerbation
- If only using scheduled SABA -> I will follow up with you in 3 days to see if your symptoms have improved and if you feel that it has treated the exacerbation.
- If using scheduled SABA & prednisone -> I will follow up with you in 2-3 days to see if your symptoms have improved and if you feel the exacerbation is getting better/completely treated
Describe monitoring for asthma when adding or increasing ICS
- Monitor for SE of the ICS daily and sx improvement weekly
- Monitor for sx improvement after about 1 month. It takes about 4-8 weeks to reach full effect
- ICS SE -> thrush and hoarseness
When to go to the doctor for asthma when adding or increasing ICS
- Go to doctor if notice no improvement after about 3-4 months
- “It does take a while for this medication to reach its full benefit, so hopefully by your next refill of this inhaler we can talk again about if your symptoms have improved. I would want to wait around 3 months before we decide if you need an increased dose or not.”
When to go to emergency for asthma when adding or increasing ICS
Go to emergency if experiencing an exacerbation (SOB at rest, unable to speak, SABA isn’t working)
Non-pharms for asthma when adding or increasing ICS
- *Adherence, triggers, and technique
- Annual flu shot
- Healthy diet
- Physical activity
Follow-up for asthma when adding or increasing ICS
I will follow up with you in 2 weeks to see if you are having any SE. Unfortunately, we can’t really discuss sx improvement for at least 4 weeks, so I will discuss that with you the next time you refill your prescription
What is important to remember when someone comes in w/ an Rx for a LABA for asthma?
- Only for those 12 and older
- Prefer an ICS/LABA combo inhaler (ex: Symbicort, zenhale, advair)
