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Overview of Asthma Management: Dr. Noor Aliza Bte Md. Tarekh. Chest Physician, HSAJB
Overview of Asthma Management: Dr. Noor Aliza Bte Md. Tarekh. Chest Physician, HSAJB
MANAGEMENT
airway hyperresponsiveness
Asthma COPD
population population
10% of patients
have both
conditions
Modern view of
asthma Allergen
Macrophage/
dendritic cell Mast cell
Eosinophil
Mucus plug
Epithelial shedding
Nerve activation
Subepithelial
fibrosis
Plasma leak
Sensory nerve
Oedema activation
Vasodilatation Cholinergic
Mucus New vessels reflex
hypersecretion
Hyperplasia Bronchoconstriction
Hypertrophy / hyperplasia
Barnes PJ
Inflammatory processes
Male non-smokers
p <0.001
No asthma (n = 5480)
Asthma (n = 314)
Age (years)
soldering flux
wood dust
Asthma:
diagnosis
Asthma diagnosis
Others
Allergens
exercise
animal dander
viral infection
dust mites smoke
Before bronchodilator
After bronchodilator
Day
Morning Evening
Diagnosis
‘Clinical’ exacerbation
PEF
Mild attack
Acute severe
attack
Exacerbation
Days
FEV1
Normal subject
1 2 3 4 5
Time (sec)
Note: Each FEV1 curve represents the highest of three repeat measurements
FEV1 and FVC provide a useful guides to the degree of airflow obstruction at
diagnosis and in the evaluation of the effectiveness of anti-asthma drugs.
Diagnostic challenges in
adults
heart failure
COPD
angina
bronchiectasis
lung cancer
‘Clinical’ classification of severity
Asthma severity is graded, in the GINA guidelines, according to the frequency of symptoms,
occurrence of symptoms at night, and PEF measurement before treatment.
‘Real-life’ classification of severity
Relievers Controllers
inhaled
fast-acting inhaled corticosteroids
ß2-agonists inhaled long-acting ß -
2
inhaled anticholinergics agonists
inhaled cromones
oral anti-leukotrienes
oral theophyllines
oral corticosteroids
RELIEVERS MEDICATION
ORAL
PARENTERAL
Classes of ß2-agonists
Speed of
onset RESCUE MEDICATION
Mechanism of action:
Bronchodilator
Enhance mucociliary clearance
Modulate mediators release from mast cells and
basophils
chemical structure
pharmacological properties:
mode of action in the ß2-receptor region
potency
efficacy (ie full / partial agonism)
selectivity
CONTROLLER MEDICATIONS
Inhaled : Beclomethasone
Budesonide
Fluticasone
Oral : Prednisolone
Dexamethasone
Parenteral : Hydrocortisone
Methylprednisolone
Side effects
Local effects –
use of spacer
Systemic adverse
effects depends on the dose and potency of
glucocrticosteroids , absorption in the gut, first past
effect of liver.
Systemic adverse effects include : skin thinning,
Mechanism of action:
Antiinflammatory effects &
bronchodilator.
Side effects :
GIT Symptoms – nausea, vomiting
CVS Symptoms – tachycardia,
arrhythmias
Drug interaction : Erythromycin,
cimetidine and rifampicin
Anti-cholinergics
Inhaled ipratropium bromide.
MECHANISM OF ACTION :
Block the synthesis of all leukotrienes
RELIEVER Step up
CONTROLLER: none
• Inhaled ß2- if not controlled
agonist p.r.n. (after check on
inhaler technique
Avoid or control triggers and compliance)
TREATMENT
GINA Guidelines 1998
Step 1
Future?
stepping up and down should involve both LAßA and ICS
Asthma:
rationale for adding
LAßA to ICS therapy
THE FACET STUDY
0.5
0
Pulmicort® Pulmicort® 100 µg bid Pulmicort® Pulmicort® 400 µg bid
100 µg bid + Oxis® 9 µg bid 400 µg bid + Oxis® 9 µg bid
80
Pulmicort® Pulmicort® 100 µg bid
75 100 µg bid + Oxis® 9 µg bid
Pulmicort® Pulmicort® 400 µg bid
400 µg bid + Oxis® 9 µg bid
70
-1 0 1 2 3 6 9 12
Months
-10
Pulmicort® Pulmicort® 100 µg bid
-20 100 µg bid + Oxis® 9 µg bid
Pulmicort® Pulmicort® 400 µg bid
400 µg bid + Oxis® 9 µg bid
-30
0 1 2 3 6 9 12
Months
Suppresses + ө
inflammation
Bronchodilates airways - +
Reduces AHR + +
Prevents progressive
airway damage
+ -
ө mast cell stabilising effect, reduces plasma exudation / inflammatory mediator release
Budesonide is highly effective at suppressing inflammation in the airway wall,
formoterol exerts a complementery action through stabilising mast cells and
reducing plasma exudation and inflammatory mediator realease.
Why add formoterol to budesonide?
Cellular activity Formoterol Budesonide
Activates cortico. - +
receptors
- +
Acts via ß2-receptors
+ -
Activates ß2-receptors
Salmeterol/formoterol.
Have not been tested extensively in
pregnant women.
Theophyllines.
May aggravate the nausea and gastroesophageal
reflux.
May cause transient neonatal tachycardia and
irritability.
Inhaled corticosteroids.
Has good safety profile in pregnancy.
Anti-leukotrienes.
No data is available on the use of this agent in
pregnant women.
Oral corticosteroids.
Sometimes necessary for severe asthma but usually
only for short periods.
An increased risk of cleft palate has been reported in
animals given huge doses.
Breastfeeding.
Should be continued in women with asthma.