Professional Documents
Culture Documents
Sarjan Final Project
Sarjan Final Project
Submitted to
RAJIV GANDHI PROUDYOGIKI VISHWAVIDHALAYA, BHOPAL
In Partial Fulfillment of the Requirement for the Degree of
BACHELOR OF PHARMACY
2021-2022
CERTIFICATE
He has collected the literature very sincerely and methodically and his work his
authentic.
PROJECT INCHARGE
Mrs. ABHILASHA DELOURI
ASSO. PROFESSOR
VIVEKANAND COLLEGE OF PHARMACY
VIP GAMPUS, RATIBAD, SIKANDARABAD BHOPAL, 462044
FORWARDING LETTER
MR.SARJAN MEENA has completed his project work entitled “AN OVERVIEW OF
ASTHMA & ITS TREATMENTS”Under the Supervision and Guidence of Asst. Prof.
Mrs SADHANA MANGROLE fulfillment for the degree of Bachelor of Pharmacy.
DECLARATION
This is to certify that the dissertation word entitled “AN OVERIEW OF ASTHMA &
ITS TREATMENTS" for the award of carried by our laboratories and library under
the guidance and supervision of DR. VIVEKANAND KATARE.
It also declare that present work embody has not the basic award for any
degree or fellowship previously. The particular given in this Project are true to be
best knowledge.
STUDENT
SARJAN MEENA
INDEX
1.
INTRODUCTION 02-04
2.
DEFINATION 05-06
3.
PATHOPHYSIOLOGY 07-08
4.
BRONCHOCONSTRICTION 09-11
5.
CAUSES 12-16
6.
DIAGNOSIS 17-20
7.
TREATMENT 21-23
8.
CONTROLLER MEDICATIONS 24-28
9.
CONCLUSION 29
ABSTRACT
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INTRODUCTION
Individuals with asthma typically react to concentrations of agents too low to cause
symptoms in people without asthma. Sometimes the trigger is an allergen such as
pollen, house dust mites, molds, or a particular food.
Other common triggers of asthma attacks are emotional upset, aspirin, sulfiting
agents (used in wine and beer and to keep greens fresh in salad bars), exercise, and
breathing cold air or cigarette smoke.
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Asthma affects people of all ages, but it most often starts during childhood. In the
United States, more than 25 million people are known to have asthma. About 7
million of these people are children.
To understand asthma, it helps to know how the airways work. The airways are
tubes that carry air into and out of lungs. People who have asthma have inflamed
airways.
This makes them swollen and very sensitive.They tend to react strongly certain
inhaled substances. When the airways react, the muscles around them tighten. This
narrows the airways, causing less air to flow into the lungs. The swelling also can
worsen, making the airways even narrower. Cells in the airways might make more
mucus than usual.
Mucus is a sticky, thick liquid that can further narrow the airways. This chain
reaction can result in asthma symptoms. Symptoms can happen each time the
airways are inflamed.
Asthma remains the most common chronic respiratory disease in Canada, affecting
approximately 10% of the population .
Results from the recent Reality of Asthma Control (TRAC) in Canada study suggest
that over 50% of Canadians with asthma have uncontrolled disease.
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VIVEKANAND COLLEGE OF PHARMACY
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DEFINITION
Sometimes asthma symptoms are mild and go away on their own or after minimal
treatment with asthma medicine. Other times, symptoms continue to get worse.
When symptoms get more intense and/or more symptoms occur, person is having
an asthma attack. Asthma attacks also are called flareups or exacerbations (eg-zas-
er-BA-shuns). Treating symptoms when first notice them is important.
This will help prevent the symptoms from worsening and causing a severe asthma
attack. Severe asthma attacks may require emergency care, and they can be fatal.
Outlook Asthma has no cure. Even when one feels fine, he/she still have the disease
and it can flare up at any time.
However, with today's knowledge and treatments, most people who have asthma
are able to manage the disease. They have few, if any, symptoms.
They can live normal, active lives and sleep through the night without interruption
from asthma. If one has asthma, he/she can take an active role in managing the
disease. For successful, thorough, and ongoing treatment, build strong
partnerships with doctor and other health care providers.
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PATHOPHYSIOLOGY
Various allergic (e.g., dust mites, cockroach residue, furred animals, moulds,
pollens) and non-allergic (e.g., infections, tobacco smoke, cold air, exercise)
triggers produce a cascade of immune-mediated events leading to chronic
airway inflammation.
The mediators and cytokines released during the early phase of an immune
response to an inciting allergen, trigger a further inflammatory response
(late-phase asthmatic response) that leads to further airway inflammation
and bronchial hyperreactivity .
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BRONCHOCONSTRICTION
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BRONCHIAL INFLAMMATION
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Inflammation results: chemicals are produced that cause the wall of the airway to
thicken, cells which produce scarring to proliferate and contribute to further
'airway remodeling', causes mucus producing cells to grow larger and produce
more and thicker mucus, and the cell-mediated arm of the immune system is
activated. Inflamed airways are more hyper-reactive, and will be more prone to
bronchospasm.
The "hygiene hypothesis" postulates that an imbalance in the regulation of these
TH cell types in early life leads to a long-term domination of the cells involved in
allergic responses over those involved in fighting infection. The suggestion is that
for a child being exposed to microbes early in life, taking fewer antibiotics, living
in a large family, and growing up in the country stimulate the TH1 response and
reduce the odds of developing asthma.
Asthma is associated with a procoagulant state in the bronchoalveolar space
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CAUSES
Asthma that starts before the age of 12 years old is more likely due to genetic
influence, while onset after age 12 is more likely due to environmental influence.
Asthma symptoms have two main causes [4-6], and both occur within the airways
of lungs: Airway Constriction This is the cause of asthma symptoms that one may
feel as a tightening in chest.
The muscles around the airways of lungs squeeze together or tighten. This
tightening is often called "bronchoconstriction," and it can make it hard for one to
breathe.
Many environmental factors have been associated with asthma's development
and exacerbation, including, allergens, air pollution, and other environmental
chemicals.
Smoking during pregnancy and after delivery is associated with a greater risk of
asthma-like symptoms.[42] Low air quality from environmental factors such
as traffic pollution or high ozone levels has been associated with both asthma
development and increased asthma severity.
Over half of cases in children in the United States occur in areas when air quality
is below the EPA standards. Low air quality is more common in low-income and
minority communities.
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Hygiene hypothesis
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Genetic
Family history is a risk factor for asthma, with many different genes being
implicated.] If one identical twin is affected, the probability of the other having the
disease is approximately 25%.
By the end of 2005, 25 genes had been associated with asthma in six or more
separate populations, including GSTM1, IL10, CTLA-
4, SPINK5, LTC4S, IL4R and ADAM33, among others.
Some genetic variants may only cause asthma when they are combined with
specific environmental exposures.
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several environmental sources including tobacco smoke, dogs, and farms. Risk for
asthma, then, is determined by both a person's genetics and the level of endotoxin
exposure.
Medical conditions
A triad of atopic eczema, allergic rhinitis and asthma is called atopy.[76] The
strongest risk factor for developing asthma is a history of atopic disease with
asthma occurring at a much greater rate in those who have either eczema or hay
fever.
Asthma has been associated with eosinophilic granulomatosis with
polyangiitis (formerly known as Churg–Strauss syndrome), an autoimmune
disease and vasculitis Individuals with certain types of urticaria may also
experience symptoms of asthma.
There is a correlation between obesity and the risk of asthma with both having
increased in recent years.[79][80] Several factors may be at play including decreased
respiratory function due to a buildup of fat and the fact that adipose tissue leads
to a pro-inflammatory state.[81]
Beta blocker medications such as propranolol can trigger asthma in those who
are susceptible. Cardioselective beta-blockers, however, appear safe in those with
mild or moderate disease.
Other medications that can cause problems in asthmatics are angiotensin-
converting enzyme inhibitors, aspirin, and NSAIDs.[85] Use of acid suppressing
medication (proton pump inhibitors and H2 blockers) during pregnancy is
associated with an increased risk of asthma in the child.
Exacerbation
Some individuals will have stable asthma for weeks or months and then suddenly
develop an episode of acute asthma. Different individuals react to various factors
in different ways.[87] Most individuals can develop severe exacerbation from a
number of triggering agents.
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DIAGNOSIS
Symptoms that are variable, occur upon exposure to allergens or irritants, that
worsen at night, and that respond to appropriate asthma therapy are strongly
suggestive of asthma .
During the history, it is also important to examine for possible triggers of asthma
symptoms, such as dust mites, cockroaches, animal dander, moulds, pollens,
exercise, and exposure to tobacco smoke or cold air. Exposure to agents
encountered in the work environment can also cause asthma.
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The diagnosis of asthma in young children is often more difficult since episodic
wheezing and cough are common in this patient population and spirometry is
unreliable in patients under 6 years of age.
Therefore, the absence of physical findings does not rule out a diagnosis of asthma.
The most common abnormal physical finding is wheezing on auscultation, which
confirms the presence of airflow limitation.
Physicians should also examine the upper respiratory tract and skin for signs of
concurrent atopic conditions such as allergic rhinitis or dermatitis .
It is recommended for all patients over 6 years of age who are able to undergo lung
function testing [4,6]. Spirometry must be performed according to proper protocols.
It is commonly performed in pulmonary function laboratories, but can also be
performed in primary-care offices.
During spirometry, the patient is instructed to take the deepest breath possible and
then to exhale as hard and as fully as possible into the mouthpiece of the spirometer.
Spirometry measures the forced vital capacity (FVC, the maximum volume of air that
can be exhaled) and the forced expiratory volume in 1 second (FEV1).
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In the general population, the FEV1/FVC ratio is usually greater than 0.80 (and
possibly greater than 0.90 in children) and, therefore, any values less than these
suggest airflow limitation and also support a diagnosis of asthma.
Because of the variability of asthma symptoms, patients will not exhibit reversible
airway obstruction at every visit. Therefore, to increase sensitivity, spirometry
should be repeated, particularly when patients are symptomatic .
Challenge testing When lung function tests are normal, but symptoms suggest
asthma, measurements of airway responsiveness using direct airway challenges to
inhaled bronchoconstrictor stimuli (e.g., methacholine or histamine) or indirect
challenges with mannitol or exercise may help confirm a diagnosis of asthma.
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For methacholine, a PC20 value less than 8 mg/mL is considered a positive result
indicative of airway hyperreactivity, and supports a diagnosis of asthma.
However, positive challenge tests are not specific to asthma and may occur with
other conditions such as allergic rhinitis and COPD. Therefore, challenge testing may
be most useful for ruling out asthma.
Challenge testing is contraindicated in patients with FEV1 values less than 60-70%
of the normal predicted value (since bronchoprovocation could cause significant
bronchospasms), in patients with uncontrolled hypertension or in those who
recently experienced a stroke or myocardial infarction.
Evidence suggests that exhaled nitric oxide levels may be better able to identify
asthmatic patients than basic lung function testing, and may also be useful for
monitoring patient response to asthma therapy.
Although these tests have been studied in the diagnosis and monitoring of asthma,
they are not yet widely used in Canada. With further clinical evidence and use, these
markers of airway inflammation will likely become more commonly available.
Allergy skin testing is also recommended to determine the allergic status of the
patient and to identify possible asthma triggers. Testing is typically performed using
the allergens relevant to the patient’s geographic region.
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TREATMENT
The primary goal of asthma management is to achieve and maintain control of the
disease in order to prevent exacerbations (abrupt and/or progressive worsening of
asthma symptoms that often require immediate medical attention and/or the use of
oral steroid therapy) and reduce the risk of morbidity and mortality.
The level of asthma control should be assessed at each visit using the criteria , and
treatment should be tailored to achieve control. In most asthma patients, control can
be achieved through the use of both avoidance measures and pharmacological
interventions.
The pharmacologic agents commonly used for the treatment of asthma can be
classified as controllers (medications taken daily on a long-term basis that achieve
control primarily through anti-inflammatory effects) and relievers (medications
used on an as-needed basis for quick relief of bronchoconstriction and symptoms)
Systemic corticosteroid therapy may also be required for the management of acute
asthma exacerbations. A simplified, stepwise algorithm for the treatment of asthma
is provided in.
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Avoidance measures
However, compliance with this recommendation is poor and, therefore, the use of
highefficiency particulate air (HEPA) filters and restricting the animal from the
bedroom or to the outdoors may be needed to attempt to decrease allergen levels.
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Reliever medications
Inhaled rapid-acting beta2-agonists are the preferred reliever medications for the
treatment of acute symptoms, and should be prescribed to all patients with asthma.
Unlike other LABAs, formoterol has a rapid onset of action and, therefore, can be
used for acute symptom relief. However, given that LABA monotherapy has been
associated with an increased risk of asthma-related morbidity and mortality,
formoterol should only be used as a reliever in patients 12 years of age or older who
are on regular controller therapy with an ICS [4,6,7].
However, these agents appear to be less effective than inhaled rapid-acting beta2-
agonists and, therefore, should be reserved as second-line therapy for patients who
are unable to use SABAs
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CONTROLLER MEDICATIONS
ICSs are the most effective anti-inflammatory medications available for the
treatment of asthma and represent the mainstay of therapy for most patients with
thedisease.
However, ICSs do not “cure” asthma, and symptoms tend to recur within weeks to
months of ICS discontinuation. Therefore, most patients will require long-term, if
not life-long, ICS treatment.
Since ICSs are highly effective when used optimally, factors other than treatment
efficacy need to be considered if ICS therapy is unsuccessful in achieving asthma
control.
These factors include: misdiagnosis of the disease, poor adherence to ICS therapy,
improper inhaler technique, or the presence of other comorbidities.
If, after addressing such factors, patients fail to achieve control with low-to-
moderate ICS doses, then treatment should be modified. For most children, ICS dose
escalation (to a moderate dose) is the preferred approach to achieve control, while
the addition of another class of medications (usually a LABA) is recommended for
patients over 12 years of age.
The most common local adverse events associated with ICS therapy are
oropharyngeal candidiasis (also known as oral thrush) and dysphonia (hoarseness,
difficulty speaking).
Rinsing and expectorating (spitting) after each inhalation and/or the use of a spacer
device can help reduce the risk of these side effects. Systemic adverse effects with
ICS therapy are rare, but may include adrenal suppression, changes in bone density,
cataracts, glaucoma and growth retardation.
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The LTRAs montelukast and zafirlukast are also effective for the treatment of
asthma and are generally considered to be safe and well tolerated.
However, because these agents are less effective than ICS treatment when used as
monotherapy, they are usually reserved for patients who are unwilling or unable to
use ICSs.
LTRAs can also be used as add-on therapy if asthma is uncontrolled despite the use
of low-to-moderate dose ICS therapy. It is important to note, however, that LTRAs
are considered to be less effective than LABAs as add-on therapy in adults .
In children, however, the data are less clear and, therefore, the child’s symptoms
and the presence of comorbidities may help direct treatment. For example, if a child
with asthma also has allergic rhinitis, the addition of montelukast should be
considered.
If, however, the child has persistent airway obstruction, the addition of a LABA may
be preferred.
LABAs are only recommended when used in combination with ICS therapy. The
combination of a LABA and ICS has been shown to be highly effective in reducing
asthma symptoms and exacerbations, and is the preferred treatment option in
adolescents or adults whose asthma is inadequately controlled on low-dose ICS
therapy, or in children over 6 years of age who are uncontrolled on moderate ICS
doses.
Although there is no apparent difference in efficacy between ICSs and LABAs given
in the same or in separate inhalers, combination ICS/ LABA inhalers are preferred
because they preclude use of the LABA without an ICS, are more convenient and may
enhance patient adherence.
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It should only be used in patients whose asthma is not adequately controlled with
low-tomoderate ICS doses or whose disease severity warrants treatment with
combination therapy.
. Theophylline
Anti-IgE therapy
The anti-IgE monoclonal antibody, omalizumab, has been shown to reduce the
frequency of asthma exacerbations by approximately 50%. The drug is administered
subcutaneously once every 2-4 weeks and is approved in Canada for the treatment
of moderate to severe, persistent allergic asthma in patients 12 years of age or older.
At present, omalizumab is reserved for patients with difficult to control asthma who
have documented allergies and whose asthma symptoms remain uncontrolled
despite ICS therapy.
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Systemic corticosteroids
Systemic corticosteroids, such as oral prednisone, are generally used for the acute
treatment of moderate to severe asthma exacerbations. While chronic systemic
corticosteroid therapy may also be effective for the management of difficult to
control asthma, prolonged use of oral steroids are associated with well-known and
potentially serious adverse effects and, therefore, their long-term use should be
avoided if at all possible.
Adverse events with short-term, high-dose oral prednisone are uncommon, but may
include: reversible abnormalities in glucose metabolism, increased appetite, edema,
weight gain, rounding of the face, mood alterations, hypertension, peptic ulcers and
avascular necrosis.
Allergen-specific immunotherapy
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Although it has been widely used to treat allergic asthma, it is not universally
accepted by all clinical practice guideline committees due to the potential for serious
anaphylactic reactions with this form of therapy.
The injections must be given in clinics that are equipped to manage possible life-
threatening anaphylaxis where a physician is present. Furthermore, to reduce the
risk of serious reactions, asthma must be controlled and the FEV1 > 70% of
predicted at the time of each immunotherapy injection
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CONCLUSION
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