Respirology Section

When should you step down on asthma treatment?

- time span of 3-6 mos is sufficient for assessing asthma control and step down (then
doses of controller meds can be reduced with close supervision)

SABAs:
- monotx is not recommended for most pts with mild sxs
- compatible for childhood, pregnancy and BF
- Have an onset of 5-15 min and with a shorter duration of action of 3-6 hours to treat the
acute phase
- If SABAs do not provide adequate relief, may be a sign of worsening asthma of incorrect
diagnosis
Asthma severity:
- classified based on the level of tx that is required to treat the sxs and exacerbations
ICS – show a reduction in asthma sxs, improvement in lung function (FEV1), reduction in
mortality, asthma exacerbations and hospitalization and improve QOL
- they do not cure asthma but they influence airway remodelling and reduce bronchial
hyperreactivity
- sx control can occur within days of regular use but reduction in airway
hyperresponsiveness may take months
- Local a/e of iCS= hoarseness, dysphonia, oral candidiasis, sore throat and metallic taste
o minimized through using an aero chamber or washing mouth after using
o Risk of systemic AE (osteoporosis, cataracts, glaucoma, adrenal suppression) –
inc with long term use of high dose ICS, use of more potent formulations
(fluticasone, mometasone) and frequent use of oral ICS to treat exacerbations
o Reduced growth rate and use of ICS

- Asthma in pregnancy should be treated the same as non-pregnant ppl (can lead to
complications for the baby – low birth weight, increased perinatal mortality and pre-
eclampsia). Amongst ICS – bud is most preferred, most studied.
- ONLY agent to be cautious of: theophylline due to its narrow therapeutic index

- LTRAs (leukotriene receptor antagonists)

o LTRA inhibit the release of inflammatory mediators (leukotrienes)
reducing inflammation and bronchoconstriction
 o They are indicated for use in children >2 years old as second line asthma
maintenance tx
o Can be used as adjunct tx with high doses of ICS/LABA to achieve asthma
control
o Addition of LABA is preferred over an LTRA to achieve sx improvement in
adult asthmatic pts on ICS
o Can be used safely in pregnancy, may cause abdominal pain as an AE

16 year old, history of asthma + eczema. NKDA. Just discharged from hospital following severe
asthma exacerbation:
- Salbutamol via spacer should be administered at inc doses q20min
- A short course from 5-14 days of prednisone should be initiated
- Should be prescribed controller tx or have its dose inc for 1-2 weeks
- No need for antibiotics for asthma exacerbations

Oral CS s/e: increase BG, BP, mood disturbances. Not likely to cause diarrhea.

- Oral thrush can be prevented by using a spacer device with an MDI when using ICS +
rinsing mouth afterwards
- No interaction bw nystatin + asthma meds

Montelukast has neuropsychiatric effects (depression, agitation/aggression, hallucinations,

suicidal ideation) – include part of action plan

For non-pharm: do not use humidifiers

MDIs:
- MDIs with aerochambers are recommended for children <6
- MDIs are pressurized inhalers that use a chemical propellant to release the medication
- Shake the MDI before each use
- Should wait 15-30 sec before taking a second pull of the same medication

- even tho pt has sxs of nocturnal

awakening don’t start at medium ICS
that is a step up

- Always start low, low dose ICS then

make your way up
24 year old male, hx of changes in asthma sxs (trigger – cold weather), one exacerbation years
ago. He takes SABA prn (lately using 3x per week), cetirizine prn, acet prn

What would you do? he is worried about cost?

Initiate low dose ICS daily and continue SABA prn
buf/form = more expensive, and offers more complexity than is necessary for his level of sxs

Turbuhalers
- they are DPIs
- Do not require the pt to coordinate the administration of the dose with their breath
(unlike MDIs, there is no coordination required when administering a turbuhaler)
- Include dose indicators
- The inhaler is breath activated and involves turning of the colored wheel to load the
dose

19 year old male, uncontrolled asthma maybe due to new dog. Day time sxs 3x/wk and night
awakenings 1x/week. Currently using Symbicort prn – what is the most appropriate course?
- Initiate low dose ICS (first line when starting) – also even tho he has sxs of nocturnal
awakening, in adults you would not inc to a medium dose ICS right away

15 year old, uncontrolled asthma. Has been using a low dose ICS which he started a few months
ago but it isn’t working. Using Symbicort prn. Asthma disruption QOL:
- Switch the controller med from ICS to an ICS/LABA combination – this has shown to
reduce the rates of asthma exacerbations + hospitalizations

BB, NSAIDs and dyes (i.e. sulphites) may worsen/exacerbate asthma

25 year old female, on fluticasone/salmeterol 250/50 for many years, no exacerbation in 2 yrs
and rarely uses SABA (1x/month). Recommend step down

Timeline for effectiveness of ICS:

- 1-2 weeks for improvements and 4-8 weeks for maximum improvements

LABAs
- vilanterol is approved for once daily as opposed to salmeterol and formoterol which
have a shorter duration of action
 - LABA/ICS has shown a reduction in exacerbations and helps to reduce exercise-induced
bronchospasm
- Bud/for can be used as both a reliever and cotroller for asthma management
- LABAs are not the preferred step up in tx for kids 6-11 as increasing the dose of ICS is
preferred

Anticholinergic agents – indicated during emergency tx of asthma eacerbations (SAMA),

common AE= dry mouth, metallic taste. Useful in beta-blocker induced bronchospasm.

Prednisone is generally safe during BF, should be taken earlier in the day to avoid insomnia, and
take with food.

Red zone sign of asthma: chest tightness, gasping voice, sweating

COPD – spirometry/imaging is not used to monitor tx. Performed once a year only if there is an
indication.

Asthma exacerbatins risk factors: poor medication adherence, current smoker, ICU admission
for asthma

Local AE of iCS: hoarseness, sore throat, oral candidiasis. (Adrenal suppression is a systemic
effect and occurs after long term use of high doses)

Aerochambers:
- Reduces risk of oral cadidiassis due to more effective lung deposition
- Facilitates the action of breathing in while activating the MDI
- A spacer should be replaced with a new one after a year of continuous use
- If a whistling sound is heard it indicates that the pt is breating too fast

Omalizumab – there are several biologic agents that can be considered as add on tx in asthma.
Omalizumab is used in severe persistent allergic asthma. Common AE= injection site rxns, URTI,
headaches and hypersensitivity rxn. Constipation is NOT an AE.

Azithro logn term tx:

- QTc should be taken into account, risk of ototoxicity, and antibiotic resistance
- CVD events don’t need to be taken into account
- Low dose azithro for a year has shown to dec exacerbations