Medical Care: The goals for successful management of asthma outlined in the 2002 US National Heart, Lung, and Blood Institute publication "Global Strategy for Asthma Management and Prevention" include the following:
" Achieve and maintain control of symptoms.
" Prevent asthma exacerbations.
" Maintain pulmonary function as close to normal levels as possible.
" Maintain normal activity levels, including exercise.
" Avoid adverse effects from asthma medications.
" Prevent the development of irreversible airflow limitation.
" Prevent asthma mortality.
The long-term outpatient management of asthma should follow the stepwise therapy model based on the Global Initiative for Asthma guidelines. These recommendations were updated during the 1997 National Asthma Education and Prevention Program, the results of which were published by the National Institutes of Health. Management should incorporate 4 treatment components: (1) objective measures of lung function, (2) environmental control measures and avoidance of risk factors, (3) comprehensive pharmacologic therapy, and (4) patient education. Two additional management strategies include management of exacerbations and regular follow-up care. Classify the severity of asthma before treatment, based on symptom prevalence and measurement of lung function. Classification of severity and treatment options are shown below.
" Step 1 - Intermittent
o Intermittent symptoms occurring less than once a week
o Brief exacerbations
o Nocturnal symptoms occurring less than twice a month
o Asymptomatic with normal lung function between exacerbations
o No daily medication needed
o FEV1 or PEF rate greater than 80%, with less than 20% variability
" Step 2 - Mild persistent
o Symptoms occurring more than once a week but less than once a day
o Exacerbations affect activity and sleep
o Nocturnal symptoms occurring more than twice a month
o Inhaled steroid (low dose), cromolyn (adult: 2-4 puffs tid/qid; child: 1-2 puffs tid/qid), or nedocromil (adult: 2-4 puffs bid/qid; child: 1-2 puffs bid/qid) (Children usually begin with a trial of cromolyn or nedocromil.)
o FEV1 or PEF rate greater than 80% predicted, with variability of 20-30%
" Step 3 - Moderate persistent
o Daily symptoms
o Exacerbations affect activity and sleep
o Nocturnal symptoms occurring more than once a week
o Anti-inflammatory, inhaled steroid (medium dose), or inhaled steroid (low-to-medium dose) and long-acting bronchodilator, especially for nighttime symptoms (either long-acting inhaled beta2-agonist [adult: 2 puffs q12h, child: 1-2 puffs q12h], sustained-release theophylline, or long-acting beta2-agonist tablets) (If needed, give inhaled steroids in a medium-to-high dose.)
o FEV1 or PEF rate 60-80% of predicted, with variability greater than 30%
" Step 4 - Severe persistent
o Continuous symptoms
o Frequent exacerbations
o Frequent nocturnal asthma symptoms
o Physical activities limited by asthma symptoms
o Anti-inflammatory or inhaled steroid (high dose) and long-acting bronchodilator (either long-acting inhaled beta2-agonist [adult: 2 puffs q12h, child: 1-2 puffs q12h] and sustained-release theophylline or long-acting beta2-agonist tablets and steroid tablets or syrup long term) (Make repeated attempts to reduce systemic steroid and maintain control with high-dose inhaled steroid.)
o FEV1 or PEF rate less than 60%, with variability greater than 30%
Diet:
" No special diets are generally indicated. Food allergy as a trigger for asthma is uncommon. Avoidance of foods is recommended after a double-blind food challenge that yields positive results. Sulfites have been implicated in some severe asthma exacerbations and should be avoided in sensitive individuals.
Activity:
" Activity is generally limited by patients' ability to exercise and their response to medications. No specific limitations are recommended for patients with asthma, although they should avoid exposure to agents that may exacerbate their disease.
" A significant number of patients with asthma also have EIA, and baseline control of their disease should be adequate to prevent exertional symptoms. The ability of patients with EIA to exercise is based on the level of exertion, degree of fitness, and environment in which they exercise.
" Many patients have fewer problems when exercising indoors or in a warm, humid environment compared with outdoors or in a cold, dry environment.
Medications used for asthma are generally divided into 2 categories, quick relief (also called reliever medications) and long-term control (also called controller medications). Quick relief medications are used to relieve acute asthma exacerbations and to prevent EIA symptoms. These medications include short-acting beta-agonists, anticholinergics (used for severe exacerbations), and systemic corticosteroids, which speed recovery from acute exacerbations. Long-term control medications include inhaled corticosteroids, cromolyn sodium, nedocromil, long-acting beta-agonists, methylxanthines, and leukotriene antagonists.
Other medications that have been used to reduce oral systemic corticosteroid dependence include cyclosporine, methotrexate, gold, intravenous immunoglobulin, dapsone, troleandomycin, and hydroxychloroquine. Their use in patients with asthma is extremely limited because of variable responses, adverse effects, and limited experience. Only an asthma specialist should administer these medications.
The newest asthma medication is omalizumab (Xolair), a recombinant DNA-derived humanized immunoglobulin G monoclonal antibody that binds selectively to human immunoglobulin E on the surface of mast cells and basophils. The drug reduces mediator release, which promotes an allergic response. Indicated for moderate-to-severe persistent asthma in patients who react to perennial allergens, in whom symptoms are not controlled by inhaled corticosteroids. The dose (adults and children >12 y) is 150-375 mg subcutaneously every 2-4 weeks (precise dose and frequency is established by serum immunoglobulin E levels). The estimated annual cost is $12,000-15,000.
Two 52-week pivotal phase 3 clinical trials with 1071 asthma subjects were designed to study a reduction in asthma exacerbations with omalizumab. Subjects were randomized to receive subcutaneous omalizumab or placebo every 2 or 4 weeks. Inhaled corticosteroid doses were kept stable over the initial 16 weeks of treatment (stable-steroid phase) and tapered during a further 12-week treatment period (steroid-reduction phase). When used as an add-on therapy to inhaled corticosteroids, in both pivotal clinical trials, omalizumab reduced mean asthma exacerbations (ie, asthma attacks) per subject by 33-75% during the stable-steroid phase and by 33-50% during the steroid-reduction phase
MEDICATION :
Medications used for asthma are generally divided into 2 categories, quick relief (also called reliever medications) and long-term control (also called controller medications). Quick relief medications are used to relieve acute asthma exacerbations and to prevent EIA symptoms. These medications include short-acting beta-agonists, anticholinergics (used for severe exacerbations), and systemic corticosteroids, which speed recovery from acute exacerbations. Long-term control medications include inhaled corticosteroids, cromolyn sodium, nedocromil, long-acting beta-agonists, methylxanthines, and leukotriene antagonists. Use of these medications by the stepwise approach is outlined in Medical Care.
Other medications that have been used to reduce oral systemic corticosteroid dependence include cyclosporine, methotrexate, gold, intravenous immunoglobulin, dapsone, troleandomycin, and hydroxychloroquine. Their use in patients with asthma is extremely limited because of variable responses, adverse effects, and limited experience. Only an asthma specialist should administer these medications.
The newest asthma medication is omalizumab (Xolair), a recombinant DNA-derived humanized immunoglobulin G monoclonal antibody that binds selectively to human immunoglobulin E on the surface of mast cells and basophils. The drug reduces mediator release, which promotes an allergic response. Indicated for moderate-to-severe persistent asthma in patients who react to perennial allergens, in whom symptoms are not controlled by inhaled corticosteroids. The dose (adults and children >12 y) is 150-375 mg subcutaneously every 2-4 weeks (precise dose and frequency is established by serum immunoglobulin E levels). The estimated annual cost is $12,000-15,000.
- INJ HISTAGLOBE : AN IMMUNO-MODULATOR THERAPY IS SOME TIMES VERY EFFECTIVE IN ALLERGIC ASTHMA
DOSE : 1 AMP. EVERY WEEK FOR 3 WEEKS. THEN 4TH AFTER 6 WEEKS AND THEN EVERY 6 MONTHS FOR FEW YEARS IF RESPONSE IS GOOD.