aware
WELL Duquesne University Mylan School of Pharmacy
UPDATE from the Center for Pharmacy Care
September-October 2006
Asthma: Breathe Easy with Asthma
A
sthma is a common disease in the United States, affecting approximately 20 million people, including six million children. A chronic lung condition associated with acute attacks that can make breathing difficult, asthma accounts for more than fourteen million outpatient and two million emergency room visits each year. On occasion, these attacks are poorly responsive to therapy and can be fatal. During an attack, the smaller airways (bronchioles) within the lung become constricted or narrowed due to inflammation in surrounding tissues. This results in a reduction in air flow and difficulty in breathing. Breathlessness, chest tightness, wheezing and nighttime or early morning coughing are symptoms of these attacks. In most cases, the cause of asthma is unknown. However, many factors have been associated with triggering acute attacks. For instance, tobacco smoke, dust mites, air pollution, furry pets, mold, strenuous physical exercise, high humidity, cold temperatures, insect allergens, emotional distress, and certain foods and drugs are some of the known triggers of this condition.
Diagnosis
Treatment
The diagnosis of asthma is dependent on many factors including timing of the attack and triggering events. The frequency and nature of attacks is used to classify disease severity (see table on back) and determine optimal treatment (see table on Web site). Family history may be a contributing factor to susceptibility. A number of tests may be performed to diagnose asthma. Spirometry, the most common test for evaluating lung function, measures the volume and flow rate of air that can be exhaled after a deep breath. This procedure is completed before and after asthma medication is administered in order to further confirm the diagnosis. The doctor may order additional tests to rule out other conditions that can mimic the symptoms of asthma. A newer diagnostic technique that is believed to be more accurate than spirometry measures nitric oxide, an asthma marker, in exhaled air.
There is currently no cure for asthma, but many therapies are available to control symptoms and prevent attacks. These include avoiding known asthma triggers and the administration of oral and/or inhaled medications. The choice of therapy is patient specific and dependent on the severity of disease. There are two main types of medications used in managing asthma. One group is prescribed to provide quick relief during acute attacks and the other for long-term prevention and control of the disease. They can be used alone or in combination. Please see the electronic version of this issue (www.duq. edu/wellaware) to view a table identifying the individual agents used in managing asthma.
Immediate Relief– Short-Acting Medications Short-acting medications provide relief within minutes after administration. There are two main groups of short-acting drugs continued on back
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Asthma: Breathe Easy with Asthma – beta-2 agonists (such as albuterol-Proventil®, Ventolin®, etc.) and anticholinergic compounds (ipratropium-Atrovent®). Short-acting beta-2 (beta-2 is the designation for specific sites in the lung that produce bronchodilation) agonists/ stimulants relax the bronchial airways during an attack and their effects may last up to six hours. In acute situations, these drugs are administered using a metered-dose inhaler, but they also can be given by nebulizer. Anticholinergic agents such as ipratropium block acetylcholine, a chemical that constricts the airways. Neither group of drugs reduces the frequency of future attacks. Corticosteroids decrease inflammation, one of the major contributing factors in asthma. They are available for inhalation in products such as beclomethasone-Vanceril®, etc. and can be taken orally or intravenously in forms such as prednisone and methylprednisolone. Oral and intravenous corticosteroids do not provide immediate relief, but may be used during severe attacks, especially in hospitalized patients. Inhaled products are typically used to prevent acute bronchospasm.
Long-Acting Control Medications Long-acting medications are effective in preventing asthma attacks, but must be taken on a daily basis. They are not used to treat acute episodes. Classes of long-acting medications include corticosteroids (discussed earlier); long-acting beta-2 agonists/stimulants (salmeterol-Serevent®); leukotriene modifiers (monteleukast-Singulair®; zafirlukast-Accolate®); mast-cell stabilizers such as cromolyn-Intal®, etc.; theophylline; and antibody antagonists like Xolair®. When used correctly, inhaled corticosteroids are effective and can often prevent the need for using these drugs in tablet form. They are now considered essential compounds in asthma prevention. Long-acting beta-2 agonists/stimulants do not work as quickly as the short-acting products, but their effects last at least 12 hours. Leukotriene modifiers block the chemical produced in the lungs that contributes to bronchial constriction. Cromolyn inhibits the release of various chemicals which cause inflammation in the lungs. It is not the most effective long-acting medication, but may be helpful in some patients. Theophylline is an older compound that can help relax the airways and may be useful in some patients with more
resistant disease. However, the correct dosage is necessary to maintain safe and effective blood levels. Anti-IgE antibodies (Xolair®) are especially helpful in asthma caused by allergens.
Recommendations for Patients Once diagnosed with asthma, there are many steps patients can take to actively control their disease. If prescribed a metered-dose inhaler, it is important to learn how to use it properly. Drug delivery and effect depend on good technique. If you have any questions on the use of inhalation devices, ask your doctor or pharmacist. Visit http://familydoctor.org/040. xml for instructions on how to properly use metered-dose inhalers. Similarly, if you are
advised to administer medication through a nebulizer, make sure you know how the device is to be used. To monitor lung function and the effectiveness of prescribed medications, patients can perform lung function tests at home using a peak flow meter. Because asthma is a chronic disease that requires individual patient management, the doctor and patient should work together to create an effective asthma action plan.. Additionally, every patient suffering from asthma must have a thorough knowledge of the proper use and adverse effects of the medications prescribed and when to seek medical attention. Adhering to these recommendations can result in successful control of this relatively common disease.
Severity of Asthma* CLASSIFICATION
SYMPTOM FREQUENCY PREFERRED TREATMENT
Mild Intermittent
≤2 days/week and ≤2 nights/month
• as needed, short-acting inhaler • no daily medication needed
Mild Persistent
>2/week but <1/day and >2 nights/month
• as needed, short-acting inhaler • low-dose inhaled corticosteroid daily
Moderate Persistent
Daily and >1night/week
• as needed, short-acting inhaler • low-dose inhaled corticosteroid AND long-acting inhaled beta-2 agonist OR medium-dose inhaled corticosteroids
Severe Persistent
Continual daily and frequent night attacks
• as needed, short-acting inhaler • high-dose inhaled corticosteroid AND long-acting inhaled beta-2 agonist
* Adapted from National Institutes of Health: National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel report: guidelines for the diagnosis and management of asthma update on selected topics – 2002. NOTE: Alternative treatments for each of these classifications are included in the original guideline from the National Institutes of Health cited above.
Newsletter Contributors John G. Lech, Pharm.D. Margaret A. Haberman, Pharm.D. Candidate Jennifer L. Padden, Pharm.D. Candidate
For additional information, please visit the following Web sites: • www.mayoclinic.com
• www.nhlbi.nih.gov
• www.familydoctor.org
• http://www.nlm.nih.gov/medlineplus/
A publication of the Duquesne University Mylan School of Pharmacy Center for Pharmacy Care & Pharmaceutical Information Center (PIC) Additional information on any of the topics discussed may be obtained from the Pharmaceutical Information Center by calling 412-396-4600 or sending an e-mail to pic@duq.edu. Questions about screenings or programs: Christine O’Neil, Pharm.D, B.C.P.S. 412-396-6417 9/06 312145 CG
Asthma: Breathe Easy with Asthma Medications Used in the Treatment of Asthma TYPE OF MEDICATION
MEDICATION
COMMENTS
Immediate relief / Short acting
Beta-2 agonists: • albuterol (Proventil®)
• Rescue medications used as needed upon signs/ symptoms of an attack
Anticholinergics: • ipratropium (Atrovent®)
• Should be kept readily available in case of unexpected attack
Systemic corticosteroids: • Intravenous/oral methylprednisolone, prednisone, prednisolone
• If used > 2 times per week, speak with doctor about addition of control medication
(Note: corticosteroids can be administered by mouth/I.V. in acute situations, but these drugs DO NOT offer immediate relief.) Combination product: • albuterol + ipratropium (Combivent®, DuoNeb®)
Long acting / Control
Inhaled corticosteroids: • beclomethasone (Beclovent®) • budesonide (Pulmicort®) • flunisolide (Aerobid®) • fluticasone (Flovent®) • triamcinolone (Azmacort®) Leukotriene modifiers: • montelukast (Singulair®) • zafirlukast (Accolate®) • zileuton (Zyflo®) Long-acting anticholinergic: • tiotropium (Spiriva®) Long-acting beta-2 agonists: • salmeterol (Serevent®) • formoterol (Foradil®) Mast cell stabilizers: • cromolyn (Intal®) • Nedocromil (Tilade®) Methylxanthine: • theophylline Anti-IgE monoclonal antibody: • Omalizumab (Xolair®) Combination product: • fluticasone/salmeterol (Advair Diskus®)
• Used daily to control asthma • Prevents asthma attacks from occurring, but will not provide immediate relief during an attack • Adhering to doctor’s directions regarding usage will provide optimal control of asthma