In the name of God

Asthma

By: E. Salehifar (PharmD, BCPS)

Asthma: Background

At least 15 million Americans have asthma Annually cost > 12 & billion Asthma is the leading cause of lost school days in children and a common cause of lost work days among adults • • Mortality is rising for unknown reason • • After TB and HIV, Asthma had much more rise in incidence during the past 2 decades in Iran •

Pulmonary diseases

Obstructive diseases

Asthma – COPD (Bronchitis, Emphysema) –

Restrictive diseases

Pulmonary fibrosis – Pneumonia – Khyphoscoliosis – • •

Definition

A chronic inflammatory disease that causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough particularly at night and in the early morning • Airflow obstruction is reversible • The inflammation causes bronchial hyperresponsiveness •

Allergens:

Aeroalergenes Viruses pets Smoke Exercise Wood dust Chemicals • • • • • • •

Asthma

COPD

Bronchitis • Emphysema •

Fibrosis

Overlap!

Etiology

Childhood-onset

Genetic predisposition for IgE-mediated response to common aeroallergens (tree and grass pollen, pets, …) called as “Atopy” • Positive family history •

Adult-onset

Many adults have a negative family history and negative skin tests • Some may have nasal polyps, ASA sensitiity & sinusitis • Workplace allergens (wood dusts, chemicals) • • •

Allergy, Asthma

Pathophysiology

Inflammatory cells

Eosinophils, Th2 Lymphocyte, Mast cells, Macrophages, Neutrophis –

Inflamatory mediators

Leucotrienes (LTD4, LTE4), Interleukines (IL-4, – IL-5), Histamine, prostaglandines (PGD2, PGE2) • •

Pathophysiology

Pathophysiology

Airway changes

Symptoms

Classical symptoms Expiratory wheezing

•

Coughing

•

Dyspnea

• Chest tightness or a chronic cough without wheezing in some patients

Wide variety in symptoms

• • •

Step 4 Symptoms

Continual symptoms

Classification

Nighttime Symptoms

Frequent

Lung Function

FEV1 or PEF ≤60% PEF variability >30%

Step3

Daily symptoms >1 time/week

Step 2

3-6 times/week

Step 1

≤2 times/week 3-4 times/month ≤2 times/month 60%< FEV1 or PEF <80% PEF variability >30% FEV1 or PEF≥80% PEF variability 20-30% FEV1 or PEF≥80% PEF variability <20%

Classification

Step 4:

Severe Persistent

Step 3:

Moderate Persistent

Step 2:

Mild Persistent

Step 1:

Mild Intermittent Only patients in step 1 doesn't need daily medication, other patients should receive Anti-inflammatory drugs – Salbutmol (Spray) is indicated for quick relief not for – long- term control and use of salbutamol >2/week may indicate need to anti-inflammatory drugs A rescue course of systemic corticosteroid may be needed at any time and at any step!

– • • • •

Pulmonary Function Tests

Spirometry (FEV1/FVC) Peak expiratory flow (PEF) ABG (pH, PO2, PCO2, HCO3, SPO2) • • •

Spirometers

Peak flow meter

Spirometer

Mild Obstruction Severe Obstruction Restrictive Pattern

Peak flow meter

Obstructive versus Restrictive Airway Disease

Parameter Obstructive Restrictive

FEV1 ↓ Normal or ↓ • FVC Normal or ↓ ↓ • FEV1/FVC* ↓ Normal or ↑ • FEF 25%-75% ↓ Normal, ↓, ↑ • * normal: 85%

Limitations of Spirometry & Peakflowmetry

Need complete patient’s corporation Are unobtainable in severely ill patients (esp. spirometry) FEV1 and PEF are relatively insensitive to small airway changes Variations in PEF • • • •

Nebulizers

Spacers

Treatment

Asthma Exacerbation Long-Term Control • •

Treatment

Asthma Exacerbation Salbutamol (Albuterol) (Ventolin®)

MDI+Spacer: 4-8 puffs Q 20 min up to 4 hr, then every 1-4 hr as needed • Nebulizer: 2.5-5 mg Q 20 min for 3 doses, then 2.5-10 mg Q 1-4 hr as needed • –

Ipratropium bromide (Atrovent®)

MDI: 4-8 puffs as needed (Should bee added to β2-agonist therapy) • Nebulizer: 0.5 mg Q 30 min for 3 doses then Q 2-4 hr as needed • –

Tiotropium (Spirivia) inhal cap: 18 µg

–

Corticosteroids (Prednisolone, Methyl prednisolone)

Prednisolone: 120-180 mg in 3-4 divided dose for 48 hr, then 60-80 mg/d until PEF reaches 70% of personal best • –

Treatment

Long-Term Control Medications

Corticosteroids Inhaled C.: Beclomethasone (Becotide®), Fluticasone (Fluoxitide®) – • Systemic C.: Prednisolone – Long-acting β2-agonists Inhaled: Salmetrol (Serevent®) Oral: Salbutamol SR – – • Cromolyn sodium & Nedocromil • Leucotriene modifiers (Zileuton, Zafirlucast, Montelukast) • Methylxanthines (Theophylline, Aminophylline) •

Fluticasone + Salmetrole (Seretide®)

•

Budesonide + Formoterol (Symbicort®)

•

میدس نیلومورک

رثا عورش

هتفه 2 ات 1 :) 20mg/ml ( ینیب هرطق – زا رتمک : هیر هب دورو ( هتفه 6 ات 2 :) Cap: 20 mg ( یقاشنتسا )% 8 – دییات ( IBD و systemic mastocytosis یارب

: Oral

.) هدشن • •

Preferred Treatments

Stage 4: Inhaled Corticosteroids (High dose ) + Salmetrol Stage 3: Inhaled Corticosteroids (Low to Med. dose ) + Salmetrol Stage 2: Inhaled Corticosteroids (Low dose) Stage 1: no daily medication needed Theophylline SR or LT modifiers are alternative for Salmetrol – in Stage 2, Cromoly or Nedocromil, Theophylline SR or LT modifiers are alternatives – Salmetrol and LT modifiers has been added for managing young children (<5 yo) asthma – • • • •

Low/Mod/high Doses of Inhaled Corticosteroids

Beclomethason e 42 mcg/puff Fluticasone 50 mcg/puff Fluticasone 125 mcg/puff Fluticasone 250 mcg/puff Budesonide 200 mcg/puff Low Dose Mod. Dose 4-12 puffs 12-20 puffs 2-4 puffs --------------- --------------- 200-400 mcg 4-10 puffs 2-4 puffs --------------- 400-600 mcg High Dose > 20 puffs --------------- >4 puffs >2 puffs > 600 mcg

Drug Beclo 50 Beclo 250 Flixotide 50 Flixotide 125 Flixotide 250 Pulmicort Seretide 50 Seretide 125 Seretide 250

Cost

Price (Rial)

40500 (200 puff) 65000 (200 puff) 160000 (120 puff) 180700 (60 puff) 335800 (60 puff) 286900 (100 dose) 250000 (120 puff) 335000 (120 puff) 466000 (120 puff)

ندوب یا همیب

+ 58500 + + 167000 + 270000 +

-

+ + +

Drug Salmetrol Salmetrol (Serevent) Formoterol (Oxis) Formoterol (Foradil) Ipratopium (cipla) Ipratopium (Atrovent) Spirivia

Cost

Price (Rial)

40000 226000 314300 (60dose) 217500 (30 cap) 25500 (300 puff) 96500 (200 puff) 858000 (30 cap)

ندوب یا همیب

+ 40000 +

-

+ 25500 +

-

Patient Education

Patient Education

و تسا تایح دمم دوریم ورف هك يسفن ره يسفن ره رد سپ ،تاذ حرفم دیآرب نوچ يركش يتمعن ره رب و دوجوم تمعن ود !

بجاو