Stepwise approach for managing asthma

CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice)
Preferred Drug List Choices for Managing Children and Adults with Asthma (2007):
Levabuterol inhaler (XOPENEX®) (Tier 3) (SPIRIVA®) maintenance use only (Tier 2) Metaproterenol inhaler (ALUPENT®) (Tier 3) Pirbuterol (MAXAIR AUTOHALER®) (Tier 3) Prednisolone sodium (PRELONE®) (Tier 3) Cromolyn sodium (Tier 1) Cromolyn sodium (INTAL®) (Tier 3) Ipratropium bromide inhaler maintenance use only (Tier 1) Ipratropium bromide inhaler (COMBIVENT®) (Tier 2) Ipratropium inhaler (ATROVENT®) (Tier 2) Formoterol inhaler (FORADIL®) (Tier 2) Nedocromil sodium (TILADE®) (Tier 2) Flunisolide inhaler (AEROBID®) (Tier 3) CareFirst and CareFirst BlueChoice Preferred Drug List. Tier 1 generic drugs offer the lowest member copay, Tier 2 preferred brand name drugs are a higher member copay, Tier 3 non-preferred brand name drugs are the highest member copay.
For current information on the CareFirst and CareFirst BlueChoice Formulary and Tier designation, refer to the Providers and Physicians section of www.carefirst.com, click on Prescription Drugs, then FAQs.
*Recommended for prophylaxis and chronic treatment of asthma in adults and children >2 years of age (Source: Adapted from Drug Acts and Comparisons, June 2000) **Recommended for prophylaxis and chronic treatment of asthma in pediatric patients 5-6 years of age (Source: Adapted from www.accessdata.fda.gov/scripts/cder/drugsatfda, 4/27/01) General Information
The stepwise approach presents general guidelines to assist clinical decision making. It is not intended to be a specific prescription. Asthma is highly variable; clinicians should tailor specific medication plans to the needs and circumstances of individual patients.
Gain control as quickly as possible, then decrease treatment to the least medication necessary tomaintain control. Gaining control may be accomplished by either starting treatment at the step most appropriate to the initial severity of the condition or by starting at a higher level of therapy(e.g., a course of systemic corticosteroids or a higher dose of inhaled corticosteroids).
A rescue course of systemic corticosteroid (prednisolone) may be needed at any time and step.
In general, use of short acting b2-agonist on a daily basis indicates the need for additional long term control therapy. It is important to remember that there are very few studies on asthma therapy for infants. 1Adapted From: 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. National Institutes of Health pub no 102-5074. Bethesda, MD. 2003.
Consultation with an asthma specialist is recommended for patients with moderate or severe persistent asthma in the age group, 5 years and younger. Consultation should be considered for all patients with mild persistent asthma.
Severity of asthma—Asthma can be classified by severity into four categories:
severe persistent; moderate persistent; mild persistent and mild intermittent depending on the level
and variability of airway obstruction.
Long-term management of asthma—The aim of treatment is control of asthma
Minimal (ideally no) chronic symptoms, including
No limitations on activities, including exercise Minimal (or no) adverse effects from medicine Major Recommendations from the Expert Panel Report 2:
Guidelines for the Diagnosis and Management of Asthma2
Diagnose asthma and initiate partnership with patient
• A history of recurrent symptoms. • Reversible airflow obstruction using spirometry. • The exclusion of alternative diagnoses.
n Establish patient-clinician partnership: • Address patient’s concerns.
• Agree upon the goals of asthma therapy.
• Agree upon a written action plan for patient self-management.
2Practical Guide for the Diagnosis and Management of Asthma: National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health pub no 97-4051. Bethesda, MD. 1997.p.3.
Reduce inflammation, symptoms and exacerbations
n Prescribe anti-inflammatory medications to patients with mild, moderate or severe persistent asthma (i.e., inhaled steroids, cromolyn or nedocromil).
n Reduce exposures to precipitants of asthma symptoms: • Assess patient’s exposure and sensitivity to individual precipitants (e.g., allergens, irritants).
• Provide written and verbal instructions on how to avoid or reduce factors that make the patient’s asthma worse.
Monitor and manage asthma over time
n Train all patients to monitor their asthma: • All patients should monitor symptoms. • Patients with moderate to severe persistent asthma should also monitor their peak flow.
n See patients at least every 1 to 6 months: • Assess attainment of goals of asthma therapy and patient’s concerns. • Adjust treatment, if needed. • Review the action plan with patient. • Check patient’s inhaler and peak flow technique. • Review environmental control.
Treat asthma episodes promptly
n Prompt use of short acting inhaled b2-agonists and if episode is moderate to severe, a 3 to 10-day n Prompt communication and follow-up with clinician.
Key Recommendations for Managing Asthma in Infants and Young Children
Diagnosing asthma in infants is often difficult, yet underdiagnosis and undertreatment are key problems in this age group. Thus, a diagnostic trial of inhaled bronchodilators and anti-inflammatory medications may be helpful.
Diagnosis is complicated by the difficulty in obtaining objective measurement of lung function in this age group. Essential elements in the evaluation include the history, symptoms, physical examination and assessment of quality of life.
The initiation of long-term control therapy should be considered in infants and young children who have had more than 3 episodes of wheezing in the past year that lasted more than 1 day and affected sleep and who have risk factors for the development of asthma (parental history of asthma or physician-diagnosed atopic dermatitis or 2 of the following: physician-diagnosed allergic rhinitis, wheezing apart from colds, >4% peripheral blood eosinophilia).
In general, infants and young children consistently requiring symptomatic treatment more than two times per week or experiencing severe exacerbations (requiring inhaled b2-agonist more frequently than every 4 hours over 24 hours) that occur less than 6 weeks apart should be given daily anti-inflammatory therapy.
Initiate daily anti-inflammatory therapy with inhaled corticosteroids.
Response to therapy should be carefully monitored. If there is no clear response within 4 to 6 weeks, therapy should be discontinued and alternative therapies or alternative diagnoses considered. If there is a clear and positive response after 2 to 4 months, a step down in therapy should be undertaken to the lowest possible doses of medication required to maintain asthma control.
Pharmacology Therapy: Stepwise Approach for Managing Infants and Young Children
(5 years of age and younger) With Acute or Chronic Asthma Symptoms Long-Term Control
Quick Relief
Step 1 Mild Intermittent
Bronchodilator as needed for symptoms ≤ 2 times a week. Intensity of treatment will depend upon severity of exacerbation.
Use of short-acting b2-agonists >2 times a week may indicate the need to initiate Either: n Inhaled short acting b2-agonist by n Oral b2-agonist for symptomsWith viral respiratory infection: n Bronchodilator q 4-6 hours up to 24 Consider systemic corticosteroid if current history of previous severe exacerbations.
Step 2 Mild Persistent
corticosteroids with nebulizer or MDI.
(Accolate®) or Montelukast (Singulair®) or Step 3 Moderate Persistent
(Singulair®)].
If needed (particularly in patients with recurring severe exacerbations): n Preferred treatment: medium-dose n Alternative treatment: medium-dose inhaled Step 4 Severe Persistent
agonists AND if needed, oral corticosteroids (2 mg/kg/day, do not exceed 60mg/day).
corticosteroids and maintain control with 4 Patients should start treatment at the step most appropriate to the initial severity of their condition4 A rescue course of systemic corticosteroids may be needed at any time and at any step Stepwise Approach for Adults and Children
(older than 5 years of age) With Acute or Chronic Asthma Symptoms Long-Term Control
Quick Relief
Step 1 Mild Intermittent
Step 2 Mild Persistent
n Symptoms > 2 times per week but < Step 3 Moderate Persistent
n PEF or FEV 1 >60% - <80% predicted; bronchodilator (i.e., Theophylline).
If needed, for recurring severe leukotriene modifier or theophylline.
Step 4 Severe Persistent
4 Avoid or control triggers4 Patients should start treatment at the step most appropriate to the initial severity of their condition4 A rescue course of systemic corticosteroids may be needed at any time and at any step Stepwise Approach for Managing Asthma During Pregnancy and Lactation: Treatment
Long-Term Control
Quick Relief
Clinical Features Before
Treatment or Adequate Control
Step 1 Mild Intermittent
n Symptoms ≤2 days/week
needed for symptoms.
Intensity of treatment will depend needed.
Daily use of short-acting inhaled b2-agonist‡, or increasing use, may Step 2 Mild Persistent
n Symptoms >2 days/week but < daily Daily use of short-acting inhaled b2-agonist‡, or increasing use, may Step 3 Moderate Persistent
n PEF or FEV1 >60% - <80% predicted; Alternative treatment: low-dose inhaled Step 4 Severe Persistent
* There are more data on using budesonide during pregnancy than on using other inhaled corticosteroids.
† There are minimal data on using leukotriene receptor antagonists in humans during pregnancy, although there are reassuring animal data submitted to FDA.
‡ There are more data on using albuterol during pregnancy than on using other short-acting inhaled b -agonists.
Step down:
• Review treatment every 1 to 6 months
• A gradual stepwise reduction in treatment may be possible Step up:
First
• Review patient medication technique
• Environmental control (avoidance of allergens and other factors that contribute to asthma) If control is not maintained, consider step up Prevention (refer to Preventive Service Guidelines):
• Influenza vaccine
Adapted from:
National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and
Management of Asthma - Update on Selected Topics 2002. National Institutes of Health Pub. no. 0-07.
Bethesda, MD. June 00.
National Heart Lung and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report : Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health Pub. no. 97-0. Bethesda, MD. October 1997. National Asthma Education and Prevention Program. Quick Reference from the Working Group Report: Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment – Update 2004. National Institutes of Health Pub. no. 0-. January 00.
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