Chronic asthma in adults

Chronic asthma in adults

The assessment of the frequency of daytime and nighttime symptoms and limitation of physical activity determines whether asthma is intermittent or persistent. There are 4 categories (see Table 9.5).

Therapy is stepwise (Step 1–5) based on the category of asthma and consists of:

• Preventing the inflammation leading to bronchospasm (controllers)

• Relieving bronchospasm (relievers)

Controller medicines in asthma

• Inhaled corticosteroids (ICS), e.g. Beclomethasone, Budesonide, Fluticasone

• Leukotriene modifiers, e.g. Montelukast can be added from Step 2 patients (should be administered when low-dose ICS or ICS-LABA has failed to achieve the desired outcome)

• Long-acting muscarinic antagonists (LAMA), e.g. Tiotropium

• Long-acting β2 agonists (LABA), e.g. Formoterol, Salmeterol

Reliever medicines in asthma

• Short-acting β2 agonists (SABA), e.g. Salbutamol

• Short-acting muscarinic antagonists (SAMA), e.g. Ipratropium bromide (should be used in acute asthma attack)

Things you can do to avoid or reduce these side effects

• Rinsing your mouth and gargling after taking an inhaled steroid

• Using a spacer/holding chamber to reduce the amount of steroid landing in your mouth and throat (for children and elderly patients)

Long-term treatment of asthma according to severity

Step 1 – Intermittent asthma

Clinical features

• Intermittent symptoms < once/week

• Nighttime symptoms < twice/month

• Normal physical activity

Treatment

As needed low-dose ICS

OR

ICS and LABA

• Budesonide (inhalation) 100–200 mcg every 12 hours

OR

• Budesonide (inhalation) 100–200 mcg every 12 hours

AND

• Salmeterol 100–200 mcg, 2 puffs every 12 hours

OR

• Low-dose ICS taken whenever SABA is taken

Step 2 – Mild persistent asthma

Clinical features

• Symptoms > once/week but < once/day

• Nighttime symptoms > twice/month

• Symptoms may affect activity

Treatment

• Daily low-dose ICS plus as needed SABA

OR

• As needed low-dose ICS + Salmeterol

OR

• Low-dose ICS taken whenever SABA is taken

Add

LTRA

• Montelukast (PO):

  • 4 mg nocte (6 months to 6 years)

  • 5 mg nocte (>6 years to 15 years)

  • 10 mg nocte (>15 years)

(For a period not less than 3 months)

Step 3 – Moderate persistent asthma

Clinical features

• Daily symptoms

• Symptoms affect activity

• Nighttime symptoms > once/week

• Daily use of Salbutamol

Treatment

Refer these patients to a physician/respiratory physician/pulmonologist.

• Low-dose ICS + LABA

OR

• Medium-dose ICS

OR

• Low-dose ICS + LTRA

LTRA

• Montelukast (PO):

  • 4 mg nocte (6 months to 6 years)

  • 5 mg nocte (>6 years to 15 years)

  • 10 mg nocte (>15 years)

(For a period not less than 3 months)

Step 4 – Severe persistent asthma

Clinical features

• Daily symptoms

• Frequent nighttime symptoms

• Physical activity limited by symptoms

Treatment

Refer this patient to a respiratory physician/pulmonologist.

• Medium-dose ICS + LABA

OR

• High-dose ICS

Add

• Tiotropium Mist (inhalation) 6 mcg, 2 puffs every 24 hours

OR

Add-on LTRA

• Montelukast (PO):

  • 4 mg nocte (6 months to 6 years)

  • 5 mg nocte (>6 years to 15 years)

  • 10 mg nocte (>15 years)

(For a period not less than 3 months)

Add

• Tiotropium Mist inhaler 6 mcg, 2 puffs every 24 hours

OR

• Ipratropium bromide (inhalation) 40 mcg, 2 puffs every 12 hours

For patients with rhinitis and asthma, add sublingual immunotherapy (SLIT) provided FEV1 >70% predicted.

Step 5 – Severe asthma

Clinical features

• Symptoms throughout the day

• Night symptoms seven times per week

• Physical activity extremely limited by symptoms

Treatment

Refer to expert opinion (respiratory physician/pulmonologist) for phenotypic investigation ± add-on treatment.

• High-dose ICS-LABA

• Low-dose OCS, but consider side effects

• Tiotropium (inhalation) as in Step 4

• Biologics as indicated

Biologic therapy

• Omalizumab (SC) 75–600 mg every 2–4 weeks

Table: Low, medium and high dose inhaled corticosteroids in adults and adolescents (≥12 years)

Abbreviations:

• DPI = Dry Powder Inhaler

• HFA = Hydrofluoroalkane

• CFC = Chlorofluorocarbon propellant (included for comparison)

Table: Low, medium and high dose inhaled corticosteroids in children 6–11 years