1. The Saudi Initiative for Asthma Guidelines for the Diagnosis and Management of Asthma in Adults and Children
Out-patient Management of Asthma in Adults
On behalf of the SINA panel
Mohamed S. Al-Moamary, FRCP (Edin) FCCP
Dep. of Medicine, King Abdulaziz Medical City-Riyadh
King Saud bin Abdulaziz University for Health Sciences

2. Enter presenter name Enter the presenter’s institute
Out-patient Management of Asthma in Adults
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3. What is SINA?
SINA is developed by a task force originated from the Saudi Initiative for Asthma Group under the umbrella of the Saudi Thoracic Society
SINA is a practical approach for a comprehensive management of asthma in adults and children and when to refer to a specialist.
International recommendations were customized to the local setting for asthma diagnosis and management
Directed to HCW dealing with asthma who are not specialists in the field.

4. Purpose of SINA
To provide a document that is easy to follow, simple to understand yet totally updated and carefully prepared for use by non-asthma specialist including primary care doctors and general practice physicians

5. The SINA guidelines booklet is available at: www.sinagroup.org
Where do you find SINA?
The SINA guideline was published in the Annals of Thoracic Medicine (
Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, Al-Ghobain MO, Idrees MM, Zeitouni MO, Al-Harbi AS, Al Dabbagh MM, Al-Matar H, Alorainy HS. The Saudi initiative for asthma update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2012;7:
The SINA guidelines booklet is available at:

6. Saudi Thoracic Society commitment
The STS is committed to improve the care of asthma by a long term plan:
Periodic scientific meetings
Annual asthma meeting (since 2001)
Frequent asthma courses
Educational brochures
Publishing new and updated asthma guidelines

7. What is new in SINA-2012
Comprehensive revision with the addition of new 125 references
Addition of charts and algorithms for asthma diagnosis and management
Updating asthma management
Rewritten “asthma in children” section
New section on “difficult to treat asthma”

8. SINA Panel
Mohamed S. Al-Moamary (Chairman), King Saud bin Abdulaziz University for Health Sciences, Riyadh
Sami Alhaider, King Faisal Specialist Hospital and Research Center, Riyadh
Mohamed S. Al-Hajjaj, King Saud University, Riyadh
Mohammed O. AlGhobain, King Saud bin Abdulaziz University for Health Sciences, Riyadh
Majdy M. Idrees, Military Hospital, Riyadh
Mohamed O. Zeitouni, King Faisal Specialist Hospital and Research Center, Riyadh
Adel S. Alharbi, Military Hospital, Riyadh
 Hussain Al-Matar, Imam Abdulrahman Al Faisal, Dammam
Maha M. Al Dabbagh, King Fahd Armed Forces Hospital, Jeddah
 Hassan S Alorainy, King Faisal Specialist Hospital and Research Center, Riyadh

9. Acknowledgment
The SINA panel would like to thank the following reviewers :
Prof. J. Mark FitzGerald from the University of British Columbia, Vancouver, BC, Canada
Prof. Qutayba Hamid from the Meakins-Christie Laboratories, and the Montreal Chest Research Institute
Prof. Sheldon Spier, the University of British Columbia, Vancouver, Canada
Prof. Eric Bateman from the University of Cape Town Lung Institute, Cape Town, South Africa (SINA 2009)
Prof. Ronald Olivenstein from the Meakins-Christie Laboratories and the Montreal Chest Research Institute, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada. (SINA 2009)

10. SINA Documents
Published manuscript
Booklet
Electronic version
Slides kit
Flyers
Website:

11. Sections of SINA
Epidemiology
Pathophysiology
Diagnosis
Medications
Approach to Management
Treatment Steps
Special Situations
Acute Asthma

12. Prevalence of asthma has increased between 1986 – 1995
Alfrayyah et al. Ann Allergy Asthma Immunol 2001;86:292–296

13. Burden of Asthma
Asthma is among the most common chronic illnesses in Saudi Arabia
53% had missed school or work (AIRKSA-2007)
35% attempted Unconventional therapy (Al Moamary, ATM 2008)
46% were controlled in Riyadh (AIRKSA-2007)
36% were controlled in 5 tertiary care centers in Riyadh (Aljahdali SMJ-2008)
48% were controlled in one center (Al Moamary, ATM 2008)

14. AIRKSA report (Ministry of Health)
78 % of adults & 84% of kids reported acute asthma over 12 months (AIRKSA)
54 % of adults & 80% of kids reported ER over 12 months (AIRKSA)
45-68% of adults & 37-56% of kids reported limitation of activity over 12 months (AIRKSA)
76 % of adults & 78% of kids never had spirometry(AIRKSA)

15. The prevalence of wheeze and associated symptoms in the study group
Al-Ghobain et al, NBC Pulm Med 2012;12:39

16. Pattern of asthma treatment
Al-Shimemeri, Ann Thorac Med 2006;1:20-5

17. Airway Hyper-responsiveness
Pathology of Asthma
Inflammation
Airway Hyper-responsiveness
Airway Obstruction
Symptoms of Asthma

18. Pathophysiology

19. Inflammation  Remodeling
Airway Hypersecretion
Subepithelial fibrosis
Angiogenesis

20. Diagnosis - History Episodic attacks:
Cough
Breathlessness
Wheezing
Nocturnal symptoms
Patient could be asymptomatic between attacks
co-existent conditions: GERD, rhinosinusitis.

21. Relevant Questions
Does the patient or his/her family have a history of asthma or other atopic conditions, such as eczema or allergic rhinitis?
Does the patient have recurrent attacks of wheezing?
Does the patient have a troublesome cough at night?
Does the patient wheeze or cough after exercise?
Does the patient experience wheezing, chest tightness, or cough after exposure to pollens, dust, feathered or furry animals, exercise, viral infection, or environmental smoke?

22. Relevant Questions
Does the patient experience worsening of symptoms after taking aspirin/nonsteroidal inflammatory medication or use of B-blockers?
Does the patient's cold “go to the chest” or take more than 10 days to clear up?
Are symptoms improved by appropriate asthma treatment?
Are there any features suggestive of occupational asthma

23. Physical Examination Normal between attacks
Bilateral expiratory wheezing
Examination of the upper airways
Other allergic manifestations: e.g., atopic dermatitis/eczema
Consider alternative Dx when there is localized wheeze, crackles, stridor, clubbing

24. Measurements of lung function:
Investigations
Measurements of lung function:
Spirometry
Peak expiratory flow (PEF)
Normal Spirometry does not role out asthma
Spirometry is superior to PEF

25. Bronchodilator response
Proper instructions on how to perform the forced expiratory maneuver must be given to patients, and the highest value of three readings taken.
The degree of significant reversibility is defined as an improvement in FEV1 ≥12% and ≥200 ml from the pre-bronchodilator value.

26. Clinical Assessment
Measurements of allergic status to identify risk factors (if indicated)
Chest X-ray is not routinely recommended
Routine blood tests are not routinely recommended
IgE measurement is indicated in severe cases

27. Assessment of Asthma Control

28. Asthma Control Test Level of Control: Total: 25 Control: 20-24
Partial control:
Uncontrolled: < 16

29. Differential Diagnosis
Upper airway diseases
Allergic rhinitis and sinusitis
Obstructions involving large airways
Foreign body in trachea or bronchus
Vocal cord dysfunction
Vascular rings or laryngeal webs
Laryngotracheomalacia, tracheal stenosis, or bronchostenosis
Enlarged lymph nodes or tumor
Obstructions involving small airways
Viral bronchiolitis or obliterative bronchiolitis
Cystic fibrosis
Bronchopulmonary dysplasia
Heart disease
Other causes
Recurrent cough not due to asthma
Aspiration from swallowing mechanism dysfunction or GERD

30. Differential Diagnosis
COPD (e.g., chronic bronchitis or emphysema)
Congestive heart failure
Pulmonary embolism
Mechanical obstruction of the airways (benign and malignant tumors)
Pulmonary infiltration with eosinophilia
Cough secondary to drugs (e.g., angiotensin-converting enzyme (ACE) inhibitors)
Vocal cord dysfunction

31. Management

32. Patient/Dr Partnership
Enhance the chance of disease control
Agreed goals of management
Guided self-management plan

33. Asthma Education
Creation of partnership between patient and healthcare worker
Understanding clinical presentation of asthma and diagnosis
Ability to differentiate between “relievers” and “controllers” medications and their appropriate indications
Recognition of potential side effects of medications and the appropriate action to minimize them
Performance of the proper technique of devices
Identification of symptoms and signs that suggest worsening of asthma control and the appropriate action to be taken
Understanding the approach for monitoring asthma control
Recognition of the situations that need urgent medical attention
Ability to use a written self-management plan

34. Non-Adherence Drugs: Non-drugs Poor technique of inhaler devices.
Regimen with multiple drugs.
Occurrence of Side effects from the drugs.
Cost of medications.
Non-drugs
Lack of knowledge about asthma.
Lack of partnership in the management.
Inappropriate expectations.
Underestimation of severity.
Cultural issues.

35. Precipitating Factors
Indoor Allergens and Air Pollutants
Outdoor Allergens
Occupational Exposure
Food and Drugs

36. Self-management plan

37. Self-management plan www.tnfos.com
لكل مريض خطة علاجية ذاتية خاصة به توضع تحت إشراف الطبيب المختص حسب حالته
الإجراء الواجب إتباعه : الإستمرار على الأدوية المعطاة :
إستخدام البخاخ الموسع للشعب الهوائية_____ بخة كل ____ ساعات عند الضرورة وقبل التمارين ارياضية ب 15 – 30 دقيقة .
إستخدام البخاخ الواقي _____ بخة ______ مرة يومياً و بشكل منتظم لمدة ( ) . أدوية أخرى :
1- الحالة المستقرة :
ممارسة الحياة بشكل طبيعي (لعب ، نوم ، دراسة)
إختفاء أعراض الربو في الليل .
ندرة إستخدام البخاخ في الموسع للشعب الهوائية (أقل من 3 مرات أسبوعياً)
سرعة تدفق الهواء أكثر من 80% من الحد الطبيعي
الإجراء الواجب إتخاذه :
زيادة جرعة البخاخ الواقي ______إلى ______بخة _____مرة يومياً لمدة 10أيام ثم الرجوع إلى الجرعة السابقة
إستخدام البخاخ الموسع للشعب الهوائية ( ) ( ) بخة كل ____ ساعات بإنتظام لمدة _____أيام أو حتى تتحسن الحالة
إستشارة الطبيب في أقرب وقت ممكن .
2 - الحالة المتوسطة الإستقرار (أزمة ربو على وشك الحدوث) :
إستخدام البخاخ الموسع للشعب الهوائية أكثر من مرات يومياً .
الإستيقاظ في الليل بسبب (كحة ، كتمة ، صفير في الصدر)
وجود أعراض نزلة برد فيروسية .
القدرة على نفخ الهواء بين 60 – 80 % من الحد الطبيعي .
الإجراء الواجب إتخاذه :
إستخدام البخاخ الموسع للشعب الهوائية ___بخة كل ____ ساعات
طلب الإستشارة الطبية بصفة عاجلة .
زيادة جرعة البخاخ الواقي ____)إلى ______بخة ____)مرة يومياً لمدة 10أيام ثم الرجوع إلى الجرعة السابقة عمل ما يلي :
3 - الحالة المتأزمة الحادة (سارع بطلب المساعدة الطبية) إذا لم تحدث استجابة لما سبق أو حدث :
زيادة أعراض أزمة الربو .
عدم القدرة على إتمام كلمتين في نفس واحد .
عودة أعراض الربو بعد أقل من نصف ساعة من إستخدام البخاخ الموسع للشعب الهوائية .
القدرة على نفخ الهواء أقل 50% من الحد الطبيعي .
لابد من التوجه لقسم الطوارئ فوراً .
(توجه للطوارئ أو أطلب الإسعاف) : إذا تدهورت أزمة الربو على الرغم من الإجراءات السابقة ، أو حدث إزرقاق فيالأطراف أو تدهور في مستوى الوعى ، أو تدني في سرعة تدفق الهواء لأقل من 50 % من المعدل الطبيعي

38. Asthma Medications
Controllers are medications taken daily on a long-term basis to keep asthma under clinical control chiefly through their anti-inflammatory effects.
Relievers are medications used on an as-needed basis that act quickly to reverse bronchoconstriction and relieve symptoms.

39. Controller Medications
Inhaled glucocorticosteroids
Long-acting inhaled B2-agonists
Leukotriene modifiers
Long-acting anticholinergics
Theophylline
Anti-IgE
Systemic glucocorticosteroids

40. Inhaled Corticosteroids
The most effective antiinflammatory medications for asthma treatment
Benefits of ICS:
reduce symptoms
improve quality of life
improve lung function
decrease airway hyperresponsiveness
control airway inflammation
reduce frequency and severity of exacerbations, and reduce mortality.

41. Inhaled Corticosteroids
When ICS discontinued, deterioration of clinical control may follow within weeks
Most of the benefits from ICS are achieved in adults at relatively low doses
Increasing to higher doses may provide further benefits in terms of asthma control but increases the risk of side effects
Tobacco smoking reduces the responsiveness to ICS

42. Inhaled Corticosteroids
To reach control, add-on therapy with another class of controller is preferred to increasing the dose of ICS
ICS are generally safe and well-tolerated
Though low-medium dose of ICS may affect growth velocity, this effect is clinically insignificant and may be reversible.

43. Inhaled Corticosteroids
Local adverse effects:
oropharyngeal candidiasis
dysphonia – may be e reduced by using MDI with spacer devices and mouth washing
Systemic side effects are occasionally reported with high doses and long-term treatment

44. Inhaled Corticosteroids

45. Leukotriene modifiers (LTRA)
LTRA reduces airway inflammation, improve asthma symptoms and lung function
It has less consistent effect on exacerbations when compared to ICS.
Alternative treatment to ICS for patients with mild asthma, especially in those who have clinical rhinitis
Some patients with aspirin-sensitive asthma respond well to the LTRA

46. Leukotriene modifiers (LTRA)
Available as montelokast in Saudi Arabia
Their effects are generally less than that of low dose ICS
When added to ICS, LTRA may reduce the dose of ICS required by patients with uncontrolled asthma, and may improve asthma control
LTRA are generally well-tolerated. There is no clinical data to support their use under the age of six months.

47. LABA LABA: (formoterol and salmeterol)
Should not be used as monotherapy
Combination with ICS lead to:
improves symptoms
decreases nocturnal asthma
improves lung function
decreases the use of rapid-onset inhaled B2-agonists
reduces the number of exacerbations
achieves clinical control of asthma in more patients, more rapidly, and at a lower dose of ICS

48. Dual Pathways of Inflammation
Steroid-sensitive mediators play a key role in asthmatic inflammation
CysLTs play a key role in asthmatic inflammation
Montelukast
Inhaled steroids
blocks the effects of CysLTs
block steroid- sensitive mediators
DUAL PATHWAY
The slide represents an artistic rendition.
Adapted from Peters-Golden M, Sampson AP J Allergy Clin Immunol 2003;111(1 suppl):S37-S42; Bisgaard H Allergy 2001;56(suppl 66):7-11.

49. Long acting anti-chlenergics
It was superior to a doubling of the dose of an inhaled glucocorticoid for patients at step 3
It was non-inferior to LABA
It improves lung function in patients with severe uncontrolled asthma
It is effective as add-on therapy to combination devices at step 4
Daily home peak expiratory flow measurements were higher with tiotropium doses
Peters et al. N Engl J Med 2010; 363:

50. Sympicort turbohaler: Seretide:
Combination devices
Sympicort turbohaler:
Combination of budesonide/formeterol: 160/4.5
Seretide:
Combination of fluticasone/salmeterol
Evohaler: 50/ /25 250/25
Diskus: 100/50 250/50 500/50

51. Theophylline
Weak bronchodilator with modest anti-inflammatory properties
It may provide benefit as add-on therapy in patients who do not achieve control on ICS alone
Less effective than LABA and LTR.
Side effects:
gastrointestinal symptoms
cardiac arrhythmias
seizures, and even death
drug interaction

52. Omalizumab (Xolair) indication:
Anti-IgE
Omalizumab (Xolair) indication:
Uncontrolled severe allergic asthma on high dose ICS and other controllers.
Needs specialist consultation.
Side effects:
Pain and bruising at injection site and very rarely anaphylaxis (0.1%).

53. Oral glucocorticosteroids
Long-term oral glucocorticosteroid therapy may be required for uncontrolled asthma despite maximum standard therapy.
It is limited by the risk of significant adverse effects.
Side effects:
Osteoporosis, hypertension, diabetes, adrenal insufficiency, obesity, cataracts, glaucoma, skin thinning, and muscle weakness.
Withdrawal can elicit adrenal failure.
In patients prescribed long-term systemic glucocorticosteroids, prophylactic treatment for osteoporosis should be considered.

54. Reliever Medications Short-acting inhaled B2-agonists Anticholinergics
Theophylline

55. Short-acting B2-agonists
The medications of choice for symptoms relief
Pretreatment for exercise-induced bronchoconstriction.
Formoterol is used for symptom relief because of its rapid onset of action.
Increased use, especially daily use, is a warning of deterioration of asthma control
Side effects: B2-agonists are associated with adverse systemic effects such as tremor and tachycardia.

56. Short-Acting Anticholinergics
Less effective than SABA.
Used in combination with SABA in acute asthma.
An alternative bronchodilator for patients with adverse effects from rapid acting B2agonists.
Side effects: can cause a dryness of the mouth and a bitter taste.

57. Asthma control Control asthma symptoms
Minimal use (≤2 days a week) of reliever therapy
Maintain (near) normal pulmonary function
Maintain normal exercise and physical activity levels
Prevent recurrent exacerbations of asthma
Minimize the need for ER visits or hospitalizations
Optimize control with the minimal dose of medications
Reduce mortality
Optimize quality of life

58. Principles of management
The principles of asthma management in adults will follow 3 stages:
Initiation
Adjustment
Maintenance

59. Initiation based on SINA approach
The consensus among SINA panel is to simplify the approach to initiate asthma therapy by using ACT score
ACT Score ≥ 20  Step 1
ACT Score 16–19  Step 2
ACT Score 16  Step 3
Al-Moamary et al, BMC Pulm Med 2012;12

60. Initiation based on GINA approach
Step 1  SABA on as needed bases
Step 2  For patients who are not currently taking long-term controller medications.
Step 3  If the initial symptoms are more frequent.

61. SINA v.s. GINA approaches
Al-Moamary et al, BMC Pulm Med 2012;12

62. Adults Patients with Asthma

63. Adjustment of treatment
Clinical Assessment
Obtain ACT score and perform PFM
Based on ACT, Adjust treatment:
ACT = 20-25: Controlled  Maintain treatment
ACT = 16-19: Partial control Step up
ACT < 16: Uncontrolled Step up
 Introduce self-management plan

64. Approach to Asthma Treatment in Adults and children > 5 years

65. Principles of Asthma Treatment
Daily long-term controller medication is the corner stone of treatment
ICS are considered as the most effective controller
Relievers or rescue medications must be available to all patients at any step
SABA should be taken as needed to relieve symptoms
Increasing use of reliever treatment is an early sign of worsening asthma control

66. Principles of Asthma Treatment
Treat patients who may have seasonal asthma as having uncontrolled asthma during the season, then at step 1 for the rest of the year
Patients who had two or more exacerbations requiring oral corticosteroids or hospital admissions in the past year, should be treated as patients with uncontrolled asthma

67. Step 1 - Recommendations
Mild and infrequent symptoms
Initial ACT 20 – 25
Consider rapid onset B2-agonist to be taken “as needed” to treat symptoms
Patient experiencing sudden, severe, or life-threatening exacerbations  treat flare-up accordingly

68. Step 2 - Recommendations
Daily ICS at a low dose (< 500 μg of beclomethasone equivalent/day or equivalent)
Alternative treatment isLTRA (montelukast)

69. Step 3 – Recommendations
Add a LABA to a low-medium dose ICS for patients whose asthma is not controlled on a low dose ICS alone, such as:
Fluticasone/Salmeterol (Seretide)
Budesonide/Formoterol (Symbicort)
Use a maintenance dose of the combination drugs twice daily
Use the rapid onset B2-agonist as a reliever treatment.

70. Step 3 - GOAL study
GOAL study has shown that an escalating dose of combination of Fluticasone/ Salmeterol (Seretide) achieves
Well controlled asthma in 85% of patients
Totally controlled asthma in 30% of patients

71. Step 3 - S.M.A.R.T® approach
S.M.A.R.T® approach: Use of Formoterol/Budesonide for both rescue and maintenance
Maintenance dose single inhaler (1–2 puff 160/4.5 BID) plus extra puffs from the same inhaler up to a total of 12 puffs per day.
Those patients who require such high dose should seek medical advice to step up therapy that may include use of short course of oral prednisone.

72. Step 3 – Alternative therapy
Adding LTRA to ICS, especially those with concomitant rhinitis or
Increasing ICS dose to the medium to high dose range as a monotherapy or
Adding sustained release theophylline or
Adding long acting anti-cholinergic
Consultation with a specialist is recommended for patients whenever there is a difficulty in achieving control

73. Step 4 – Recommendations
Maximizing treatment is recommended by combining high-dose ICS with LABA or
Adding LTRA, tiotropium, or theophylline to high-dose ICS and LABA or
Omalizumab may be considered:
Allergic asthma (as determined by skin test or RAST study) and still uncontrolled.
Special knowledge about the drug
Consultation is recommended

74. Step 5 - Recommendations
Omalizumab to be considered for patients who have allergic asthma and persistent symptoms despite the maximum therapy mentioned above
lowest possible dose of long-term oral corticosteroids for patient who:
Does not have allergic asthma
Omalizumab is not available or not adequately controlling the disease

75. Step 5 – long term steroids
Long-term systemic corticosteroids:
lowest possible dose to maintain control
Monitor for the development of side effects
Continue attempts to reduce the dose
Maintaining high-dose of ICS therapy
Strongly consider concurrent treatments with calcium supplements and vitamin D
Consultation is mandatory

76. Obtain ACT score and perform PFM Based on ACT score, adjust treatment:
Maintaining Control
Clinical Assessment
Obtain ACT score and perform PFM
Based on ACT score, adjust treatment:
ACT= 20-25: well controlled Maintain treatment with lowest ICS dose (may step down)
ACT= 16-19: Partial control Step up
ACT < 16: uncontrolled  Step up
Follow-up at 1 to 3 month intervals

77. Allergen-specific immunotherapy (AIT)
Gradual administration of increasing quantities of an allergen product to an individual with IgE-mediated allergic disease
administered either subcutaneously or sublingually
induces clinical and immunologic tolerance, has long term efficacy, and may prevent the progression of allergic disease, may improves the quality of life

78. Allergen-specific immunotherapy (AIT)
more effective in seasonal asthma than in perennial asthma, particularly when used against a single allergen.
may be considered if strict environmental avoidance and comprehensive pharmacologic It has been a controversial treatment for asthma; however, beneficial clinical effects have been demonstrated
concerns regarding safety and cost, there was no demonstrated consistent effect on lung function

79. Special Situations

80. Asthma and pregnancy - 1
Unpredictable course: one third will have worsening of their of asthma control
Maintaining adequate control of asthma during pregnancy is essential for the health and well-being of the mother and her baby.
Identifying and avoiding triggering factors should be the first step of therapy for asthma during pregnancy

81. Asthma and pregnancy - 2
Same stepwise approach as in non-pregnant patient.
Salbutamol is the preferred SABA
ICSs are the preferred controllers
Use of ICS, theophylline, antihistamines, B2-agonists, and LTRA is generally safe
Acute exacerbations of asthma during pregnancy should be treated on the same outlines as in non-pregnant patients

82. Asthma and pregnancy - 3
Continuous fetal monitoring in severe asthma exacerbation
If anesthesia is required during labor, regional anesthesia is recommended whenever possible
The use of prostaglandin F2α may be associated with severe bronchospasm

83. Cough is the main symptom
Cough-variant asthma
Cough is the main symptom
It is common in children, and is often more problematic at night
Other diagnoses to be considered are:
Drug-induced cough caused by angiotensin-converting-enzyme inhibitors
GERD
Postnasal drip and chronic sinusitis
Treatment is similar to long-term management of asthma

84. Exercise-induced Asthma
Bronchoconstriction peaks within 10 to 15 minutes after completing the exercise and resolves within 60 minutes.
Prevention:
SABA before exercise
Warm-up period before exercise
Some patients may need maintenance therapy
Regular use of LTRA may help in this condition especially in children

85. Aspirin/NSAID induced Asthma
Occurs in 10–20% of adults with asthma
The majority experience first symptoms during the third to fourth decade.
Once aspirin or NSAID hypersensitivity develops, it is present for life.
Within 1-2 hours following ingestion of aspirin, an acute, severe attack may develop, and is usually accompanied by rhinorrhea, nasal obstruction, conjunctival irritation, and scarlet flush of the head and neck

86. Aspirin/NSAID induced Asthma
Prevention by avoidance of aspirin/NSAID
Patients for whom aspirin is considered essential, they should be referred to an allergy specialist for aspirin desensitization
Aspirin and NSAID can be used in asthmatic patients who do not have aspirin induced asthma

87. GERD is more prevalent in asthmatics
GERD triggered asthma
GERD is more prevalent in asthmatics
Mechanisms of GERD triggered asthma:
vagal mediated reflex
reflux of micro-aspiration of gastric contents into the upper airways
If GERD symptoms presents, a trial of GERD therapy for 6–8 weeks wit lifestyle modifications
Asymptomatic patients with uncontrolled asthma may not benefit from GERD therapy

88. Difficult to treat asthma (DTA) - 1
It is also called chronic severe asthma, steroid-dependent asthma, difficult-to-control asthma, and refractory asthma
Defined as asthma in patients who require very high doses of inhaled steroids with other controller agents, or near continuous oral steroid treatment to maintain asthma control.
Accounts for 5-10 % of adult asthma, but the health cost is disproportionally high
Morbidity and mortality are also higher than in regular asthma

89. Difficult to treat asthma (DTA) - 2
Prior to labeling a patient to have DTA:
Ensure patient is adherent to medications with good technique
Misdiagnosis e.g. bronchiectasis, endo-bronchial tumors, and vocal cord dysfunction
Control other diseases preciptatnts, e.g. chronic sinusitis, gastro-esophageal disease, sleep apnea syndrome, obesity, and congestive heart failure (CHF)
Confounding factors, e.g. non-adherence with treatment, the presence of allergens at home

90. Difficult to treat asthma (DTA) - 3
Some patients may have the "pseudo-steroid" resistance in patients with persistent symptoms despite high doses of ICS and other "non-steroidal" asthma therapy
The aim is to reach the best possible outcome as it may be difficult to achieve full control
Patients should be at maximum therapy is given (Step 5 therapy)
Anti-IgE treatment (Omalizumab) is given if the patients fulfill the criteria for this treatment

91. Difficult to treat asthma (DTA) - 4
There are New modalities that may help to control DTA e.g.,:
Mepolizumab has been shown to reduce exacerbations and improves asthma control in patients with refractory eosinophilic asthma
Bronchial thermoplasty that utilizes radiofrequency energy to alter the smooth muscles of the airways. In severe persistent asthma, it leads to improvements in various measures of asthma, including FEV1, quality of life, asthma control, and use of rescue medications