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Use of Medications in Asthma Cyril Grum, M.D. Department of Internal Medicine *Based on the University of Michigan Guidelines for Clinic Care and the National.

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Presentation on theme: "Use of Medications in Asthma Cyril Grum, M.D. Department of Internal Medicine *Based on the University of Michigan Guidelines for Clinic Care and the National."— Presentation transcript:

1 Use of Medications in Asthma Cyril Grum, M.D. Department of Internal Medicine *Based on the University of Michigan Guidelines for Clinic Care and the National Asthma Education and Prevention Progam (NAEPP) 2002 Update

2 Recommended therapies are based on clinical severity See Powerpoint presentation on “Diagnosing and Staging Asthma” for background

3 Regimens for long-term control of asthma

4 Children 5 years and under-1 Step 1 (mild, intermittent) – No daily medications indicated Step 2 (mild, persistent) – Preferred treatment: Low-dose inhaled corticosteroids (with nebulizer or MDI with holding chamber with or without face mask or DPI). – Alternative treatment (listed alphabetically): Cromolyn (nebulizer is preferred or MDI with holding chamber) Leukotriene receptor antagonist.

5 Children 5 years and under-2 Step 3 (moderate persistent) – Preferred treatments: Low-dose inhaled corticosteroids AND long-acting inhaled  -agonists Medium-dose inhaled corticosteroids. – Alternative treatment: Low-dose inhaled corticosteroids AND either leukotriene receptor antagonist or theophylline. – In patients with recurring severe exacerbations: Medium-dose inhaled corticosteroids AND – long-acting  2-agonists (preferred), OR – leukotriene receptor antagonist (alternate) OR – theophylline (alternate)

6 Children 5 years and under-3 Step 4 (severe, persistent), preferred treatment: – High-dose inhaled corticosteroids PLUS – Long-acting inhaled  2-agonists AND if needed, – Corticosteroid tablets or syrup long term (2 mg/kg/day, but not >60 mg/day, with repeat attempts to reduce systemic corticosteroids

7 Adults and Children >5 years - 1 Step 1 (mild, intermittent) – No medications are recommended – If severe exacerbations occur infrequently, separated by asymptomatic intervals --> oral corticosteroids Step 2 (mild, persistent) – Preferred treatment: Low-dose inhaled corticosteroids. – Alternative treatments (listed alphabetically) cromolyn or nedocromil, OR leukotriene modifier, OR sustained release theophylline to serum conc. of 5–15 mcg/mL.

8 Adults and Children >5 years - 2 Step 3 (moderate, persistent) – Preferred treatment: Low-to-medium dose inhaled corticosteroids AND long-acting inhaled  2-agonists – Alternative treatments (listed alphabetically): Increase inhaled corticosteroids within medium-dose range Low-to-medium dose inhaled corticosteroids AND either leukotriene modifier OR theophylline. – In patients with recurring severe exacerbations: Add long-acting  2-agonists (preferred), OR Increase inhaled corticosteroid to medium-dose range (alternate), OR leukotriene receptor antagonist (alternate) OR theophylline (alternate)

9 Adults and Children >5 years - 3 Step 4 (severe, persistent) – High-dose inhaled corticosteroids AND – Long-acting inhaled  2-agonists AND (if needed) – Oral corticosteroids 2 mg/kg/day, up to 60 mg per day, with repeated attempts to reduce systemic corticosteroids.

10 Medications and dosing: selected corticosteroid inhalers MedicationAdult dosesPediatric doses Budesonide (Pulmocort®) 200mcg/inhalation Administered bid Low Medium High >1200 Low Medium High >800 Triamcinolone (Azmacort®) 100mcg/inhalation Administered bid-qid Low Medium High >2000 Low Medium High >1200 Fluticasone (Flovent®) 44, 110 or 220mcg/puff Administered bid Low Medium High >660 Low Medium High >440 Salmeterol/fluticasone Advair Diskus ®) Low 100/50 1 puff bid Medium 250/50 1 puff bid High 500/50 1 puff bid Low 1 puff bid Medium 1 puff bid High 1 puff bid

11 Medications and dosing: Bronchodilators and mast cell stabilizers MedicationAdult dosesPediatric doses Albuterol 90mcg/puff (Proventil®, Ventolin ®) 2 puffs tid-qid Pirbuterol 200mcg/puff (Maxair Autoinhaler®) 2 puffs tid-qid Salmeterol 50mcg/dose (Serevent Diskus®) 1 blister bid Cromolyn sodium 800mcg/puff (Intal®) 2-4 puffs tid-qid1-2 puffs tid-qid Nedocromil sodium 1750mcg/puff (Tilade ®) 2-4 puffs tid-qid1-2 puffs tid-qid

12 Medications and dosing: Oral medications MedicationAdult dosesPediatric doses Zafirlukast (Accolate ®) 20 mg bid10 mg bid Montelukast (Singulair®) 10 mg q hsage 6-14: 5 mg hs age 2-5: 4 mg hs age mo: 4 mg hs (oral granules) Theophylline300mg bidStarting dose:10mg/kg/day; usual max: >1 year of age: 16 mg/kg/day < 1 yr: 0.2 (age in weeks) + 5 = mg/kg/day

13 Regimens for quick relief of acute symptoms

14 Quick relief of acute symptoms in children age 5 and under Bronchodilator prn. Intensity of rx depends on severity. – Preferred rx: Short-acting, inhaled  2-agonist, by nebulizer or face mask and space/holding chamber – Alternative rx: Oral  2-agonist With viral respiratory infection – Bronchodilator q4–6 hours up to 24 hours (longer with physician consult); do not repeat < q6 weeks – Consider systemic corticosteroid if severe or patient has hx of previous severe exacerbations

15 Quick relief of acute symptoms in adults and children > age 5 Short-acting bronchodilator: 2–4 puffs short- acting inhaled  2-agonists as needed for symptoms. Intensity of treatment depends on severity; up to 3 treatments at 20-minute intervals or a single nebulizer treatment as needed. A course of systemic corticosteroids may be needed.

16 A note on intensity of treatment for acute symptoms in all age groups Excessive use of short-acting  2-agonists may indicate a need to increase long-term-control therapy Defined as: – >2 times a week in intermittent asthma – daily or increasingly in persistent asthma

17 Emergency room or in-hospital treatment DrugAdult doseChild dose Nebulized albuterol 2.5–5 mg q20 mins x3 doses, then 2.5–10 mg q1- 4hr prn, or 10–15 mg/hr continuously 0.15 mg/kg (min= 2.5 mg) q20 mins x3 doses, then 0.15–0.3 mg/kg (≤ 10 mg) every 1-4 hrs prn, or 0.5 mg/kg/hr continuously Albuterol MDI (90 mcg/puff) 4–8 puffs q 20 mins up to 4 hrs, then every 1-4 hrs prn 4–8 puffs q20 mins x 3 doses, then q1-4 hrs by inhalation using spacer/ holding chamber. Nebulized ipratropium Br (with albuterol) 0.5 mg q30 mins x 3 doses, then q2-4 hrs prn 0.25 mg q20 mins x3 doses, then q2 -4 hrs

18 DrugAdult doseChild dose levalbuterolSame as albuterol, but 5mg albuterol=2.5 mg levalbuterol Epinephrine 1:1000 (1mg/mL) mg sq q20 mins x mg/kg sq (up to 0.3–0.5 mg) q20 mins x3 Terbutaline (1 mg/mL) Prednisone, methylprednisolone, prednisolone 0.25 mg sq q20 mins x3 120–180 mg/day in 3 or 4 divided doses x 48 hrs, then 60–80 mg/day until PEF reaches 70% of predicted or personal best 0.01 mg/kg sq q20 mins x3, then q2–6 hrs prn 1 mg/kg q6 hrs x 48hrs, then 1-2 mg/kg/day (max.=60 mg/day) in 2 divided doses until PEF 70% of predicted or personal best


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