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 200-600 Medium 600-1200 High >1200 Low 200-400 Medium 400-800 High >800 Triamcinolone (Azmacort®) 100mcg/inhalation Administered bid-qid Low 400-1000 Medium 1000-2000 High >2000 Low 400-800 Medium 800-1200 High >1200 Fluticasone (Flovent®) 44, 110 or 220mcg/puff Administered bid Low 88-264 Medium 264-660 High >660 Low 88-176 Medium 176-440 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 12-23 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) 0.3-0.5 mg sq q20 mins x 3 0.01 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