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EDUCATION

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Asthma: Help to promote a breath of fresh air

Laura Carter Smoot, Pharm.D., BCPS Clinical Assistant Professor, Auburn University Harrison School of Pharmacy, Auburn, Ala. Ambulatory Care Pharmacist, Columbus Regional Healthcare System, Columbus, Ga.

The University of Florida College of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
ACPE # 012-99905-206-H01

This lesson is no longer valid for CE credit after 9/30/07.

To obtain immediate CE credit, take the test online at www.drugtopics. com. Just click on the Continuing Education box in the lower right side of the Drug Topics home page, which will take you to the CE site. Log in, find and click on this lesson, and follow the three simple steps. Test results will be displayed immediately and you can print the certificate showing your earned CE credits.

sthma is a chronic inflammatory disorder of the airways. Many cells and cellular elements play a role in this inflammation. Susceptible patients may experience wheezing, breathlessness, chest tightness, and cough. It can present in early childhood as well as in adulthood. Diagnosis is based on recurrent symptom history, reversibility of airflow obstruction on spirometry, and exclusion of other causes. Asthma management focuses on controlling inflammation and preventing exacerbations. Each year, asthma and its exacerbations contribute to major healthcare expenditures that can be greatly reduced with appropriate care. Morbidity and mortality are linked largely to both underdiagnosis and undertreatment. Knowledge of this condition and appropriate pharmacotherapy treatment are essential for helping patients live better with asthma.

four million of them had experienced an attack the previous year. Women appear to be affected more often than men and the overall incidence of asthma seems to have increased over the past 20 years, especially in children. Its prevalence has risen in both developed and developing countries. Asthma resulted in 12.7 million physician visits and an additional 1.2 million hospital outpatient department visits in 2002, according to U.S. medical care surveys conducted through the National Center for Health Statistics (NCHS). A survey of emergency departments in 2003 revealed 1.7 million visits related to asthma. In 2002, there were over 4,000 deaths from this disease, according to data from the CDC/NCHS/National Vital Statistics System. Estimated expenditures reported by the National Heart, Lung, and Blood Institute (NHLBI) in 2002 were as much as $14 billion for both direct and indirect costs.

Epidemiology
According to Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2003, approximately 22 million adults have been diagnosed with asthma in their lifetime. A similar survey of children in 2003 revealed that over nine million U.S. children had been diagnosed with asthma, and over

Pathophysiology
Inflammatory changes contribute to the primary process of airway obstruction, causing airflow limitation that resolves either spontaneously or with pharmacologic assistance. The resultant airway narrowing of asthma is multifactorial. The major cause is contraction of

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bronchial smooth muscle triggered by agonists released from inflammatory cells, including histamine, prostaglandins, and leukotrienes. This contraction is worsened by thickening of the airway due to acute edema, cellular infiltration, and remodeling. Airflow can be further limited if the airways become filled with additional secretions. This increased resistance worsens subsequent breathing, which can lead to fatigue and possible respiratory failure. Airway hyperresponsiveness additionally characterizes a limitation of airflow seen in asthma patients. Airways either narrow too easily and/or respond in excess to certain triggers. The mechanism responsible for causing this hyperresponsiveness is unknown, although it represents a clinically significant abnormality of the disease. Assessment of this condition can be performed using a pharmacologic stimulant such as histamine or methacholine until a decline in lung functionusually FEV1 (forced expiratory volume in one second)is seen. Natural stimuli can include exercise or cold, dry air that potentially stimulates release of cellular mediators. The resultant bronchoconstriction more accurately represents daily exposure to stimuli.

GOAL:
To provide pharmacists with an overview of asthma presentation and management

CREDIT:
This lesson provides two hours of CE credit and requires a passing grade of 70%.*

OBJECTIVES:
Upon completion of this article, the pharmacist should be able to:  Outline the pathophysiology, incidence, presentation, and diagnosis of asthma  Define processes and therapy in chronic management and exacerbation treatment of asthma  Counsel patients about nonpharmacologic options for optimizing control of their disease  Explain how to recognize exacerbation symptoms and the need for additional referral
*To receive credit you must score 70% or higher on the quiz and complete the evaluation. Upon successful completion, the University of Florida College of Pharmacy will mail Statements of Credit for written quizzes within 10 working days. Participants completing the program on-line may print a Statement of Credit after successfully completing the program. picture. Less commonly, patients with obstruction of the large airways appear to have similar presence of wheezing. Causes of these obstructions include tumors, vocal cord dysfunctions, and sarcoidosis. In infants, congenital malformations should be considered and appropriate evaluations performed to rule out such conditions. Young children can suffer viral infections that create symptoms similar to asthma. Supportive care helps alleviate these symptoms and continued treatment is not always warranted. Exclusions also include foreignbody obstruction for children with rapid-onset unilateral wheezing. Other conditions such as cystic fibrosis and immunodeficiency diseases should be differentiated in children with chronic cough and excess sputum production. Exclusion of other potential causes of airway obstruction further supports a diagnosis of asthma. Disease classification is based primarily on clinical symptom presentation along with peak expiratory flow (PEF) and/or FEV1. Although subjective in nature, patients report the occurrence of daytime and nighttime symptoms, indicating presence of airflow obstruction. Daytime symptoms include dyspnea and wheezDRUG TOPICS SEPTEMBER 26 2005

Clinical presentation and diagnosis

Asthma presentation can vary greatly in its severity, clinical course, response to treatment, and complications. Individuals should be assessed for these differences. Diagnosis is based on patient history, pulmonary function tests such as spirometry and peak expiratory flow, and blood gases in certain patients. Allergic skin tests for the presence of IgE antibodies and measurement of peripheral blood eosinophils further differentiate patients with suspected atopic or allergic causes of asthma, although these tests are not routinely performed. Spirometry assessment provides an objective measurement of FEV1 and FVC (forced vital capacity). These values are measured using a forced expiratory effort by the patient. Although considered an objective measure, patient effort may limit the reproducibility of these tests, especially in patients suffering an acute exacerbation. In general, the highest of three attempts is usually recorded. Results are then compared with predictive values that take into account patient characteristics. The FEV1/FVC helps to distinguish between other types of airway diseases. Diagnosis of asthma is made when there is at least partial reversibility of airway obstruction (12% increase in FEV1) via spirometry measurement, either spontaneously or post-bronchodilator challenge. Appropriate asthma diagnosis also includes exclusion of other possible causes such as chronic obstructive pulmonary disease (COPD) and heart failure in adults. COPD does not typically respond to a bronchodilator challenge unless the patient has a mixed asthma/COPD
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ing. Nocturnal symptoms represent a worsening of asthma that often awakens the patient. The number of occurrences of each of these helps determine the severity of asthma, which further determines drug therapy management. Patients monitoring their peak flow measurements further assist with severity identification. Asthma classifications include mild intermittent, mild persistent, moderate persistent, and severe persistent (Table 1). sions based on current treatment, pharmacologic properties of the drug (including ease of use and availability), and economic considerations help individualize treatment. Treatment choices also depend on a patients age. While childhood and adult asthma share the same underlying pathophysiology, choice of treatment also varies based on processes of growth and development. Younger children tend to metabolize certain medicationsglucocorticosteroids, 2-agonists, and theophylline, for examplefaster than adults and older children. Younger children may also have difficulty with different types of dosage forms and thus require alternative agents.

Chronic treatment
Overall goals for the treatment of asthma are to eliminate or minimize symptoms and exacerbations, maintain normal or near normal pulmonary function, minimize interference with daily activities, and maximize use of medications. Medication goals also include minimizing use of short-acting beta2-agonists as well as decreasing adverse effects of medications. Asthma therapy consists of a stepwise approach, where patients are stepped up if control is not maintained and stepped down in a gradual dose reduction for stable patients. Recommendations also include gaining control as quickly as possible, then stepping down to the least medication needed to maintain this control. Guidelines established by the National Asthma Education and Prevention Program (NAEPP) help distinguish both classification and treatment for patients with asthma. The most recent recommendations from the Expert Panel were revised in 2002. An additional program, the Global Initiative for Asthma (GINA), focusing on a more global approach to asthma information dissemination, released updated recommendations in 2004. Little has changed in the overall approach to the diagnosis and management of asthma over the last few years, but information to assist with clinical decisionmaking is updated as new evidence arises. Classification or stage of asthma guides individual treatment for patients, primarily with respect to preferred medication agent (Tables 2 and 3). Guidelines recommend that patients with any severity greater than mild intermittent asthma receive daily pharmacotherapy options to more effectively control symptoms by suppressing and reversing airway inflammation. It is also recommended that patients at any stage receive a prescription for as-needed 2-agonists to help control acute bronchoconstriction and symptoms. Little has changed with these recommendations, with the exception of treatment for mild persistent asthma. Ongoing debate exists on whether or not this classification requires daily preventive therapy or simply treatment with as-needed corticosteroids during periods of exacerbation. Further research is needed. Choice of daily medication treatment should be guided by several factors. In addition to severity, deci42
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Corticosteroids
Inhaled corticosteroids have become the cornerstone of asthma management. They help prevent asthma attacks by exerting nonspecific anti-inflammatory effects on cytokines, eosinophils, and other inflammatory mediators. As topical agents, their action is generally confined to the lungs. Inhaled corticosteroids should be taken on a daily basis, regardless of symptom presence, to help prevent inflammation. Most agents are dosed twice daily for maintenance therapy, with the exception of the first inhaled corticosteroid, which was approved for once-daily dosing early this year. Mometasone (Asmanex, Schering-Plough) was approved by the Food & Drug Administration and is expected to be available later this year. But until it sees more clinical use data, its exact role in therapy is yet to be determined. (See Table 4 for a comparison of available inhaled corticosteroid agents.) Let patients know they will not see an immediate benefit with inhaled corticosteroids. The agents do, however, help minimize reliance on short-acting 2-agonist use, a goal of asthma therapy. Adverse effects are tolerable, but patients need to rinse their mouth following each dose to prevent conditions such as oropharyngeal candidiasis and hoarseness. Spacers also assist in minimizing local and systemic adverse effects. Studies involving over 3,500 children followed for a period of one to 13 years have helped lessen the concern that inhaled corticosteroids stunt growth in children. While the agents may slow bone growth, overall growth does not appear to be affected. Additionally, long-term treatment with inhaled corticosteroid agents has not been shown to increase the incidence of osteoporosis or bone fracture, another prior concern for these medications. In general, the inhaled corticosteroid agents have established a fairly safe adverse-effect profile. Systemic corticosteroids are typically used for shortcourse bursts with initiation of therapy and during periods of deterioration. Their role for daily use is limited due to an extensive adverse-effect profile.
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Table 1

Clinical presentation and classification

Mild intermittent Daytime symptoms Nighttime symptoms PEF or FEV1 2/week 2/month 80% Mild persistent
2/week but 1/day

Moderate persistent Daily 1/week 60% to 80%

Severe persistent Continual Frequent 60%

2/month 80%

Adapted from National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma Update on selected topics 2002. Bethesda, Md.: U.S. Department of Health & Human Services; Public Health Service; National Institutes of Health; National Heart, Lung, and Blood Institute, 2002; NIH publication no. 02-5075.

Bronchodilators
Beta2-agonists, the most commonly used bronchodilators, are central to the management of patient symptoms in acute exacerbations. Patients with any severity of asthma should receive a 2-agonist for acute management. These agents work by directly stimulating adrenergic receptors, resulting in bronchial relaxation. Additional benefits potentially include increasing mucociliary clearance and decreasing release of histamine, leukotrienes, and prostaglandins from mast cells. Patients who suffer exercise or allergen-induced asthma also benefit from short-term use of these medications. Short-acting inhaled 2-agonists should be prescribed on an as-needed basis only. The most widely used agent in this class is albuterol (Proventil and Ventolin, GlaxoSmithKline). Onset of action occurs generally within five to 15 minutes, with a duration of two to six hours. Most commonly seen adverse effects include tachycardia and tremor. Consistent use of this medication may result in drug dependencea concern for patients needing immediate response following stimuli exposure. Levalbuterol (Xopenex, Sepracor), an L-isomer of albuterol, was released within the past few years, but its use remains controversial. Adverse effects are reportedly reduced with this agent, but clinical relevance may not substantiate its additional cost. As it is available only in a nebulizer formulation, its use is also limited. Longer-acting 2-agonistssalmeterol (Serevent, GlaxoSmithKline) and formoterol (Foradil, ScheringPlough)are available for use in greater disease severity. In general, longer-acting agents are recommended when routine bronchodilator use is warranted along with an inhaled corticosteroid; they also help decrease short-acting 2-agonist use and may also be useful for nocturnal or exercise-induced asthma. Long-acting 2agonists work in a similar fashion to short-acting agents but have a longer duration of action. Combination therapy with inhaled corticosteroids also helps decrease the dose of the latter and provide an additional benefit of smooth-muscle bronchodilation. Advair (GlaxoSmithKline), a premixed combination of fluticasone and salwww.drugtopics.com

meterol, can help improve adherence by reducing both number of inhalers and required doses. Tolerance does not appear to be a problem for the long-acting agents, supporting their use as maintenance therapy. Onset of action for salmeterol is close to 30 minutes, with a peak effect seen in two to four hours. Formoterol, however, has an onset of action seen within three minutes and a peak within 15 minutes. Both have durations of action around 12 hours. Although long-acting 2-agonists are typically not used in acute situations, formoterols faster onset may additionally expand its role in this situation. These agents are typically dosed twice daily and have similar adverse effects of tremor and tachycardia. The primary concern for these agents is when used as monotherapy. The Salmeterol Multi-center Asthma Research Trial (SMART), begun in 1996, was halted in late 2002 due to concerns with life-threatening asthma episodes and asthma-related deaths. Salmeterol showed a nonsignificant trend toward complications versus the placebo group, especially in black patients. Patients using an inhaled corticosteroid along with salmeterol did not demonstrate the same results and further supports the use of this long-acting 2-agonist as adjunctive therapy to the anti-inflammatory actions of inhaled corticosteroids.

Methylxanthines
Methylxanthine agents offer an additional option for asthma therapy, but their use has steadily declined over the years. Although they are viable options for bronchodilation and once preferred, their use ceded to the availability of newer, safer options. The most common agents in this class are theophylline and its counterpart, aminophylline, containing approximately 85% anhydrous theophylline. These agents produce bronchodilation via several mechanisms, e.g., phosphodiesterase inhibition resulting in increased cAMP levels, prostaglandin antagonism, and stimulation of endogenous catecholamines. Since theophylline poses difficulty with monitoring due to a narrow therapeutic index and mulDRUG TOPICS SEPTEMBER 26 2005

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Table 2

Drug therapy management for adults, children OVER age five

Mild intermittent Preferred treatment No daily medication needed Mild persistent Low-dose inhaled corticosteroid Moderate persistent Low/medium-dose inhaled corticosteroid PLUS longacting 2-agonist Severe persistent High-dose inhaled corticosteroid PLUS long-acting 2-agonist

All patients Stepwise approach

As-needed short-acting bronchodilator Short course of systemic steroids may be needed for exacerbations Step upconsider if control is not maintained (first need to review compliance, inhaler technique, and environmental control) Step downtreatment may be gradually decreased once good control is attained can be reviewed every one to 6 months Minimal symptoms or exacerbations, no limitations on activities, no missed school/work days, near normal pulmonary function, minimal use of 2-agonists, minimal adverse effects from medications

Goals of therapy

Adapted from National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma Update on selected topics 2002. Bethesda, Md.: U.S. Department of Health & Human Services; Public Health Services; National Institutes of Health; National Heart, Lung, and Blood Institute, 2002; NIH publication no. 02-5075.

tiple drug interactions, its use is typically preferred as third-line therapy or as adjunct therapy in patients requiring high doses of inhaled steroids. Patients suffering from nocturnal asthma also show benefit. Monitoring parameters include targeting a therapeutic level of 515 mcg/ml. Adverse effects of these agents include nausea/vomiting, GERD, nervousness, tremors, insomnia, headache, arrhythmias, and seizures.

action potential, and screening should be performed when these medications are dispensed.

Mast-cell stabilizers
The use of mast-cell stabilizers for the treatment of asthma has decreased in recent years. Available agents include cromolyn (Intal, King Pharmaceuticals) and nedocromil (Tilade, Aventis), currently recommended as alternative, but not preferred, agents for the treatment of mild, persistent asthma. They typically have a slow onset of action. Initial effects can take two weeks to appear, while full effects may take up to four to eight weeks. Adverse effects are typically rare, mostly consisting of cough and taste disturbances.

Leukotriene receptor antagonists

The use of leukotriene-modifying agents remains controversial in asthma treatment. Guidelines typically recommend their use as adjunctive therapy for patients having symptoms despite use of inhaled corticosteroids and long-acting 2-agonists. Available agents include montelukast (Singulair, Merck), zafirlukast (Accolate, AstraZeneca), and zileuton (Zyflo, Abbott). They modify the inflammatory response to leukotrienes by inhibiting 5-lipoxygenase or blocking the leukotriene receptor site (LDE4 & LTE4), thus providing dual benefits of anti-inflammatory and bronchodilator properties. The oral dosage form is typically recommended for aspirin/NSAID and exerciseinduced bronchospasm or for patients unable to use inhalers. Benefits have also been seen in children or patients with nocturnal symptoms and/or concomitant allergic rhinitis. Adverse effects of headache and GI upset are usually fairly mild, but some concern exists with elevated hepatic enzymes, primarily with zileuton. Monitoring should include watching for ChurgStrauss syndrome (rare pulmonary vasculitis) with tapering doses of steroids in patients on zafirlukast or montelukast. Zileuton and zafirlukast have drug-inter44
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Immunoglobulins
Monoclonal antibodies represent a new area for asthma treatment, with omalizumab (Xolair, Genentech) the first biologic therapy indicated for asthma. Dosed subcutaneously, it inhibits IgE binding to high-affinity IgE receptors on mast cells and basophils and may possibly benefit patients with moderate to severe persistent allergy-related asthma. But questions remain about its overall role in asthma therapy. Dosing is unique, with 150-375 mg given every two to four weeks, and is based on baseline serum IgE levels and body weight. Injection-site reactions, urticaria, transient thrombocytopenia, and rare cases of anaphylaxis may occur. Its cost and lack of indication for children under age 12 limits its widespread use.

Monitoring
Patient monitoring has an important role in asthma management. Symptom reporting, spirometry assessment, and peak flow monitoring are the basis of an apwww.drugtopics.com

Table 3

Drug therapy management for infants and children age five

Mild intermittent Preferred treatment No daily medication needed Mild persistent Low-dose inhaled corticosteroid Moderate persistent Low/medium-dose inhaled corticosteroid PLUS long-acting 2-agonist OR Medium-dose inhaled corticosteroid Severe persistent High-dose inhaled corticosteroid PLUS long-acting 2-agonist

All patients

Medications typically given via nebulizer or MDI with holding chamber, or DPI As-needed short-acting bronchodilator (given via nebulizer or orally) With respiratory viral infections, use bronchodilator every four to six hours as needed for one day Short course of systemic steroids may be needed for exacerbations Same as adults and children age five Same as adults and children age five

Stepwise approach Goals of therapy

Adapted from National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma Update on selected topics 2002. Bethesda, Md.: U.S. Department of Health & Human Services; Public Health Services; National Institutes of Health; National Heart, Lung, and Blood Institute, 2002; NIH publication no. 02-5075.

propriate monitoring plan. (Arterial blood gas measurement is a monitoring technique used more for exacerbations than routine monitoring.) Patients should keep track of their short-acting 2-agonist use as well as the number of nighttime symptoms and limitations in daily activities to help both them and their healthcare provider adjust therapy to best control symptoms. Spirometry, helpful for detecting reversibility of airway obstruction on initial assessment, can assist with follow-up monitoring. Airflow measures can help indicate severity of the disease and exacerbations as well as response to therapy. Self-monitoring with a peak flow meter has a primary role in patient self-management. Peak flow meters help measure peak expiratory flow rate (PEFR), and early awareness helps the patient and/or caregiver take steps to minimize the severity of an attack, especially with moderate to severe asthma. Peak flow monitoring is done by establishing zones of control for each individual patient, thus guiding appropriate follow-up or continued care. Patients with poor perception of disease control and symptoms greatly benefit from continued monitoring. Patients should first establish their personal best reading recorded over two to three weeks during a stable period. A green zone represents 80% or higher of personal best and indicates stability. A yellow zone represents 50%-80% of personal best and indicates a need for action. A red zone represents 50% or less of personal best and strongly encourages emergency assistance.

Exacerbation management
Asthma worsens for a variety of reasons. It worsens primarily when a patient is exposed to a trigger that
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causes inflammation, produces bronchoconstriction, or a combination of both. Treatment of an individual exacerbation varies depending on multiple factors. These include the individual patient, the experience of the healthcare professional with managing asthma, available medication agents along with the patients response to that agent, and type of emergency services available. Some patients will require expedient emergency care for exacerbations to prevent serious or fatal outcomes. Patients with an O2 saturation 90% often require the use of oxygen. Beta2-agonists (inhaled or nebulized) and/or anticholinergic agents serve as short-acting bronchodilators to assist with management. Corticosteroids, both oral and intravenous, are often employed for patient care depending on the severity of the attack. Intubation may be required for patients with severe respiratory failure. Close monitoring for response to treatment is necessary for all patients, especially for severe exacerbations, as these can be life threatening. Once released from emergency care, patients should continue to be followed to ensure that therapeutic objectives are met and further exacerbations are reduced or eliminated. Length of time before follow-up should be based on individual patient risks. Systemic corticosteroids commonly used in exacerbations include hydrocortisone (Solu-Cortef, National Pharmpak Services), methylprednisolone (SoluMedrol, Pharmacia), and prednisone (Deltasone, Douglas Pharmaceuticals). These agents have nonspecific anti-inflammatory effects on cytokines, eosinophils, and other inflammatory mediators. They work quickly and effectively to relieve acute symptoms. Use
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Table 4

Comparison of available inhaled corticosteroid agents

Daily dosing range (low, medium, and high) in mcg Inhaled corticosteroid Beclomethasone HFA 40 or 80 mcg/puff Budesonide* 200 mcg/inhalation Flunisolide 250 mcg/puff Fluticasone MDI: 44, 110, or 220 mcg/puff DPI: 50, 100, or 250 mcg/inhalation QVar Brand names Adults 80-240 240-480 480 200-600 600-1200 1200 500-1000 1000-2000 2000 88-264 264-660 660 100-300 300-600 600 100/50 250/50 500/50 (All dosed BID) 220-440 880 (with prior oral steroids) 400-1000 1000-2000 2000 Children 12 years old 80-160 160-320 320 200-400 400-800 >800 500-750 1000-1250 1250 88-176 176-440 440 100-200 200-400 400 Use 100/50 strength (BID)

Pulmicort Turbuhaler and Respules

Aerobid

Flovent

Flovent Rotadisk

DPI: 100, 250, or 500 mcg/inhalation

Advair Diskus (combined with salmeterol 50 mcg/puff for all strengths)

Mometasone furoate 220 mcg/inhalation (approved 4/05) Triamcinolone acetonide 100 mcg/puff

Asmanex Twisthaler

Not approved for children 12

Azmacort

400-800 800-1200 1200

*Pediatric doses for budesonide suspension for inhalation (nebulization): 0.5 mg (low), 1.0 mg (medium), and 2.0 mg (high)
Adapted from National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma Update on selected topics 2002. Bethesda, Md.: U.S. Department of Health & Human Services; Public Health Service; National Institutes of Health; National Heart, Lung, and Blood Institute, 2002; NIH publication no. 02-5075.

of these agents is suggested to continue until the patient reaches 80% of personal best with peak flow meter. Adverse effects include Cushings syndrome, growth retardation, osteoporosis, hypertension, glucose intolerance, impaired wound healing, cataracts, and CNS effects (depression, euphoria), making their routine use undesirable when there are safer options available. Certain patients are candidates for managing exacerbations based on an established action plan. Home management of these exacerbations is based on PEFR reading. Although action plans are patient-specific, the NAEPP provided general guidelines for home treatment of asthma exacerbations. For example, if initial
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PEFR is 50%-80%, a patient should use an inhaled 2agonist with a maximum of three treatments of two to four puffs at 20-minute intervals. If PEFR increases 80% after therapy, the patient should continue the 2agonist every three to four hours for one to two days as needed and double his/her dose of inhaled corticosteroid for the next seven to 10 days, although doubling the dose has been questioned in more recent literature vis--vis continuing normal maintenance doses. If the PEFR remains 50%-80% after acute treatment, the patient should continue the 2-agonist and start oral prednisone 40-60 mg/day for three to 10 days if a prescription is available for such occasions. If PEFR is ever below 50%, either before or after initial 2-agonist treatwww.drugtopics.com

ment, the patient should use a 2-agonist, start oral prednisone, and seek medical care immediately.

Preventative care
In addition to medication therapy, overall goals of therapy include the prevention and control of patient risk factors. With inflammation being a key part in airway obstruction, goals should include prevention and suppression of underlying inflammation. Patients should be counseled regarding self-management skills to help improve adherence to medication regimens as well as in the understanding of the use of healthcare services. Education of the pathogenesis of asthma and appropriate use of medications are important, but selfmanagement also includes recognition of individual triggers and identification of early exacerbations. Patients with asthma should also avoid allergens that aggravate symptoms, such as animal dander, dust mites, cockroach allergens, outdoor allergens, fungi/mold, and smoke. Precautions taken to avoid exposure to specific triggers can minimize an inflammatory response. For example, patients with dust-mite allergies can use plastic pillow and mattress covers, remove bedroom carpets, and wash sheets in hot water to help eliminate this allergen. Smoking cessation should be encouraged in all households where patients suffer from asthma. Certain patients receive exposure during occupational environments and should take precautions during working hours to minimize contact with known triggers. Viral respiratory infections are also known to aggravate patients suffering from asthma. For this reason, it is recommended that patients receive an annual influenza vaccine. Recent literature has evaluated other nonpharmacologic interventions such as the Buteyko technique of breathing and dietary manipulation. The Buteyko technique is a breathing method consisting of a series of exercises in which subjects reduce the depth and frequency of respiration. Theories exist that the technique benefits patients with symptoms due to hyperventilation and hypocapnia. Clinical studies and reviews, however, have not shown this intervention to help improve lung function, and it should not be recommended for all asthma patients. Dietary manipulation focuses on changing the diet to include more antioxidants and less dietary fat. Currently, no strong evidence exists to support dietary modifications and improvement in lung function, although some patients may benefit from this intervention in the future. Asthma may also mimic some disease states and coincide with others. Patients having difficulty controlling their symptoms should be evaluated for other conditions and treated appropriately. Asthma patients often have concomitant allergic rhinitis and should receive
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either intranasal steroids and/or antihistamines/decongestants for symptom control. Sinusitis can often lead to exacerbations of asthma and patients should receive antibiotic therapy if bacterial infection is highly suspected. If viral illness is suspected, patients should receive supportive symptom management to help prevent an asthma exacerbation. Disease states such as GERD can often mimic the symptoms of asthma. Patients experiencing symptoms with adequate asthma therapy and normal PEFR readings should be evaluated for GERD. Preventative measures and/or medications used for this disease may help to further alleviate symptoms.

Patient counseling
Pharmacists play a valuable role in asthma education. Medication administration can be overwhelming for patients due to the number of different devices available as well as the different mechanisms of action of the medications. Patients may become confused with the different types of inhalers on the market and should be counseled frequently on proper inhaler techniques. Nebulizers also represent a source of confusion for patients. Proper medication loading, use, and cleaning should be discussed for patients and/or caregivers when using nebulized medications. With a large variety of nebulizers available, patients may need to bring in their device for proper demonstration. Patients should be counseled on the proper use and importance of using their peak flow meters. Pharmacists can help to reinforce establishment of a patients peak flow zones and help develop treatment plans for each zone. Reinforcement of the benefit of continuous monitoring helps patients recognize a normal level of control for their disease and realize when to seek more assistance for care. This approach also helps pharmacists recognize when more emergent care is needed and refer patients in this situation.

Conclusion
While considered a chronic disease, asthma can be effectively controlled with proper identification and treatment. Asthma management requires appropriate education, objective lung function measures, environmental control, and proper pharmacologic therapy based on a stepwise approach. Goals of therapy include controlling symptoms with the least possible medication while improving patient quality of life and reducing exacerbations. Patients need to be aware of situations predisposing them to an exacerbation and should be educated about seeking appropriate follow-up during these times. Pharmacists play a vital role in asthma management due to the large involvement of medication therapy as well as the different medication delivery devices available. References available upon request
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TEST QUESTIONS
Write your answers on the answer form appearing on page 49 (photocopies of the answer form are acceptable) or on a separate sheet of paper. Mark the most appropriate answer.
1. Common symptoms of asthma include all of the 11. Which one of the following medications has

following except:
a. Palpitations b. Wheezing c. Chest tightness d. Cough

become the mainstay of asthma therapy?

a. Short acting 2-agonists b. Long-acting 2-agonists c. Leukotriene antagonists d. Inhaled corticosteroids 12. Which adverse effect is seen most commonly with

2. How many adults have reported being diagnosed

with asthma in their lifetime?

a. 5 million b. 9 million c. 22 million d. 31 million

inhaled corticosteroids?
a. Growth suppression b. Oropharyngeal candidiasis c. Osteoporosis d. Hyperglycemia

3. The primary process of airway obstruction in asth-

ma is a result of which one of the following?

a. Inability of diaphragm to contract b. Airway thickening c. Airway hyperresponsiveness d. Inflammatory changes 4. Which pharmacological agent can be used to test

13. What is the appropriate use for short-acting 2-

agonists?
a. Should be given to all patients on a scheduled basis b. Should be given on a scheduled basis to patients with severe persistent asthma c. Should be given to all patients on an as-needed basis d. Should be used only for exercise-induced bronchospasms 14. Which of the following agents is considered a long-

for airway hyperresponsiveness in asthma patients?

a. Atropine b. Methacholine c. Adenosine d. Acetylcysteine

5. A 15-year-old patient reports having daily asthma

symptoms and nocturnal symptoms twice a week. How would this patients asthma be classified?
a. Mild intermittent b. Mild persistent c. Moderate persistent d. Severe persistent

acting 2-agonist, yet has an onset of action within five minutes?

a. Omalizumab b. Formoterol c. Mometasone d. Salmeterol

6. A 26-year-old patient reports having daytime asth-

ma symptoms three to four times per week and 15. Which of the following is true with regard to nocturnal symptoms four to five times per month. methylxanthine use in asthma therapy? How would this patients asthma be classified? a. It is typically recommended as alternative or adjunct
a. Mild intermittent b. Mild persistent c. Moderate persistent d. Severe persistent therapy. b. Infrequent monitoring allows it to be used easily and safely. c. Lack of drug interactions makes these attractive agents. d. Lack of efficacy creates frequent treatment failure. 16. Which of the following patients would benefit from

7. All of the following disease states should be ex-

cluded in adults with suspected asthma except:

a. Heart failure b. COPD c. Airway obstruction d. Congenital malformations

8. Asthma diagnosed via spirometry requires how

the addition of a leukotriene antagonist?

a. A seven-year-old with exercise-induced bronchospasm b. An 18-year old with concomitant allergic rhinitis c. A 4-year-old who is uncooperative in using inhalers or nebulizers d. All of these patients would potentially benefit

much improvement in the FEV1 measurement?

a. 12% b. 15% c. 17% d. 22%

9. Which of the following maintenance medications is

recommended for a patient with mild intermittent 17. Which of the following is a characteristic of mast asthma? cell stabilizers? a. Low-dose inhaled corticosteroid a. Slow onset of action that limits their use in asthma b. Long-acting 2-agonist
c. Leukotriene antagonists d. No daily medication is needed 10. A 22-year-old patient with mild persistent asthma is

currently receiving a low-dose inhaled corticosteroid. What medication changes would be recommended if the patient worsens to moderate persistent?
a. Increase to high-dose inhaled corticosteroid b. Add a leukotriene antagonist c. Add a long-acting 2-agonist d. Add a scheduled short-acting 2-agonist 48
DRUG TOPICS SEPTEMBER 26 2005

b. Preferred therapy for patients with mild persistent asthma c. Multiple drug interactions that represent challenges with therapy d. Side effects that make them unattractive to patients

18. Which of the following monitoring techniques is

used to develop individual action plans for exacerbations?

a. Blood gases b. Spirometry readings c. Symptom reporting d. Peak flow monitoring
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TEST QUESTIONS
19. All of the following actions should be taken by a

patient with a PEFR that is 45% of his/her personal best except:

a. Using a short-acting 2-agonist immediately b. Doubling his/her dose of inhaled corticosteroid c. Beginning oral prednisone if available d. Seeking emergency care immediately 20. Which of the following is true with respect to

preventative care for asthma patients?

a. Annual flu vaccines are not recommended in asthma patients. b. Dietary modifications such as increasing antioxidant use have proven successful in the prevention of asthma. c. Smoking cessation should be encouraged in households with asthma patients. d. Patient education plays a minor role in asthma prevention.

Evaluation of CE
Drug Topics is conducting an evaluation of this CE article. Please  box that best reflects your opinion of the evaluation questions. Please keep this evaluation attached to your answer form.
Strongly Agree 1. The program objectives were met. 2. The program content was useful and relevant. 3. The program was educational and not promotional. 4. The programwas fair, objectiv, balanced, and of scientific rigor. 5. The program will help me in my practice. Agree Disagree Strongly Disagree

2005 CEU CREDIT REQUEST

To obtain immediate CE credit, take the test on-line at www.drugtopics.com. Just click on the Continuing Education box in the lower right side of the Drug Topics home page, which will take you to the CE site. Log in, find and click on this lesson, and follow the three simple steps. Test results will be displayed immediately and you can print the certificate showing your earned CE credits.

ANSWER FORM
ASTHMA: HELP TO PROMOTE A BREATH OF FRESH AIR

SEPTEMBER 26, 2005 012-999-05-206-H01

Test questions start on preceding page

1. 2. 3. 4.

a. a. a. a.

b. b. b. b.

c. c. c. c.

d. d. d. d.

5. 6. 7. 8.

a. a. a. a.

b. c. d. b. c. d. b. c. d. b. c. d. No longer

9. a. b. c. d. 13. a. b. c. 10. a. b. c. d. 14. a. b. c. 11. a. b. c. d. 15. a. b. c. 12. a. b. c. d. 16. a. b. c. valid for CE credit after 9/30/07

d. d. d. d.

17. 18. 19. 20.

a. a. a. a.

b. b. b. b.

c. c. c. c.

d. d. d. d.

Amount enclosed:

$6.00 for this lesson $54.00 for any 12 lessons you take over the next year, starting from the date you sign up Already series-enrolled for 2005

Submit your check (payable to The University of Florida) and form to:
University of Florida College of Pharmacy, P.O. Box 100482, Gainesville, FL 32610 E-mail address: continuinged@cop.ufl.edu Fees not refundable or transferable

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For questions concerning PRINT CEs, call (352) 273-6275. For questions concerning ON-LINE CEs, call (866) 261-3558. REGISTRANT INFORMATION

Name:
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Address:
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ATTENTION FLORIDA PHARMACISTS: The State of Florida has changed to a new record maintenance system for all continuing education, using a private company,cebroker.com. The University of Florida is registered with the Florida Board of Pharmacy as a Provider, and will report continuing education records for all pharmacists who are registered in Florida. Please provide your license number ___________________________

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DRUG TOPICS SEPTEMBER 26 2005

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