3. WHAT IS ASTHMA
• Chronic inflammatory airway disease which
manifests as recurrent episodes of chest
tightness, wheezing, breathlessness and cough
• Airway hyper-responsiveness
• Variability and reversibility of the symptoms with
or without treatment
Agarwal, et al Asthma guidelines
4.
5. PREVALENCE OF ASTHMA
• Global prevalence of asthma is about 4.5%; it
being one of the most prevalent chronic diseases
in the world
• 315 million individuals are suffering from the
disease
• INSEARCH- multicentric study in India estimated
the prevalence of around 2% which accounts to
disease burden of around 17.23 million
Agarwal, et al Asthma
guidelines
6. RISK FACTORS
NON-MODIFIABLE
• Age and gender
• Atopy
• Family history
• Genetic risk factors
MODIFIABLE
• Tobacco smoke
• Biomass exposure
• Infections
• Occupational
exposure
• Diet
• Obesity
Agarwal, et al Asthma
guidelines
7. DIAGNOSIS
• Clinical features
• Family history/ presence of atopy
• Presence of wheeze
• Hyperinflated chest
• Role of spirometry
• Demonstration of reversibility and variability
Agarwal, et al Asthma
guidelines
8. GOALS OF MANAGEMENT OF STABLE
ASTHMA- GINA
• Achieve and maintain control of daytime as well
as nocturnal symptoms
• Maintain normal activity including exercise
• Maintain normal or near normal pulmonary
functions
• Minimise the adverse effects of asthma
medications
• Prevent asthma exacerbations and mortality from
9. MANAGEMENT OF STABLE ASTHMA
• Need to be taken
regularly
• Prevent and control
symptoms
• Reduce airway
inflammation
• Decrease the risk of
exacerbations
• Rescue medications
• To relieve acute
symptoms
CONTROLLER DRUGS RELIEVER DRUGS
10.
11. CONTROLLER MEDICATIONS
• Inhaled corticosteroids
• Inhaled Long acting beta agonists LABA
• Inhaled Long acting anti muscarinic agents
LAMA
• Oral Leukotriene inhibitors
• Oral Methylxanthines
• Oral corticosteroids
• Anti IgE- Omalizumab
12. RELIEVER MEDICATIONS
• Inhaled short acting beta agonists SABA
• Inhaled short acting anti muscarinic agents
SAMA
• Oral beta agonists
14. INHALED CORTICOSTEROIDS
• Corner stone in the management of asthma
• Suppress airway inflammation
• Improve the quality of life
• First choice of controller medication in
management of asthma
• Superior to all other available controller
medications
16. ADVERSE EFFECTS
• Oral candidiasis
• Dysphonia
• Perioral dermatitis
• Reflex cough
• Sensation of thirst
• Tongue hypertrophy
• HPA axis suppression
• Lower respiratory tract infections
• Growth suppression and decreased bone mineral
density
17. Factors determining the adverse effects
• Dose of ICS used
• Frequency
• Proportion of drug in oropharynx
• Type of drug used- prodrug vs active drug
Preventive measures include
• Using lowest possible dose and frequency
• Rinsing mouth and oropharynx by gargling
• Use of spacer devices
18. RECOMMENDATIONS FOR ICS
• Controller medication of choice
• Equally efficacious in equipotent doses
• Maximum effect obtained at low to moderate
doses
• High doses to be avoided
• Use of valved holding chambers and spacers
when using high dose or moderate dose
Agarwal, et al Asthma
guidelines
19.
20.
21. LABA
• Selective and potent beta-2 agonists
• Cause smooth muscle relaxation up to 12 h, given
twice a day
• Commonly used drugs are- Formoterol and
Salmeterol
• Formoterol vs salmeterol
âś“ Faster onset of action (5 min vs. 15 min)
âś“ Higher intrinsic receptor affinity
âś“ Also be used as reliever medication for symptom
22. Dosage of LABAs to be given:
• Salmeterol 50-100 µg/day
• Formoterol 12-24 µg/day
Novel drugs in this category: ultra long acting with
once daily usage
• Vilanterol
• Indacaterol
• olodaterol
23. • LABA monotherapy is not recommended in the
management of stable asthma
• Addition of LABA to ICS is preferred choice
when symptoms are not controlled despite ICS
alone
Agarwal, et al Asthma
guidelines
24.
25.
26.
27.
28. Common adverse effects are:
• Nausea, vomiting
• Headache
• Tremors
• Hypokalemia
• Tachycardia
Adverse effects are dose dependent, generally
mild.
30% patients may experience some of these
adverse
effects
29. ANTICHOLINERGICS-LA MA
• As an add on therapy to the uncontrolled asthma
on ICS/LABA
• As an add on therapy to the ICS therapy alone
they benefit was similar to LABA but not
recommended as alternative to it
• Drug- Tiotropium
• Dosage- 18µg/day
30.
31. METHYL XANTHINES
• Methyl xanthines are used as an add on therapy
to the patients who are uncontrolled on
ICS/LABA combination.
• Inferior to ICS/LABA combination
• As effective as increasing the dose of low dose
ICS to moderate to high dose
Agarwal, et al Asthma
guidelines
32.
33. • Commonly prescribed because of easy
availability and low cost
• Mechanism of action- anti inflammatory action
HDAC 2 activation, PDE4 inhibition and airway
bronchodilation; adenosine receptor antagonism
• Available drugs- theophylline, doxophylline
• Dosage- 200-400 mg/day
• Doxophylline has lesser adverse effects as
compared to theophylline because of lack of
action on adenosine receptors and calcium
channels
34. ADVERSE EFFECTS OF XANTHINES
• Nausea and vomiting
• Headache
• Cardiac arrhthymias
• Epileptic seizures
• Due to narrow therapeutic range and multiple
drug interactions
35. ANTILEUKOTRIENES
• LTC4, LTD4 and LTE4 are potent inflammatory
mediators in asthma.
• Production via 5-lipoxygenase pathway
• Other benefits- control other allergic
manifestations like rhinorrhoea and
conjunctivitis
• Targets- LOX inhibitors i.e. Zileuton
• LTRAs- montelukast, zafirlukast, pranlukast
• Most commonly used- Montelukast 10 mg OD
36. • As a monotherapy in mild asthma as an
alternative to ICS
• Can be used as an add on therapy to the patients
uncontrolled on LABA/ICS combination therapy
• As monotherapy are inferior to ICS
• Inferior to LABA as an add on to ICS
• Safety profile- Zileuton is associated with
hepatotoxicity and liver function monitoring is
needed
• Rarely associated with Churg Strauss syndrome
Agarwal, et al Asthma guidelines
37. MAST CELL STABILISERS
• Cromolyn sodium and nedocromil are the two
drugs of this category
• Mast cell membrane stabilisers and prevent
release of the mediators
• Inhalational route
• Short duration of action
• Now have been taken over by ICS
38. RELIEVER THERAPY
• Includes SABA and SAMA
• SABA- Salbutamol, Levosalbutamol
• SAMA- Ipratropium
• Preferred choice- SABA
• Delayed action of the anti-muscarinic agents
• Used as drug of choice in mild asthma
• Dosage- 100µg for salbutamol
• 50µg for levosalbutamol
• Ipratropium- 20µg
44. STEPPING UP
• Intervals of 1-3 months
• Before stepping up therapy, ensure
âś“ Correct inhalational technique
âś“ Compliance (using dosimeter readings, drug
diaries, etc.)
âś“ Avoidance of allergens
• For patients using ICS+LABA combination, the
dose of the LABA component should not exceed
the upper limit of its recommended dosage
45. STEPPING DOWN
• For patients who are on > 3 controller
medications the non-ICS, non-LABA controllers
should be stopped sequentially
• For patients who remain well controlled on
medium to high-dose ICS with or without LABA,
the dose of ICS be decreased by 50% every 3
months till a low dose of ICS is reached
• When a patient remains well controlled on
low-dose ICS + LABA, LABA should be stopped
and ICS continued or frequency to be decreased
46. ANTI IG-E: OMALIZUMAB
• Antibody against IgE antibody which plays role
in pathogenesis of hypersensitivity reaction
• As an adjunct therapy to the patients who are not
controlled with Step 4 therapy
• Elevated serum IgE levels in the range of
140-1300
• Positive skin allergy test
• Target IgE <50
• Dosage is 75-600 mg per dosage; commonly used
is 375 mg s/c every 2weeks
• Duration- 12-24 weeks
47.
48.
49. • Adverse effects:
• Serum sickness
• Type III hypersensitivity reaction
• Thrombocytopenia
• Increased non melanoma skin malignancies
• Arterial thromboembolic events
• Adverse effects on fetus
50.
51. BRONCHIAL THERMOPLASTY
• Ablation of airway smooth muscle by delivering
controlled radiofrequency energy via catheter
inserted via bronchoscopy
• Second mechanism is decreased contractility of
the muscles due to actin and myosin stiffening
• Cochrane meta analysis has shown only modest
clinical benefit in quality of life and decreased
rate of exacerbations
• No difference in asthma control scores
• Various trials conducted were- AIR, AIR2, RISA
52.
53.
54. IMMUNOTHERAPY
• Modest benefit with the use of immunotherapy
• No difference in the efficacy of single allergen vs
multiple allergens immunotherapy
• Risk of severe life threatening reactions like
anaphylaxis may occur
• Can be tried in mild to moderate asthma
• Contra indicated in severe asthma
55.
56. PULMONARY REHABILITATION
• Improvement in exercise capacity
• Improvement in dyspnea
• Improved quality of life
• Improvement in oxygenation is seen
• No improvement in the pulmonary functions is
documented
57.
58. REFRACTORY ASTHMA
• Difficult to treat asthma
• Symptoms are not controlled despite step 4
therapy i.e. maximum inhalational therapy for 1-3
months
• 2 major patterns observed are-
Persistent poor lung functions
Frequent exacerbations
59. EXERCISE INDUCED ASTHMA
• Defined as a fall in FEV1 of 10% or greater on an
exercise challenge test (4-6 min of exercise at
near-maximum targets with a total duration of
exercise of 6-8 min)
• Pretreatment with bronchodilator agents
(SABA,SAMA, and LABA) as well as
anti-inflammatory agents (LTRA but not ICS) is
effective
• Regular use of ICS or LTRAs is effective in
prevention of exercise-induced bronchospasm
60. ASPIRIN INDUCED ASTHMA
• Occurs because of the inhibition of the enzyme
COX-1 by aspirin and other NSAIDS
• Diagnosis can be established by oral, nasal or
bronchial challenge testing with aspirin in
patients with a suggestive history
• All NSAIDS inhibiting COX-1 to be avoided,
COX-2 inhibitors can be safely used
• Can have cross-reactions to paracetamol (esp. in
doses >1000 mg) but milder
• Aspirin desensitization may be useful
61. OCCUPATIONAL ASTHMA
• New onset or worsening of the symptoms of
asthma after employment or history of exposure
to known or suspected sensitizing agents
• Removal and reduction of exposure of stimulus is
effective in treatment with removal more
effective than reduction
62. PREGNANCY & ASTHMA
• Adequate asthma control should be attempted
with routinely available asthma medications as in
non-pregnant state
• Poorly controlled asthma and asthma
exacerbations associated with adverse pregnancy
outcomes- both maternal and fetal
• None of the drugs are contraindicated
• Theophyllines should be used cautiously during
pregnancy and lactation as they can cause
irritability in infants
