asthma – 2005 “why we do the things we do” a miniature literature review
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Asthma – 2005
“Why We Do the Things We Do”
A Miniature Literature Review
Michael E. Ruff, MD
Dallas, Texas
Photo: Personal collection, Dr. Dennis Williams Pharm.D.
Effect of Inhaled Corticosteroids on Inflammation
Pre– and post–3-month treatment with budesonide (BUD) 600 mcg b.i.d.
E = Epithelium
BM = Basement Membrane
Laitinen et al. J Allergy Clin Immunol. 1992;90:32-42. Reprinted with permission.
Mean Annual Increase in FEV1 During ICS Therapy
12
10
8
6
4
2
0
AnnualChange in
% PredictedFEV1
<2 2-3 3-5 >5
Asthma Duration at Start of ICS therapy (yrs)
Agertoft L, Pederson S. Respir Med. 1994; 88:373-381.
Assessment of the Effects of Inhaled Corticosteroids on Growth
cm
0 1 2 3 4
Time (y)
0
130
135
140
150
160
145
155
Standing Height
*Children aged 5 to 12 years.Childhood Asthma Management Program Research Group. N Engl J Med. 2000;343:1054-63.
Standing-Height Velocity
cm
/y
Time (y)0 1 2 3 4
0.0
4.5
5.0
5.5
6.5
6.0
Nedocromil PlaceboBudesonide
Girls
Boys
Mea
sure
d A
dult
Hei
ght
(cm
)
Target Adult Height (cm)
200
190
180
170
160
150150 160 170 180 190 200
Effect of Long-term Treatment with Inhaled Budesonide on Adult Height in Children with Asthma
Agertoft L, Pedersen S. N Engl J Med. 2000;343:1064-1069.
NIH Treatment Guidelines
NIH-preferred options are highlighted.
Guidelines for the Diagnosis and Management of Asthma. 2002.NIH Publication No. 02-5075.
• Step 1 - Mild Intermittent Asthma– No daily medication
• Step 2 - Mild Persistent Asthma– Low-dose inhaled corticosteroid (ICS)– Cromolyn/nedocromil, theophylline or leukotriene modifier
(alternative Rx)• Step 3 - Moderate Persistent Asthma
– Low to medium dose ICS + long-acting β2-agonist (LABA)– Medium-dose ICS – Low or medium ICS + LTRA or theophylline (alternative Rx)
• Step 4 - Severe Persistent Asthma– High-dose ICS + LABA– If needed, add oral steroids
NIH Treatment Guidelines
NIH-preferred options are highlighted.
Guidelines for the Diagnosis and Management of Asthma. 2002.NIH Publication No. 02-5075.
• Step 1 - Mild Intermittent Asthma– No daily medication
• Step 2 - Mild Persistent Asthma– Low-dose inhaled corticosteroid (ICS)– Cromolyn/nedocromil, theophylline or leukotriene modifier
(alternative Rx)• Step 3 - Moderate Persistent Asthma
– Low to medium dose ICS + long-acting β2-agonist (LABA)– Medium-dose ICS – Low or medium ICS + LTRA or theophylline (alternative Rx)
• Step 4 - Severe Persistent Asthma– High-dose ICS + LABA– If needed, add oral steroids
• Teach and re-teach and re-check inhaler technique• Always assume that patients are poorly compliant,
especially if their asthma is poorly controlled • Monitor objective parameters of airway function (i.e.,
spirometry)• Assume that most asthmatics (and almost all children with
asthma) are allergic• Identify and counsel avoidance for triggering factors• Treat allergic rhinitis• Consider allergen-specific immunotherapy (i.e.,
allergy shots)• Realize that the natural history of persistent asthma is not
benign• Identify persistent asthmatics as early as possible and
institute treatment with anti-inflammatory agents• Monitor for drug side effects (e.g., plot growth curves), and
attempt to use the lowest effective therapeutic dose of inhaled corticosteroids
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