Question

A patient with a history of severe late-phase asthma response is prescribed an inhaled short acting Bronchodilator, corticosteroid, ad a mast cell stabilizer.  Explain in LAY terms when each of these drugs is indicated and highlight any special considerations concerning sequence, side effects, and what to expect as positive outcomes.

Answer 1

Definition of Late phase asthma: about 60% of early phase of asthmatics experience this late phase asthma, during early phase mediators of inflammation are released, some immediately cause inflammation. In Late phase asthma the mast cells and T cells cause inflammation.

Usually the late phase asthma is responded to prescription of short acting bronchodilators,LTMs and mast cell stabilizers.

Treatment: Medical management involves chronic management and a plan for Acute exacerbation,otherwise known as asthma action plan.

Medications : The medications are mainly

1. First line,

2. Second line,

3. Other non pharmacologic Therapies.

1. First Line: A) Short acting bronchodilators : Quick relief medications used as needed basis for long term management of all severities of asthma as well as for rapid treatment of exacerbation given via either MDI or Nebulization,

- for long term management, a SABA used on an as needed basis ( eg: Albuterol) is appropriate,

- During an exacerbation, reversal of airflow obstruction is acheived most effectively by frequent administration of an SABA.

- For a mild to moderate exacerbation, initial treatment starts with two to six puffs of Albuterol via MDI or 2.5 mg via nebulizer and is repeated q20min until improvement is obtained or toxicity is noted,

- for a severe exacerbation, Albuterol 2.5 to5.0 mg with ipratropium bromide 0.5 mg q20 min via Nebulization,

- Levalbuterol four to eight puffs,

- subcutaneous administration of a Beta2 adrenergic agonist is unnecessary if inhaled medications can be administrated quickly with Acute response, In rare instances aqueous epinephrine or Terbutalin upto three doses can be used,

- their use is a contraindicated in Myocardial Infraction within the last 6 months or is having active angina.

- all SABAs now use hydrofluoroalkaline as a propellent.

B. Inhalational Corticosteroids : ICS s are safe and effective for the treatment of persistent asthma,

- dosing depends on assessment of severity and control,

- Systemic Corticosteroids absorption can occur in patients who use high doses of ICS.

C. LABAs ( Long acting beta 2 agonists): recommend for persistent asthma, in pt with not controlled with ICSs,

- salmeteol or formetrol added to ICS improve lung function, both day and night time symptoms and excerbations.

- the benefits of adding LABAs are more substantial than those acheived by leukotriene modifiers,. Theophylline or increased doses of ICS.

D. Systemic Corticosteroids : to gain control of disease quickly via oral or IV route,

- If chronic symptoms are severe and accompanied by short course of oral Corticosteroids ( prednisolone) might be necessary.

2. Second Line :A) Leukotriene modifiers : Montelukast (10mg PO daily) and Zafirlukast (20mg PO bid) and oral Leukotriene receptor antagonists and Zileuyon ( extended released)1200mg bid,

- the LTRAs are recommend for mild asthma and add on ICS for more severe form of asthma, these agents shown to improve lung function, improve quality of life and lead to fewer excerbations,

- An LTM should be strongly considered for pts with aspirin induced asthma ,

B. Cromolyn Sodium : anti inflammatory inhaled medication is an alternative to ICS in children with mild persistent asthma or first line for excercised induced asthma,

- the usual dose is 8 to 12 puffs q day ,

- little additional benefit accures using with ICSs.

C. Anti IgE Therapy : Omalizumab: Monoclonal antibody against IgE, it can decrease airway inflammation, decreases eosinophil count,attenuates lymphocyte proliferation and cytokine production.

- Omalizumab administrated subcutaneously q 2-4 wk and dosed based upon the patient's baseline IgE level.

Methylxanthines : Sustained release theophylline at low doses 300 mg per day I. Persistent asthma.

Other non pharmacologic Therapies :

- supplemental oxygen,

- mechanical ventilation,

- alleegen immuno therapy.