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
Recommended therapies are based on
clinical severity
• See Powerpoint presentation on “Diagnosing and
Staging Asthma” for background
Regimens for long-term
control of asthma
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.
Children 5 years and under-2
• Step 3 (moderate persistent)
– Preferred treatments:
• Low-dose inhaled corticosteroids AND long-acting inhaled
•
b2-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 b2-agonists (preferred), OR
– leukotriene receptor antagonist (alternate) OR
– theophylline (alternate)
Children 5 years and under-3
• Step 4 (severe, persistent), preferred treatment:
– High-dose inhaled corticosteroids PLUS
– Long-acting inhaled b2-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
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.
Adults and Children >5 years - 2
•
Step 3 (moderate, persistent)
– Preferred treatment:
• Low-to-medium dose inhaled corticosteroids AND long-acting inhaled
b2-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 b2-agonists (preferred), OR
Increase inhaled corticosteroid to medium-dose range (alternate), OR
leukotriene receptor antagonist (alternate) OR
theophylline (alternate)
Adults and Children >5 years - 3
• Step 4 (severe, persistent)
– High-dose inhaled corticosteroids AND
– Long-acting inhaled b2-agonists AND (if
needed)
– Oral corticosteroids 2 mg/kg/day, up to 60 mg
per day, with repeated attempts to reduce
systemic corticosteroids.
Medications and dosing:
selected corticosteroid inhalers
Medication
Adult doses
Pediatric 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
Medications and dosing:
Bronchodilators and mast cell stabilizers
Medication
Adult doses
Pediatric doses
Albuterol 90mcg/puff
(Proventil®, Ventolin ®)
2 puffs tid-qid
2 puffs tid-qid
Pirbuterol 200mcg/puff
(Maxair Autoinhaler®)
2 puffs tid-qid
2 puffs tid-qid
Salmeterol 50mcg/dose
(Serevent Diskus®)
1 blister bid
1 blister bid
Cromolyn sodium
800mcg/puff
(Intal®)
2-4 puffs tid-qid
1-2 puffs tid-qid
Nedocromil sodium
1750mcg/puff
(Tilade ®)
2-4 puffs tid-qid
1-2 puffs tid-qid
Medications and dosing:
Oral medications
Medication
Adult doses
Pediatric doses
Zafirlukast
(Accolate ®)
20 mg bid
10 mg bid
Montelukast
(Singulair®)
10 mg q hs
age 6-14: 5 mg hs
age 2-5: 4 mg hs
age 12-23 mo: 4 mg hs
(oral granules)
Theophylline
300mg bid
Starting 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
Regimens for quick relief
of acute symptoms
Quick relief of acute symptoms in
children age 5 and under
• Bronchodilator prn. Intensity of rx depends on
severity.
– Preferred rx: Short-acting, inhaled b2-agonist, by
nebulizer or face mask and space/holding chamber
– Alternative rx: Oral b2-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
Quick relief of acute symptoms in adults
and children > age 5
• Short-acting bronchodilator: 2–4 puffs short-
•
•
acting inhaled b2-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.
A note on intensity of treatment for
acute symptoms in all age groups
• Excessive use of short-acting b2-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
Emergency room or in-hospital treatment
Drug
Adult dose
Nebulized
albuterol
2.5–5 mg q20 mins x3
doses, then 2.5–10 mg q14hr prn, or 10–15 mg/hr
continuously
Albuterol MDI
(90 mcg/puff)
Nebulized
ipratropium Br
(with albuterol)
Child dose
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
4–8 puffs q 20 mins up to 4 4–8 puffs q20 mins x 3
hrs, then every 1-4 hrs prn doses, then q1-4 hrs by
inhalation using spacer/
holding chamber.
0.5 mg q30 mins x 3 doses, 0.25 mg q20 mins x3 doses,
then q2-4 hrs prn
then q2 -4 hrs
Drug
Adult dose
Child dose
levalbuterol
Same as albuterol, but
5mg albuterol=2.5 mg
levalbuterol
Same as albuterol, but 5mg
albuterol=2.5 mg levalbuterol
Epinephrine 1:1000
0.3-0.5 mg sq q20 mins
x3
0.01 mg/kg sq (up to 0.3–0.5
mg) q20 mins x3
(1mg/mL)
Terbutaline
mg/mL)
(1
0.25 mg sq q20 mins x3 0.01 mg/kg sq q20 mins x3,
then q2–6 hrs prn
Prednisone,
120–180 mg/day in 3 or
methylprednisolone, 4 divided doses x 48
prednisolone
hrs, then 60–80 mg/day
until PEF reaches 70%
of predicted or personal
best
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