The Saudi Initiative for Asthma
Guidelines for the Diagnosis and Management of
Asthma in Adults and Children
2013 update
On behalf of the SINA panel
Mohamed S. Al-Moamary, FRCP (Edin) FCCP
Dep. of Medicine, King Abdulaziz Medical City-Riyadh
King Saud bin Abdulaziz University for Health Sciences
www.sinagroup.org
January 2013
Enter presenter name
Enter the presenter’s institute
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January 2013
What is SINA?
SINA is developed by a task force originated from the Saudi
Initiative for Asthma Group under the umbrella of the Saudi
Thoracic Society
SINA is a practical approach for a comprehensive management
of asthma in adults and children and when to refer to a
specialist.
International recommendations were customized to the local
setting for asthma diagnosis and management
Directed to HCW dealing with asthma who are not specialists in
the field.
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January 2013
Purpose of SINA
To provide a document that is easy to follow,
simple to understand yet totally updated and
carefully prepared for use by non-asthma
specialist including primary care doctors and
general practice physicians
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January 2013
Where do you find SINA?
The SINA guideline was published in the Annals of
Thoracic Medicine (www.thoracicmedicine.org):
Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, Al-Ghobain MO,
Idrees MM, Zeitouni MO, Al-Harbi AS, Al Dabbagh MM, AlMatar H, Alorainy HS. The Saudi initiative for asthma - 2012
update: Guidelines for the diagnosis and management of
asthma in adults and children. Ann Thorac Med 2012;7:175204
The SINA guidelines booklet is available at:
www.sinagroup.org
www.sinagroup.org
January 2013
Saudi Thoracic Society commitment
The STS is committed to improve the care of
asthma by a long term plan:
Periodic scientific meetings
Annual asthma meeting (since 2001)
Frequent asthma courses
Educational brochures
Publishing new and updated asthma guidelines
www.sinagroup.org
January 2013
What is new in SINA-2012
Comprehensive revision with the addition of
new 125 references
Addition of charts and algorithms for asthma
diagnosis and management
Updating asthma management
Rewritten “asthma in children” section
New section on “difficult to treat asthma”
www.sinagroup.org
January 2013
SINA Panel
Mohamed S. Al-Moamary (Chairman), King Saud bin Abdulaziz University for
Health Sciences, Riyadh
Sami Alhaider, King Faisal Specialist Hospital and Research Center, Riyadh
Mohamed S. Al-Hajjaj, King Saud University, Riyadh
Mohammed O. AlGhobain, King Saud bin Abdulaziz University for Health
Sciences, Riyadh
Majdy M. Idrees, Military Hospital, Riyadh
Mohamed O. Zeitouni, King Faisal Specialist Hospital and Research Center,
Riyadh
Adel S. Alharbi, Military Hospital, Riyadh
Hussain Al-Matar, Imam Abdulrahman Al Faisal, Dammam
Maha M. Al Dabbagh, King Fahd Armed Forces Hospital, Jeddah
Hassan S Alorainy, King Faisal Specialist Hospital and Research Center,
Riyadh
www.sinagroup.org
January 2013
Acknowledgment
•
•
•
•
•
The SINA panel would like to thank the following reviewers :
Prof. J. Mark FitzGerald from the University of British Columbia,
Vancouver, BC, Canada
Prof. Qutayba Hamid from the Meakins-Christie Laboratories, and
the Montreal Chest Research Institute
Prof. Sheldon Spier, the University of British Columbia, Vancouver,
Canada
Prof. Eric Bateman from the University of Cape Town Lung Institute,
Cape Town, South Africa (SINA 2009)
Prof. Ronald Olivenstein from the Meakins-Christie Laboratories
and the Montreal Chest Research Institute, Royal Victoria Hospital,
McGill University, Montreal, Quebec, Canada. (SINA 2009)
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January 2013
SINA Documents
Published manuscript
Booklet
Electronic version
Slides kit
Flyers
Website: www.sinagroup.org
www.sinagroup.org
January 2013
Sections of SINA – update cover
Epidemiology
Pathophysiology
Diagnosis
Medications
Approach to Management
Treatment Steps
Special Situations
Acute Asthma
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January 2013
Prevalence
Prevalence of
asthma has
increased between
1986 – 1995
Alfrayyah et al. Ann Allergy Asthma
Immunol 2001;86:292–296
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January 2013
Burden of Asthma
Asthma is among the most common chronic illnesses
in Saudi Arabia
53% had missed school or work (AIRKSA-2007)
35% attempted Unconventional therapy (Al Moamary, ATM
2008)
46% were controlled in Riyadh (AIRKSA-2007)
36% were controlled in 5 tertiary care centers in
Riyadh (Aljahdali SMJ-2008)
48% were controlled in one center (Al Moamary, ATM 2008)
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January 2013
AIRKSA report (Ministry of Health)
78 % of adults & 84% of kids reported acute asthma
over 12 months (AIRKSA)
54 % of adults & 80% of kids reported ER over 12
months (AIRKSA)
45-68% of adults & 37-56% of kids reported
limitation of activity over 12 months (AIRKSA)
76 % of adults & 78% of kids never had
spirometry(AIRKSA)
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January 2013
The prevalence of wheeze and
associated symptoms in the study group
Al-Ghobain et al, NBC Pulm Med 2012;12:39
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January 2013
Pattern of asthma treatment
Al-Shimemeri, Ann Thorac Med 2006;1:20-5
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January 2013
Pathology of Asthma
Inflammation
Airway Hyper-responsiveness
Airway Obstruction
Symptoms of Asthma
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January 2013
Pathophysiology
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January 2013
Inflammation  Remodeling
Inflammation
Airway Hypersecretion
Subepithelial fibrosis
Angiogenesis
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January 2013
Diagnosis - History
Episodic attacks:
Cough
Breathlessness
Wheezing
Nocturnal symptoms
Patient could be asymptomatic between attacks
co-existent conditions: GERD, rhinosinusitis.
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January 2013
Relevant Questions
Does the patient or his/her family have a history of asthma
or other atopic conditions, such as eczema or allergic
rhinitis?
Does the patient have recurrent attacks of wheezing?
Does the patient have a troublesome cough at night?
Does the patient wheeze or cough after exercise?
Does the patient experience wheezing, chest tightness, or
cough after exposure to pollens, dust, feathered or furry
animals, exercise, viral infection, or environmental smoke?
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January 2013
Relevant Questions
Does the patient experience worsening of symptoms after
taking aspirin/nonsteroidal inflammatory medication or use
of B-blockers?
Does the patient's cold “go to the chest” or take more than
10 days to clear up?
Are symptoms improved by appropriate asthma treatment?
Are there any features suggestive of occupational asthma
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January 2013
Physical Examination
Normal between attacks
Bilateral expiratory wheezing
Examination of the upper airways
Other allergic manifestations: e.g., atopic
dermatitis/eczema
Consider alternative Dx when there is localized
wheeze, crackles, stridor, clubbing
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January 2013
Investigations
Measurements of lung function:
Spirometry
Peak expiratory flow (PEF)
Normal Spirometry does not role out asthma
Spirometry is superior to PEF
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January 2013
Bronchodilator response
Proper instructions on how to perform the forced
expiratory maneuver must be given to patients, and
the highest value of three readings taken.
The degree of significant reversibility is defined as an
improvement in FEV1 ≥12% and ≥200 ml from the
pre-bronchodilator value.
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January 2013
Clinical Assessment
Measurements of allergic status to identify
risk factors (if indicated)
Chest X-ray is not routinely recommended
Routine blood tests are not routinely
recommended
IgE measurement is indicated in severe cases
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January 2013
Assessment of Asthma Control
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January 2013
Asthma Control Test
Level of Control:
• Total:
25
• Control:
20-24
• Partial control: 16-19
• Uncontrolled:
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< 16
January 2013
Differential Diagnosis
Upper airway diseases
Allergic rhinitis and sinusitis
Obstructions involving large airways
Foreign body in trachea or bronchus
Vocal cord dysfunction
Vascular rings or laryngeal webs
Laryngotracheomalacia, tracheal stenosis, or bronchostenosis
Enlarged lymph nodes or tumor
Obstructions involving small airways
Viral bronchiolitis or obliterative bronchiolitis
Cystic fibrosis
Bronchopulmonary dysplasia
Heart disease
Other causes
Recurrent cough not due to asthma
Aspiration from swallowing mechanism dysfunction or GERD
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January 2013
Differential Diagnosis
COPD (e.g., chronic bronchitis or emphysema)
Congestive heart failure
Pulmonary embolism
Mechanical obstruction of the airways (benign and
malignant tumors)
Pulmonary infiltration with eosinophilia
Cough secondary to drugs (e.g., angiotensinconverting enzyme (ACE) inhibitors)
Vocal cord dysfunction
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January 2013
Management
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January 2013
Patient/Dr Partnership
Enhance the chance of disease control
Agreed goals of management
Guided self-management plan
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January 2013
Asthma Education
Creation of partnership between patient and healthcare worker
Understanding clinical presentation of asthma and diagnosis
Ability to differentiate between “relievers” and “controllers”
medications and their appropriate indications
Recognition of potential side effects of medications and the
appropriate action to minimize them
Performance of the proper technique of devices
Identification of symptoms and signs that suggest worsening of
asthma control and the appropriate action to be taken
Understanding the approach for monitoring asthma control
Recognition of the situations that need urgent medical attention
Ability to use a written self-management plan
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January 2013
Non-Adherence
Drugs:
Poor technique of
inhaler devices.
Regimen with multiple
drugs.
Occurrence of Side
effects from the drugs.
Cost of medications.
www.sinagroup.org
Non-drugs
Lack of knowledge about
asthma.
Lack of partnership in
the management.
Inappropriate
expectations.
Underestimation of
severity.
Cultural issues.
January 2013
Precipitating Factors
Indoor Allergens and Air Pollutants
Outdoor Allergens
Occupational Exposure
Food and Drugs
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www.tnfos.com
January 2013
Self-management plan
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January 2013
‫‪Self-management plan‬‬
‫لكل مريض خطة عالجية ذاتية خاصة به توضع تحت إشراف الطبيب المختص حسب حالته‬
‫‪ -1‬الحالة المستقرة ‪:‬‬
‫‪ ‬ممارسة الحياة بشكل طبيعي (لعب ‪ ،‬نوم ‪ ،‬دراسة)‬
‫‪ ‬إختفاء أعراض الربو في الليل ‪.‬‬
‫‪ ‬ندرة إستخدام البخاخ في الموسع للشعب الهوائية (أقل من ‪ 3‬مرات أسبوعيا ً)‬
‫‪ ‬سرعة تدفق الهواء أكثر من ‪ %80‬من الحد الطبيعي‬
‫‪ - 2‬الحالة المتوسطة اإلستقرار (أزمة ربو على وشك الحدوث) ‪:‬‬
‫‪ 3‬مرات يوميا ً ‪.‬‬
‫‪ ‬إستخدام البخاخ الموسع للشعب الهوائية أكثر من‬
‫‪ ‬اإلستيقاظ في الليل بسبب (كحة ‪ ،‬كتمة ‪ ،‬صفير في الصدر)‬
‫‪ ‬وجود أعراض نزلة برد فيروسية ‪.‬‬
‫‪ ‬القدرة على نفخ الهواء بين ‪ % 80 – 60‬من الحد الطبيعي ‪.‬‬
‫‪ - 3‬الحالة المتأزمة الحادة (سارع بطلب المساعدة الطبية)‬
‫إذا لم تحدث استجابة لما سبق أو حدث ‪:‬‬
‫‪ ‬زيادة أعراض أزمة الربو ‪.‬‬
‫‪ ‬عدم القدرة على إتمام كلمتين في نفس واحد ‪.‬‬
‫‪ ‬عودة أعراض الربو بعد أقل من نصف ساعة من إستخدام البخاخ الموسع‬
‫للشعب الهوائية ‪.‬‬
‫‪ ‬القدرة على نفخ الهواء أقل ‪ %50‬من الحد الطبيعي ‪.‬‬
‫(توجه للطوارئ أو أطلب اإلسعاف)‪ :‬إذا تدهورت أزمة الربو على الرغم من‬
‫اإلجراءات السابقة ‪ ،‬أو حدث إزرقاق فياألطراف أو تدهور في مستوى الوعى ‪ ،‬أو تدني‬
‫في سرعة تدفق الهواء ألقل من ‪ % 50‬من المعدل الطبيعي‬
‫‪www.tnfos.com‬‬
‫‪January 2013‬‬
‫اإلجراء الواجب إتباعه ‪ :‬اإلستمرار على األدوية المعطاة ‪:‬‬
‫‪ ‬إستخدام البخاخ الموسع للشعب الهوائية _____بخة كل ____ ساعات عند الضرورة‬
‫وقبل التمارين ارياضية ب ‪ 30 – 15‬دقيقة ‪.‬‬
‫‪ ‬إستخدام البخاخ الواقي _____ بخة ______ مرة يوميا ً و بشكل منتظم لمدة (‬
‫أدوية أخرى ‪:‬‬
‫)‪.‬‬
‫اإلجراء الواجب إتخاذه ‪:‬‬
‫‪ ‬زيادة جرعة البخاخ الواقي______ إلى ______بخة _____مرة يوميا ً لمدة ‪10‬أيام‬
‫ثم الرجوع إلى الجرعة السابقة‬
‫(‬
‫‪ ‬إستخدام البخاخ الموسع للشعب الهوائية‬
‫) بخة كل ____ساعات بإنتظام لمدة _____أيام أو حتى تتحسن الحالة‬
‫‪ ‬إستشارة الطبيب في أقرب وقت ممكن ‪.‬‬
‫)(‬
‫اإلجراء الواجب إتخاذه ‪:‬‬
‫‪ ‬إستخدام البخاخ الموسع للشعب الهوائية___ بخة كل ____ ساعات‬
‫‪‬طلب اإلستشارة الطبية بصفة عاجلة ‪.‬‬
‫‪ ‬زيادة جرعة البخاخ الواقي ____)إلى______ بخة ____)مرة يوميا ً لمدة‬
‫‪10‬أيام ثم الرجوع إلى الجرعة السابقة عمل ما يلي ‪:‬‬
‫‪‬البد من التوجه لقسم الطوارئ فوراً ‪.‬‬
‫‪www.sinagroup.org‬‬
Asthma Medications
Controllers are medications taken daily on a
long-term basis to keep asthma under clinical
control chiefly through their antiinflammatory effects.
Relievers are medications used on an asneeded basis that act quickly to reverse
bronchoconstriction and relieve symptoms.
www.sinagroup.org
January 2013
Controller Medications
Inhaled glucocorticosteroids
Long-acting inhaled B2-agonists
Leukotriene modifiers
Long-acting anticholenergics
Theophylline
Anti-IgE
Systemic glucocorticosteroids
www.sinagroup.org
January 2013
Inhaled Corticosteroids
The most effective antiinflammatory
medications for asthma treatment
Benefits of ICS:
reduce symptoms
improve quality of life
improve lung function
decrease airway hyperresponsiveness
control airway inflammation
reduce frequency and severity of exacerbations,
and reduce mortality.
www.sinagroup.org
January 2013
Inhaled Corticosteroids
When ICS discontinued, deterioration of
clinical control may follow within weeks
Most of the benefits from ICS are achieved in
adults at relatively low doses
Increasing to higher doses may provide
further benefits in terms of asthma control
but increases the risk of side effects
Tobacco smoking reduces the responsiveness
to ICS
www.sinagroup.org
January 2013
Inhaled Corticosteroids
To reach control, add-on therapy with another
class of controller is preferred to increasing
the dose of ICS
ICS are generally safe and well-tolerated
Though low-medium dose of ICS may affect
growth velocity, this effect is clinically
insignificant and may be reversible.
www.sinagroup.org
January 2013
Inhaled Corticosteroids
Local adverse effects:
oropharyngeal candidiasis
dysphonia – may be e reduced by using MDI with
spacer devices and mouth washing
Systemic side effects are occasionally
reported with high doses and long-term
treatment
www.sinagroup.org
January 2013
Inhaled Corticosteroids
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January 2013
Leukotriene modifiers (LTRA)
LTRA reduces airway inflammation, improve
asthma symptoms and lung function
It has less consistent effect on exacerbations
when compared to ICS.
Alternative treatment to ICS for patients with
mild asthma, especially in those who have
clinical rhinitis
Some patients with aspirin-sensitive asthma
respond well to the LTRA
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January 2013
Leukotriene modifiers (LTRA)
Available as montelokast in Saudi Arabia
Their effects are generally less than that of
low dose ICS
When added to ICS, LTRA may reduce the
dose of ICS required by patients with
uncontrolled asthma, and may improve
asthma control
LTRA are generally well-tolerated. There is no
clinical data to support their use under the
age of six months.
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January 2013
LABA
LABA: (formoterol and salmeterol)
Should not be used as monotherapy
Combination with ICS lead to:
improves symptoms
decreases nocturnal asthma
improves lung function
decreases the use of rapid-onset inhaled B2-agonists
reduces the number of exacerbations
achieves clinical control of asthma in more patients, more
rapidly, and at a lower dose of ICS
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January 2013
Dual Pathways of Inflammation
Steroid-sensitive
mediators
CysLTs
play a key role
in asthmatic
inflammation
play a key role
in asthmatic
inflammation
Montelukast
Inhaled steroids
blocks the
effects of
CysLTs
block
steroidsensitive
mediators
DUAL PATHWAY
The slide represents an artistic rendition.
Adapted from Peters-Golden M, Sampson AP J Allergy Clin Immunol 2003;111(1 suppl):S37-S42; Bisgaard H
Allergy 2001;56(suppl 66):7-11.
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January 2013
Long acting anti-chlenergics
It was superior to a doubling of the dose of an inhaled
glucocorticoid for patients at step 3
It was non-inferior to LABA
It improves lung function in patients with severe
uncontrolled asthma
It is effective as add-on therapy to combination
devices at step 4
Daily home peak expiratory flow measurements were
higher with tiotropium doses
Peters et al. N Engl J Med 2010; 363:1715-1726
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January 2013
Combination devices
Sympicort turbohaler:
Combination of budesonide/formeterol: 160/4.5
Seretide:
Combination of fluticasone/salmeterol
Evohaler:
50/25
125/25
250/25
Diskus:
100/50
250/50
500/50
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January 2013
Theophylline
Weak bronchodilator with modest antiinflammatory properties
It may provide benefit as add-on therapy in
patients who do not achieve control on ICS alone
Less effective than LABA and LTR.
Side effects:
gastrointestinal symptoms
cardiac arrhythmias
seizures, and even death
drug interaction
www.sinagroup.org
January 2013
Anti-IgE
Omalizumab (Xolair) indication:
Uncontrolled severe allergic asthma on high dose
ICS and other controllers.
Needs specialist consultation.
Side effects:
Pain and bruising at injection site and very rarely
anaphylaxis (0.1%).
www.sinagroup.org
January 2013
Oral glucocorticosteroids
Long-term oral glucocorticosteroid therapy may be
required for uncontrolled asthma despite maximum
standard therapy.
It is limited by the risk of significant adverse effects.
Side effects:
Osteoporosis, hypertension, diabetes, adrenal
insufficiency, obesity, cataracts, glaucoma, skin thinning,
and muscle weakness.
Withdrawal can elicit adrenal failure.
In patients prescribed long-term systemic
glucocorticosteroids, prophylactic treatment for
osteoporosis should be considered.
www.sinagroup.org
January 2013
Reliever Medications
Short-acting inhaled B2-agonists
Anticholinergics
Theophylline
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January 2013
Short-acting B2-agonists
The medications of choice for symptoms relief
Pretreatment for exercise-induced
bronchoconstriction.
Formoterol is used for symptom relief because of its
rapid onset of action.
Increased use, especially daily use, is a warning of
deterioration of asthma control
Side effects: B2-agonists are associated with adverse
systemic effects such as tremor and tachycardia.
www.sinagroup.org
January 2013
Short-Acting Anticholinergics
Less effective than SABA.
Used in combination with SABA in acute
asthma.
An alternative bronchodilator for patients
with adverse effects from rapid acting
B2agonists.
Side effects: can cause a dryness of the
mouth and a bitter taste.
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January 2013
Asthma control
Control asthma symptoms
Minimal use )≤2 days a week) of reliever therapy
Maintain (near) normal pulmonary function
Maintain normal exercise and physical activity levels
Prevent recurrent exacerbations of asthma
Minimize the need for ER visits or hospitalizations
Optimize control with the minimal dose of medications
Reduce mortality
Optimize quality of life
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January 2013
Principles of management
The principles of asthma management in adults
will follow 3 stages:
1. Initiation
2. Adjustment
3. Maintenance
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January 2013
Initiation based on SINA approach
The consensus among SINA panel is to
simplify the approach to initiate asthma
therapy by using ACT score
ACT Score ≥ 20
 Step 1
ACT Score 16–19
 Step 2
ACT Score 16
 Step 3
Al-Moamary et al, BMC Pulm Med 2012;12
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January 2013
Initiation based on GINA approach
Step 1  SABA on as needed bases
Step 2  For patients who are not currently
taking long-term controller medications.
Step 3  If the initial symptoms are more
frequent.
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January 2013
SINA v.s. GINA approaches
www.sinagroup.org
Al-Moamary et al, BMC Pulm Med 2012;12
January 2013
Adults Patients with Asthma
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January 2013
Adjustment of treatment
Clinical Assessment
Obtain ACT score and perform PFM
Based on ACT, Adjust treatment:
ACT = 20-25: Controlled  Maintain treatment
ACT = 16-19: Partial control Step up
ACT < 16:
Uncontrolled Step up
Introduce self-management plan
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January 2013
Approach to Asthma Treatment
in Adults and children > 5 years
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January 2013
Principles of Asthma Treatment
Daily long-term controller medication is the corner
stone of treatment
ICS are considered as the most effective controller
Relievers or rescue medications must be available to
all patients at any step
SABA should be taken as needed to relieve
symptoms
Increasing use of reliever treatment is an early sign
of worsening asthma control
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January 2013
Principles of Asthma Treatment
Treat patients who may have seasonal asthma
as having uncontrolled asthma during the
season, then at step 1 for the rest of the year
Patients who had two or more exacerbations
requiring oral corticosteroids or hospital
admissions in the past year, should be treated
as patients with uncontrolled asthma
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January 2013
Step 1 - Recommendations
Symptoms are mild and infrequent
Consider rapid onset B2-agonist to
be taken “as needed” to treat
symptoms
Patient experiencing sudden, severe,
or life-threatening exacerbations 
treat exacerbations accordingly
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January 2013
Step 2 - Recommendations
Daily ICS at a low dose (< 500 μg of
beclomethasone equivalent/day or
equivalent)
Alternative treatment isLTRA
(montelukast)
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January 2013
Step 3 – Recommendations
Add a LABA to a low-medium dose
ICS for patients whose asthma is not
controlled on a low dose ICS alone,
such as:
Fluticasone/Salmeterol (Seretide)
Budesonide/Formoterol (Symbicort)
Use a maintenance dose of the
combination drugs twice daily
Use the rapid onset B2-agonist as a
reliever treatment.
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January 2013
Step 3 - GOAL study
GOAL study has shown that an escalating dose
of combination of Fluticasone/ Salmeterol
(Seretide) achieves
Well controlled asthma in 85% of patients
Totally controlled asthma in 30% of patients
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January 2013
Step 3 - S.M.A.R.T® approach
S.M.A.R.T® approach: Use of
Formoterol/Budesonide for both rescue and
maintenance
Maintenance dose single inhaler (1–2 puff 160/4.5
BID) plus extra puffs from the same inhaler up to a
total of 12 puffs per day.
Those patients who require such high dose should
seek medical advice to step up therapy that may
include use of short course of oral prednisone.
www.sinagroup.org
January 2013
Step 3 – Alternative therapy
Adding LTRA to ICS, especially those with
concomitant rhinitis or
Increasing ICS dose to the medium to
high dose range as a monotherapy or
Adding sustained release theophylline or
Adding long acting anti-cholinergic
Consultation with a specialist is
recommended for patients whenever
there is a difficulty in achieving control
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January 2013
Step 4 – Recommendations
Maximizing treatment is recommended
by combining high-dose ICS with LABA or
Adding LTRA, tiotropium, or theophylline
to high-dose ICS and LABA or
Omalizumab may be considered:
Allergic asthma (as determined by skin test
or RAST study) and still uncontrolled.
Special knowledge about the drug
Consultation is recommended
www.sinagroup.org
January 2013
Step 5 - Recommendations
Omalizumab to be considered for
patients who have allergic asthma and
persistent symptoms despite the
maximum therapy mentioned above
lowest possible dose of long-term oral
corticosteroids for patient who:
Does not have allergic asthma
Omalizumab is not available or not
adequately controlling the disease
www.sinagroup.org
January 2013
Step 5 – long term steroids
Long-term systemic corticosteroids:
lowest possible dose to maintain control
Monitor for the development of side effects
Continue attempts to reduce the dose
Maintaining high-dose of ICS therapy
Strongly consider concurrent treatments with
calcium supplements and vitamin D
Consultation is mandatory
www.sinagroup.org
January 2013
Maintaining Control
Clinical Assessment
Obtain ACT score and perform PFM
Based on ACT score, adjust treatment:
ACT= 20-25: well controlled Maintain treatment
with lowest ICS dose (may step down)
ACT= 16-19: Partial control Step up
ACT < 16: uncontrolled  Step up
Follow-up at 1 to 3 month intervals
www.sinagroup.org
January 2013
Allergen-specific immunotherapy (AIT)
Gradual administration of increasing quantities
of an allergen product to an individual with IgEmediated allergic disease
administered either subcutaneously or
sublingually
induces clinical and immunologic tolerance, has
long term efficacy, and may prevent the
progression of allergic disease, may improves the
quality of life
www.sinagroup.org
January 2013
Allergen-specific immunotherapy (AIT)
more effective in seasonal asthma than in
perennial asthma, particularly when used against
a single allergen.
may be considered if strict environmental
avoidance and comprehensive pharmacologic It
has been a controversial treatment for asthma;
however, beneficial clinical effects have been
demonstrated
concerns regarding safety and cost, there was no
demonstrated consistent effect on lung function
www.sinagroup.org
January 2013
Special Situations
www.sinagroup.org
January 2013
Asthma and pregnancy - 1
Unpredictable course: one third will have
worsening of their of asthma control
Maintaining adequate control of asthma
during pregnancy is essential for the health
and well-being of the mother and her baby.
Identifying and avoiding triggering factors
should be the first step of therapy for asthma
during pregnancy
www.sinagroup.org
January 2013
Asthma and pregnancy - 2
Same stepwise approach as in non-pregnant
patient.
Salbutamol is the preferred SABA
ICSs are the preferred controllers
Use of ICS, theophylline, antihistamines, B2agonists, and LTRA is generally safe
Acute exacerbations of asthma during
pregnancy should be treated on the same
outlines as in non-pregnant patients
www.sinagroup.org
January 2013
Asthma and pregnancy - 3
Continuous fetal monitoring in severe asthma
exacerbation
If anesthesia is required during labor, regional
anesthesia is recommended whenever
possible
The use of prostaglandin F2α may be
associated with severe bronchospasm
www.sinagroup.org
January 2013
Cough-variant asthma
Cough is the main symptom
It is common in children, and is often more
problematic at night
Other diagnoses to be considered are:
Drug-induced cough caused by angiotensinconverting-enzyme inhibitors
GERD
Postnasal drip and chronic sinusitis
Treatment is similar to long-term
management of asthma
www.sinagroup.org
January 2013
Exercise-induced Asthma
Bronchoconstriction peaks within 10 to 15
minutes after completing the exercise and
resolves within 60 minutes.
Prevention:
SABA before exercise
Warm-up period before exercise
Some patients may need maintenance therapy
Regular use of LTRA may help in this condition
especially in children
www.sinagroup.org
January 2013
Aspirin/NSAID induced Asthma
Occurs in 10–20% of adults with asthma
The majority experience first symptoms
during the third to fourth decade.
Once aspirin or NSAID hypersensitivity
develops, it is present for life.
Within 1-2 hours following ingestion of
aspirin, an acute, severe attack may develop,
and is usually accompanied by rhinorrhea,
nasal obstruction, conjunctival irritation, and
scarlet flush of the head and neck
www.sinagroup.org
January 2013
Aspirin/NSAID induced Asthma
Prevention by avoidance of aspirin/NSAID
Patients for whom aspirin is considered
essential, they should be referred to an allergy
specialist for aspirin desensitization
Aspirin and NSAID can be used in asthmatic
patients who do not have aspirin induced
asthma
www.sinagroup.org
January 2013
GERD triggered asthma
GERD is more prevalent in asthmatics
Mechanisms of GERD triggered asthma:
vagal mediated reflex
reflux of micro-aspiration of gastric contents into
the upper airways
If GERD symptoms presents, a trial of GERD
therapy for 6–8 weeks wit lifestyle
modifications
Asymptomatic patients with uncontrolled
asthma may not benefit from GERD therapy
www.sinagroup.org
January 2013
Difficult to treat asthma (DTA) - 1
It is also called chronic severe asthma, steroiddependent asthma, difficult-to-control asthma, and
refractory asthma
Defined as asthma in patients who require very high
doses of inhaled steroids with other controller
agents, or near continuous oral steroid treatment to
maintain asthma control.
Accounts for 5-10 % of adult asthma, but the health
cost is disproportionally high
Morbidity and mortality are also higher than in
regular asthma
www.sinagroup.org
January 2013
Difficult to treat asthma (DTA) - 2
Prior to labeling a patient to have DTA:
Ensure patient is adherent to medications with
good technique
Misdiagnosis e.g. bronchiectasis, endo-bronchial
tumors, and vocal cord dysfunction
Control other diseases preciptatnts, e.g. chronic
sinusitis, gastro-esophageal disease, sleep apnea
syndrome, obesity, and congestive heart failure
(CHF)
Confounding factors, e.g. non-adherence with
treatment, the presence of allergens at home
www.sinagroup.org
January 2013
Difficult to treat asthma (DTA) - 3
Some patients may have the "pseudo-steroid"
resistance in patients with persistent symptoms
despite high doses of ICS and other "non-steroidal"
asthma therapy
The aim is to reach the best possible outcome as it
may be difficult to achieve full control
Patients should be at maximum therapy is given
(Step 5 therapy)
Anti-IgE treatment (Omalizumab) is given if the
patients fulfill the criteria for this treatment
www.sinagroup.org
January 2013
Difficult to treat asthma (DTA) - 4
There are New modalities that may help to
control DTA e.g.,:
Mepolizumab has been shown to reduce
exacerbations and improves asthma control in
patients with refractory eosinophilic asthma
Bronchial thermoplasty that utilizes
radiofrequency energy to alter the smooth
muscles of the airways. In severe persistent
asthma, it leads to improvements in various
measures of asthma, including FEV1, quality of life,
asthma control, and use of rescue medications
www.sinagroup.org
January 2013