In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy accordingly Step 1 Step 2 Step 3 Step 4 or 5 Relative annual risk of exacerbations may be related to FEV 0-2/year > 2 /year Frequency and severity may vary over time for patients in any category <2 days/week >2 days/week not daily Daily Continuous <2x/month 3-4x/month >1x/week not nightly Often nightly none Minor limitation Some limitation Extremely limited <2 days/week >2 days/week not daily Daily Several times daily Consider short course of oral steroids • Normal FEV 1 between exacerbations • FEV 1 > 80% • FEV 1 /FVC normal • FEV 1 >80% • FEV 1 /FVC normal • FEV 1 >60% but< 80% • FEV 1 /FVC reduced 5% • FEV 1 <60% • FEV 1 /FVC reduced> 5% CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS > 12 YEARS AND ADULTS EPR-3, p74, 344
Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Patient Education and Environmental Control at Each Step Step 1 Preferred: SABA prn Step 2 Preferred: Low-dose ICS Alternative: LTRA Cromolyn Theophylline Step 3 Preferred: Medium-dose ICS OR Low-dose ICS+ either LABA, LTRA, Theophylline Or Zileutin Step 4 Preferred: Medium-dose ICS+LABA Alternative: Medium-dose ICS+ either LTRA, Theophylline Or Zileutin Step 5 Preferred: High dose ICS + LABA AND Consider Omalizumab for patients with allergies Step 6 Preferred: High-dose ICS + LABA + oral Corticosteroid AND Consider Omalizumab for patients with allergies Assess Control STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS > 12 YEARS AND ADULTS Step up if needed (check adherence, environmental control and comorbidities) Step down if possible (asthma well controlled for 3 months) EPR-3, p333-343
Asthma Control The purpose of periodic assessment and ongoing monitoring is to determine whether the goals of asthma therapy are being achieved and asthma is controlled. Well Controlled Not Well Controlled Very Poorly Controlled
Classification of Asthma Control Components of Control ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTHS > 12 YEARS OF AGE AND ADULTS IMPAIRMENT RISK Recommended Action For Treatment Well Controlled Not Well Controlled Very Poorly Controlled Symptoms Nighttime awakenings Interference with normal activity SABA use FEV 1 or peak flow Validated questionnaires ATAQ/ACT Exacerbations Progressive loss of lung function Rx-related adverse effects Consider in overall assessment of risk Evaluation requires long-term follow up care 0- 1 per year 2 - 3 per year > 3 per year none Some limitation Extremely limited < 2 days/week > 2 days/week Throughout the day < 2/month 1-3/week > 4/week < 2 days/week > 2 days/week Several times/day > 80% predicted/ personal best 60-80% predicted/ personal best <60% predicted/ personal best 0/> 20 1-2/16-19 3-4/< 15 • Maintain current step • Consider step down if well controlled at least 3 months • Step up 1 step • Reevaluate in 2 - 6 weeks • Consider oral steroids • Step up (1-2 steps) and reevaluate in 2 weeks EPR-3, p77, 345
Current Therapy Use Asthma Guidelines as a guide Poor adherence with inhaled therapy No curative therapy Many patients remain poorly controlled Recognition of different phenotypes of asthma
New/Upcoming Asthma Therapies Recognition that there are different phenotypes or endotypes of asthma Phenotype – observable characteristics or clinical presentation (e.g., transient vs. persistent wheezing)
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