4/3/2018 BRANDY BURGESS, APRN-CNS, MSN-RN APRIL 12-14, 2018

Transcription

1 BRANDY BURGESS, APRN-CNS, MSN-RN APRIL 12-14, 2018 Approach to treatment List of medication Abbreviations When to use medications Pharmokinetics Pharmacodynamics Step wise therapy both for acute and chronic disease Is a heterogeneous chronic inflammatory disease of the bronchial tubes that causes excessive narrowing of airways, airflow obstruction, airway inflammation and hyperresponsiveness 1

2 Out of control asthma contributes to Increased amount of patients with permanent obstructive disease Frequent preventable hospitalizations Death Airway inflammation and hyperresponsiveness Congestion and airflow limitation Narrowed airways and worsening symptoms Serious life threating complications and disease chronicity According to the Centers for Disease Control and Prevention 1 in 13 people have asthma which is 7.6 % of adults and 8.4 % of children As of 2017, 18.4 million people in United States (US) More common in adult women than adult men and in African-Americans Accounts for > 14 million physician office visits and almost 2 million ED visits per year Ten Americans die daily from asthma with total of 3,651 in 2017 Annual cost related to asthma is greater than $56 billion per year The problem is lack of early treatment Asthma can be controlled with proper medication and education With proper treatment the obstructive component of asthma is reversible Early and correct treatment does not cure asthma but does improve patients quality of life and reduce long-term damage from airway remodeling 2

3 Lets see what we need to know to solve the problem that is asthma! Wheezing Shortness of breath Chest tightness Cough that varies in occurrence, frequency and intensity Commonly worse at night/early AM Bronchoconstriction Expiratory airflow limitation Increased mucus Viral and bacterial infections Allergens Change in weather Car exhaust, fumes, smoke (smoking), strong smells and/or fragrances Exercise Laughter Stress Beta-blockers and NSAIDs Obesity, GERD, depression and/or anxiety 3

4 How do we diagnose Asthma? According to GINA (Global Initiative for Asthma) and The National Asthma Education and Prevention Program Expert Panel Report 3 (EPR-3) to diagnose asthma providers must consider Perform medical history Include questions regarding family history, medication, symptoms and risk factors History of characteristic and severity patterns includes Impairment Symptoms Risk Exacerbations Adverse responses and side effects of medications Perform a physical exam Look for signs and symptoms, allergies, wheezing, running nose, eczema Remember asthma can and often is intermittent which means the patient may not be having symptoms during the appointment Perform pulmonary function testing to show evidence of airflow limitations Very few primary care offices have the capability to do full pulmonary function testing but many can do spirometry An inexpensive simple measurement that can be done is to use a peak flow meter Use bronchodilators to test for reversibility Keep in mind if the patient is on treatment of any kind it can often be more difficult to confirm diagnosis Additional testing can include Methacholine challenge test (M3 receptor or Histamine challenge test (H1 receptor) Drugs that provoke bronchoconstriction with a degree of narrowing or hyperreactivity that is quantified by spirometry The patient is then given a bronchodilator to test reversibility Exercise challenge test 2 phases: Refractory and late Allergy testing and sputum eosinophil testing Inhaled corticosteroids (ICS) Long-acting beta-adrenoceptor agonists or more specifically β2-agonists (LABA) Muscarinic antagonist (LAMA) and anticholinergic (AC) Short-acting beta agonist (SABA) leukotriene receptor antagonists (LTRA) and phosphodiesterase enzyme inhibitors Monoclonal antibodies (anti-asthmatics)[anti-ige and anti-il5] 4

5 Anti-inflammatory medications that reduce airway hyperresponsiveness, inhibit inflammatory cell migration and activation, and block late phase reaction to allergen Most consistently effective long-term control medication at all steps of care for persistent asthma Reduce impairment and risk of exacerbations Aerospan (flunisolide) 80 mcg 2 puffs BID Alvesco (ciclesonide) 80 to 160 mcg 1 to 2 puffs BID Arnuity Ellipta (fluticasone) 100 or 200 mcg 1 puff Daily Asmanex (mometasone) 110 or 220 mcg 1 to 2 puffs daily to BID Azmacort (triamcinolone) 55 or 100 mcg 2 puffs TID to QID Flovent (fluticasone) 50, 100, or 250 mcg 1 puff BID Pulmicort Flexhaler (budesonide) 90 or 180 mcg 1 to 2 puffs BID Q-Var (beclomethasone) 40 or 80 mcg -Not to exceed 320 mcg BID Works to relax smooth airway muscle to open the airways for 12 hours or more after a single dose Are not to be used as monotherapy for long-term control of asthma Should be used in combination with ICSs for long-term control Prevention of symptoms in moderate or severe persistent asthma Is the preferred therapy to combine with ICS in youth s 12 years of age and adults May be used before exercise to prevent EIB but duration of action does not exceed 5 hours with chronic use Aracapta Neohaler (indacaterol) 75 mcg 1 inhalation daily Brovana (arformoterol) 15 mcg 2 ml via nebulizer BID Foradil (formoterol) 20 mcg 2 ml via nebulizer BID Perforomist (formoterol) 20 mcg 2 ml via nebulizer BID Serevent (salmeterol) 50 mcg 1 inhalation BID Striverdi Respimat (olodaterol) 2.5 mcg 2 inhalations daily A muscarinic receptor antagonist is a type of anticholinergic agent that blocks the activity of the muscarinic acetylcholine receptor. Acetylcholine is a neurotransmitter, whose receptor is a protein found in synapses and other cell membranes. Anticholinergics act as muscarinic acetylcholine receptor antagonists. Atropine 2.5 mg in 3 ml of normal saline via nebulizer every 6 to 8 hours and/or as needed Ipratropium bromide 500 mcg via nebulizer every 6 to 8 hours and/or as needed Tiotropium bromide (Spiriva Handihaler) 2 inhalation of one 18 mcg capsule daily or (Spiriva Respimat) 5 mcg 2 actuations inhaled daily Aclidinium bromide (Tudorza Pressair) 400 mcg one inhaled actuation BID Acetylcysteine (Mucomyst) 5 to 10 ml of 10% or 20% via nebulizer every 6 to 8 hours as needed Hyoscine (Scopolamine) 1 mg patch every 72 hours 5

6 Short-Acting Bronchodilators are "quick-acting," "reliever," or "rescue" medications Relax the muscles lining the airways within 5 minutes increasing airflow Relieve asthma symptoms for 3 to 6 hours Are also used before exercise to prevent exercise-induced asthma Albuterol (AccuNeb, Proair HFA, Proventil HFA, Ventolin HFA, and many other brand names) 90mcg (base)/actuation(equivalent to 108mcg abluterolsulfate) Aerosol metered-dose inhaler: 180 mcg (2 puffs) inhaled PO q4-6hr; not to exceed 12 inhalations/24 hr Powder metered-dose inhaler: 180 mcg (2 puffs) inhaled PO q4-6hr; not to exceed 12 inhalations/24 hr; in some patients 1 inhalation (90 mcg) q4hr may be sufficient Nebulizer solution 1.25mg/3mL or 2.5mg/3mL 2.5 mg every 4 to 8 hours and/or PRN Levalbuterol (Xopenex HFA) Nebulizer solution: mg 3 times daily or every 6 to 8 hours and/or PRN Aerosol: 90 mcg (2 actuations of metered-dose inhaler) every 4 to 6 hours and/or PRN Leukotriene receptor antagonists Blocks binding of leukotriene D4 to its receptor Alters pathophysiology associated with inflammatory process of asthma Accolate (zafirlukast) 20 mg PO BID Singulair (montelukast) 10 mg (single 10-mg tablet) PO once daily in evening or 2 hours before exercise Phosphodiesterase enzyme inhibitors Relaxes smooth muscles of respiratory tract Suppresses the response of the airways to stimuli May increase tissue concentration of cyclic adenine monophosphate (camp) by inhibiting 2 isoenzymes of phosphodiesterase which ultimately induces release of epinephrine from the adrenal medulla cells Theo 24, Theochron,Elixophyllin, aminophylline, Uniphyl (theophylline) Therapeutic range: mg/l ( mmol/l) 5-7 mg/kg IV/PO; not to exceed 25 mg/min IV Aminophylline: 6-7 mg/kg IV/PO; IV infused over 20 minutes Anti-IgE Selectively binds to IgE and inhibits binding to IgE receptors on surface of mast cells and basophils Xolair (Omalizumab) 150 to 375 mg subcutaneously every 2 to 4 weeks Anti-IL5 Humanized IgG1 kappa monoclonal antibody specific for IL-5; binds IL-5, and therefore stops IL-5 from binding to its receptor on the surface of eosinophils Inhibiting IL-5 binding to eosinophils reduces blood, tissue, and sputum eosinophil levels Nucala(mepolizumab) 100 mg subcutaneously every 4 weeks Cinqair(reslizumab) 3 mg/kg intravenously every 4 weeks infused over 2o to 50 minutes 6

7 Step 1 SABA PRN and consider low-dose ICS Step 2 SABA PRN Low-dose ICS and leukotriene receptor antagonists (LTRA) or low dose theophylline Step 3 SABA PRN or low dose ICS/formoterol Low-dose ICS/LABA combination or medium dose ICS or low-dose ICS and leukotriene receptor antagonists (LTRA) or low dose theophylline Step 4 SABA PRN or low dose ICS/formoterol Medium to high-dose ICS/LABA combination and leukotriene receptor antagonists (LTRA) or low dose theophylline or high dose ICS and leukotriene receptor antagonists (LTRA) or low dose theophylline Step 5 SABA PRN or low dose ICS/formoterol Continue Step 4 and add tiotropium Refer to specialist Consider anti-ige (Xolair) or anti-il5 (Mepolizumab, reslizumab or benralizumab) STEP WISE THERAPY Step1 Step2 Step3 Step4 Step5 Step6 SABA PRN Low-doseICS Low-doseICS +LABA Or Mediumdoes ICS Medium-doseICS + LABA High-dose ICS+ LABA High-dose ICS+ LABA + Oral corticosteroid Alternative Alternative Alternative AND AND Cromolyn, LTRA, Nedocromilor Theophylline Low-doseICS+either LTRA,Theophyllineor Zileuton Medium-doseICS + eitherltra, Theophyllineor Zileuton ConsiderOmalizumab for patientswhohave allergies ConsiderOmalizumab for patientswhohave allergies Components ofcontrol Classifying of Asthma Control Well Controlled NotWell Controlled VeryPoorlyControlled days/weekbutnot morethan once >2days/weekormultipletimeson 2 Throughouttheday Impairment Symptoms eachday days/week 2 Nighttimeawakenings 1x/month 2x/ >1 1-3x/week >1x/week 2x/week 4x/week month x/month x/month Short-actingbeta2 2days/week >2days/week Severaltimes per day agonistusefor symptomcontrol FeV1or peakflow Predicted/personal best Interferencewith normalactivity Validated questionnaire ATAQ ACQACT N/A >80% N/A 60-80% N/A <60% SomeLimitations ExtremeLimitations None N/A N/A N/A N/A LungFunction N/A >80% N/A 60-80% N/A <60% *FEV1(predicted)or peakflow(personal best) >80% 75-80% <75% *FeV1/FVC Risk Exacerbation requiring oral systemic corticosteroids Reductioninlung growth Treatmentrelated adverseeffects 0-1x/year >2-3x/year 2x peryear >3 2x peryear x/year N/A Requires long-termfollow-up Medicationsideeffectscanvaryinintensityfromnonetoverytroublesomeandworrisome. Thelevelof intensitydoesnot correlatetospecific levelsof control butshouldbeconsideredintheoverallassessmentof risk. 7

8 RecommendedStepfor Initiating Therapy Maintaincurrentstep Regular followups every1-6months Consider stepdownifwell controlledfor atleast3months Stepup1 step Stepup at least1 step Stepup1 step Reevaluate in2-6 weeks Consider alternative treatment options Considershortcourse of oral steroids Stepup1-2steps Consider shortcourse oforal steroids Step up1-2 steps Reevaluatein 2 weeks Consider alternative treatment options In 2-6 weeks, depending on severity, evaluate level of asthma control that is achieved Children 0-4 if no benefit observed in 4-6 weeks stop treatment and consider alternative diagnosis or adjusting therapy Children 5-11 adjust therapy accordingly Level of severity is determined by both impairment and risk Assess impairment domain by caregiver s recall of previous 2-4 weeks Assign severity to the most severe category in which any feature occurs Frequency and severity of exacerbation may fluctuate over time for patients in any severity category The more frequent and severe exacerbation indicates greater underlying disease severity Before stepping up Review adherence to medication, inhaler technique and environmental control If alternative treatment was used discontinue it and use preferred treatment for that step Reevaluate the level of asthma control in 2-6 weeks to achieve control Every 1-6 months to maintain control Components ofseverity Classifying Asthma SeverityandInitiating TherapyinChildren 12Yearsof Age Intermittent Persistent Mild Moderate Severe 12yearsof age 12yearsof age 12yearsof age 12yearsof age Impairment Symptoms 2days/week 2days/week butnotdaily Daily Throughouttheday Nighttimeawakenings 2x/month 3-4x/month >1x/week butnot Often nightly 7x/week Impairment Short-actingbeta2 2days perweek >2days/week butnot>1 Daily Severaltimes per day Normal agonistusefor time/daily FEV1/FVC symptomcontrol 8-19yrs 85% 20-39yrs80% 40-59yrs75% 60-80yrs70% Interferencewith normalactivity None Minor limitations SomeLimitations ExtremeLimitations LungFunction *FEV1(predicted)or peakflow(personal best) *FeV1/FVC NormalFEV1between exacerbations FEV1>80% FEV1/FVC Normal >80% Normal 60but80% predicted Reducedby 5% N/A <60% Reducedby 5% Risk Exacerbation requiring oral systemic corticosteroids (Consider severityand intervalsince last exacerbation) 0-1per year >2exacerbation in1 year Consider severityandinterval sincelastexacerbation. Frequencyandseveritymay fluctuate over timefor patients inanyseveritycategory. 8

9 Asthma and Allergy Foundation of America. (2018). Centers for Disease Control and Prevention. (2017). Centers for Disease Control and Prevention. (2018). Fanta, C. H., Stieb, E. S., Carter, E. L., & Haver, K. E. (2007). The asthma educator s handbook. New York, NY: McGraw-Hill. Global Initiative for Asthma. (2017). ginasthma.org Hyatt, R. E., Scanlon, P. D., & Nakamura, M. (2003). Interpretation of pulmonary function test (2nd ed.). Philadelphia, PA: Lippincott Williams and Wilkins. Makela, M. J., Backer, V., Hedegaard, M., & Larsson, K. (2013, April 7). Adherence to inhaled therapies, health outcomes and costs in patients with asthma and COPD. Respiratory Medicine, 107, Mayo Clinic. (2017). National Heart, Lung, and Blood Institute. (2017). Pollart, S. M., & Elward, K. S. (2009). Overview of changes to asthma guidelines: Diagnosis and screening. Retrieved from Validated instrument for assessment and monitoring of asthma [PDF]. (2007, August 28). Retrieved from 9