Adjustment of Inhaled Controller Therapy of Asthma in the Yellow Zone, Based on the Inhaler Product Used in the Green Zone Age 12 Years and Older

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1 Adjustment of Inhaled Controller Therapy of Asthma in the Yellow Zone, Based on the Inhaler Product Used in the Green Zone Age 12 Years and Older The Canadian Thacic Society recommends a tempary, greater the inhaled cticosteroid () dose in selected patients in response to wsening asthma symptoms. 1 The green yellow red zone framewk describes asthma symptoms that are controlled, partially controlled uncontrolled, respectively. This guideline based recommendation is distinct from the manufacturer s recommended dose in the product monograph. Any the dose requires an individual assessment by the clinician a written asthma action plan. F all examples in this document, the tempary dose does not exceed the manufacturer s recommended maximum dose. As a result, it is not possible to recommend an evidenced based greater the all dosage situations. In the absence of an evidence based option, clinicians exercising clinical judgment may choose a 2 fold the dose. Initiating prednisone in the yellow zone is also an alternative evidence based option. Dose Dose of dose in Fluticasone propionate pmdi Flovent HFA 50 /puff 2 puff ** 125 /puff 1 puff * /puff puffs *** /puff 1 puff * /puff *Although the manufacturer recommends that the usual dose be obtained using 2 puffs from each available strength of Flovent HFA pmdi, one puff multiple puffs may be required to obtain the prescribed dose. **Increasing the dose beyond may be impractical, an frequency to qid dosing may be considered. ***Switching from the 125 to the 250 pmdi will reduce the number of puffs required per dose. Dose Dose of dose in Fluticasone propionate Flovent Diskus /inhalation 1 inh 4 inhalations 250 /inhalation 1 inh inhalations /inhalation 1 inh 0 2 inhalations 0 0 Dose based on 1 inhalation from each available strength of Flovent Diskus. Me than 1 inhalation may be required to obtain the prescribed dose from the patient s inhaler Dose Dose of dose in Fluticasone furoate* Arnuity Ellipta /inhalation 1 inh 2 inhalations /inhalation 1 inh No recommendation** *Dose based on 1 inhalation from each available strength of Arnuity Ellipta. Me than 1 inhalation may be required to obtain the prescribed dose from the lower strength inhaler.. 1

2 Budesonide Pulmict Turbuhaler /inhalation 1 inh /inhalation 1 inh /inhalation 1 inh Dose 4 inhalations 4 inhalations 3 inhalations Total dose 1 dose In Dose based on 1 inhalation from each available strength of Pulmict Turbuhaler. Me than 1 inhalation may be required to obtain the prescribed dose from the patient s inhaler. Beclomethasone pmdi Qvar 50 /puff 1 puff 50 /puff /puff 1 puff /puff Dose 8 puffs Total dose dose In Dose based on 1 puff from each available strength of Qvar inhaler. Me than 1 inhalation may be required to obtain the prescribed dose from the patient s inhaler. Ciclesonide pmdi Alvesco /puff 1 puff * /puff 2 puffs /puff 1 puff /puff 2 puffs /puff Dose using the patient s existing inhaler Total dose dose In *Dose based on 1 puff from each available strength of Alvesco inhaler. Me than 1 inhalation may be required to obtain the prescribed dose from the patient s inhaler. Medication in the Green Zone Dose using the patient s existing inhaler Total dose dose Mometasone Asmanex Twisthaler /inhalation 1 inh 4 inhalations /inhalation 1 inh * 2 inhalations /inhalation 1 inh 2 inhalations /inhalation 1 inh 1 inhalation /inhalation 1 inh *Dose based on 1 puff from each available strength of Asmanex Twisthaler. Me than 1 inhalation may be required to obtain the prescribed dose from the patient s inhaler. 2

3 Advair pmdi Fluticasone/salmeterol* 125/ Dose using additional fluticasone pmdi, Flovent HFA switching to the higher strength of Advair pmdi Add fluticasone 250 /puff pmdi 3 puffs Switch to Advair 250/25 dose In /25 0 Add fluticasone 250 /puff pmdi 0 *Note: Since each puff from the Advair pmdi delivers salmeterol 25, the manufacturer s recommended dose is 2 puffs from each available strength of Advair pmdi in der to obtain 50 of salmeterol at each dose time. Advair Diskus Fluticasone/salmeterol* /50 1 inhalation Dose using additional doses from the fluticasone, Flovent Diskus switch to a higher strength of Advair Diskus combine the 2 strategies Add fluticasone 250 /inhalation, 1 inhalation add fluticasone /inhalation, 3 inhalations fold 5 fold 250/50 1 inhalation 500 Add fluticasone 250 /inhalation, 3 inhalations add fluticasone 500 /inhalation, 1 inhalation plus fluticasone 500, 1 inhalation /50 1 inhalation 0 Add fluticasone 500 /inhalation, 1 inhalation 0 *Note: Since each inhalation from the Advair Diskus delivers salmeterol 50, the manufacturer s recommended dose is 1 inhalations from each available strength of Advair Diskus in der to obtain 50 of salmeterol at each dose time. 3

4 Breo Ellipta Fluticasone furoate/vilanterol* /25 1 inhalation Dose using additional doses from the fluticasone furoate, Arnuity Ellipta switch to a higher strength of Breo Elliipta Add fluticasone furoate /inh, 1 inhalation Switch to Breo Ellipta /25, 1 inhalation /25 1 inhalation *Note: Each inhalation from either strength of Breo Ellipta delivers vilanterol 25, which is the maximum dose Note: Breo Ellipta /25 and /25 are indicated in asthma. Breo Ellipta /25 is not indicted f use in COPD. Zenhale pmdi Mometasone/fmoterol* Dose using Additional mometasone, Asmanex Twisthaler switch to a higher strength of Zenhale pmdi /5 Add mometasone /inhalation 1 inhalation Switch to Zenhale /5 /5 *Note: Since each puff from the Zenhale pmdi delivers fmoterol 5, the manufacturer s recommended dose is 2 puffs from each available strength of Zenhale pmdi in der to obtain 10 of fmoterol at each dose time. Note: The addition of mometasone, Asmanex Twisthaler as a strategy to increase the inhaled cticosteroid dose introduces a different device (breath actuated, dry powder inhaler) and may necessitate patient education on the use of the new device. 4

5 Symbict Turbuhaler Budesonide/fmoterol* /6 1 inhalation /6 1 inhalation /6 2 inhalations /6 2 inhalations Dose using Existing Symbict Turbuhaler Symbict Adjustable Maintenance Dosing Increase to 4 inhalations/day dose /6 1 inhalation /6 1 inhalation /6 2 inhalations /6 2 inhalations Increase to 4 inhalations/day alone, add budesonide 1 inhalation Or continue 2 inh + budesonide 2 inh /6 1 2 inhalations 2 inhalations /6 1 2 inhalations 2 inhalations to to Symbict Maintenance and Reliever Therapy (SMART) In addition to the dose, may take 1 additional dose as needed in response to symptoms. Not me than 6 inhalations on any single occasion. Not me than 8 inhalations per day in total ( and reliever doses).** Up to /day Up to 1600 /day Up to Up to *Dose based on 1 inhalation from each available strength of Symbict Turbuhaler. Not me than 6 inhalations should be taken on any single occasion **If satisfacty relief of asthma symptoms is not achieved with a maximum of 8 inhalations per day, seek medical attention. Reference: 1. Lougheed MD, Lemière C, Ducharme FM, et al. Canadian Thacic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults. Can Resp J 2012;19(2): Copyright This document is provided f clinicians, as resource in the management of asthma f persons aged 12 years and older. Determination of the most appropriate dose of inhaled cticosteroid f any individual is the responsibility of the clinician together with the patient. The Ontario Lung Association makes no claims about the appropriateness of the inhaled cticosteroid dose. 5