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Asthma Treatment for adults >17

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Review the response to treatment in 4 to 8 weeks

Aim of asthma management

  • No daytime symptoms.
  • No night-time waking due to asthma.
  • No need for rescue medication. 
  • No asthma attacks.
  • No limitations on activity including exercise.
  • Normal lung function (FEV1 and/or PEF > 80% predicted or best)
  • Minimal side-effects from medication.
  • Use an inhaled SABA (salbutamol) three times a week or less

Initial Asthma Appointment

  • Asthma Control Questionnaire
  • Lung function tests - spirometry or peak expiratory flow
  • Arrange specialist referral if occupational asthma is suspected.
  • Asthma Action Plan
  • Ensure that the person is up to date with all routine vaccinations, including all childhood immunizations, and the annual influenza vaccination. 
  • Patient Information  British Lung Foundation and Asthma UK.

Treatment

Reliever

  • Short-acting beta-2 agonist (SABA )reliever therapy as required - salbutamol 
  • Low Dose ICS - formorterol if needed

Preventer

Step 1

PRN low dose inhaled corticostroid (ICS)

  • QVAR - beclomethasone - 100mcg bd, increased to 200mcg bd
  • Clenil - beclomethasone - 200mcg bd, increased to  400mcg bd 
  • Pumicort Turbohaler
  • Flixotide
  • Ciclesonide 160mcg one puff daily, can be increased/ decreased from this – particularly useful in patients with mouth/ throat side effects with other ICS medications, as this only becomes activated in lung tissue (This is not on the local formulary but is a good option with recognised benefits for some patients.  As long as the reason is noted, it is reasonable to use this despite being off formulary).

Step 2 

Daily low dose ICS

Step 3

 Add Leukotriene receptor antagonist (LTRA)

  • LTRA =  Montelukast
    • 10mg in the evening
    • Review after 4 weeks - stop if ineffective, continue seasonally if effective
    • LTRA - Leukotriene receptor antagonist therapy
    • unique mechanism of action results in a combination of both bronchodilator and anti-inflammatory effects
    • Seek advice if experience neuropsychiatric reactions, including speech impairment and obsessive-compulsive symptom
    • particularly useful in atopic adults as there may be allergic triggers to their asthma

Step 4

Long-acting beta-2 agonist (LABA) & ICS

  • Fostair - beclometasone & formoterol - 100/6 2 puffs bd increased to 200/6 2 puffs bd
  • Symbicort - budesonide and formoterol 100/6 2 puffs bd increased to  200/6 2 puffs BD

Step 5

 

  • If asthma is uncontrolled on a MART regimen with a low maintenance ICS dose, with or without an LTRA, consider increasing the ICS to a moderate maintenance dose (either continuing on a MART regimen or changing to a fixed-dose of an ICS and a LABA, with a SABA as a reliever therapy.)
  • additional drug (for example, a muscarinic receptor antagonist or theophylline). Alternatively, a high maintenance dose of ICS may be appropriate. 
  • Pregnant women - no changes, same treatment
  • Spacers

Asthma 

  1. Start with ICS or ICS/LABA
    • In smokers, the effectiveness of ICS is reduced, so they will need to be started on a medium dose e.g. QVAR 200mcg bd (pMDI or easibreathe BAI); or Clenil 400mcg bd (pMDI).
  2. Review after 3 months and step down to ICS only.  May need to continue for a year. 
  3. Consider adding Montelukast 10mg in the evening 
  4. Switch to ICS/LABA
  5. ICS dose can be increased to moderate dose
  6. If no improvement in symptoms at this point then consider referring patient to respiratory services, or sooner if there are additional / occupational problems. 

https://www.researchgate.net/figure/Step-ladder-therapy-options-for-asthma-by-GINA-ICS-inhaled-corticosteroid-LABA-long_fig1_349222423

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