Use of Medications in Asthma Cyril Grum M

Use of Medications in Asthma Cyril Grum, M. D. Department of Internal Medicine *Based on the University of Michigan Guidelines for Clinic Care and the National Asthma Education and Prevention Progam (NAEPP) 2002 Update

Recommended therapies are based on clinical severity • See Powerpoint presentation on “Diagnosing and Staging Asthma” for background

Regimens for long-term control of asthma

Children 5 years and under-1 • Step 1 (mild, intermittent) – No daily medications indicated • Step 2 (mild, persistent) – Preferred treatment: Low-dose inhaled corticosteroids (with nebulizer or MDI with holding chamber with or without face mask or DPI). – Alternative treatment (listed alphabetically): • Cromolyn (nebulizer is preferred or MDI with holding chamber) • Leukotriene receptor antagonist.

• Children 5 years and under-2 Step 3 (moderate persistent) – Preferred treatments: • Low-dose inhaled corticosteroids AND long-acting inhaled • b 2 -agonists Medium-dose inhaled corticosteroids. – Alternative treatment: • Low-dose inhaled corticosteroids AND either leukotriene receptor antagonist or theophylline. – In patients with recurring severe exacerbations: • Medium-dose inhaled corticosteroids AND – long-acting b 2 -agonists (preferred), OR – leukotriene receptor antagonist (alternate) OR – theophylline (alternate)

Children 5 years and under-3 • Step 4 (severe, persistent), preferred treatment: – High-dose inhaled corticosteroids PLUS – Long-acting inhaled b 2 -agonists AND if needed, – Corticosteroid tablets or syrup long term (2 mg/kg/day, but not >60 mg/day, with repeat attempts to reduce systemic corticosteroids

Adults and Children >5 years - 1 • • Step 1 (mild, intermittent) – No medications are recommended – If severe exacerbations occur infrequently, separated by asymptomatic intervals --> oral corticosteroids Step 2 (mild, persistent) – Preferred treatment: Low-dose inhaled corticosteroids. – Alternative treatments (listed alphabetically) • cromolyn or nedocromil, OR • leukotriene modifier, OR • sustained release theophylline to serum conc. of 5– 15 mcg/m. L.

Adults and Children >5 years - 2 • Step 3 (moderate, persistent) – Preferred treatment: • Low-to-medium dose inhaled corticosteroids AND long-acting inhaled b 2 -agonists – Alternative treatments (listed alphabetically): • • Increase inhaled corticosteroids within medium-dose range Low-to-medium dose inhaled corticosteroids AND either leukotriene modifier OR theophylline. – In patients with recurring severe exacerbations: • • Add long-acting b 2 -agonists (preferred), OR Increase inhaled corticosteroid to medium-dose range (alternate), OR leukotriene receptor antagonist (alternate) OR theophylline (alternate)

Adults and Children >5 years - 3 • Step 4 (severe, persistent) – High-dose inhaled corticosteroids AND – Long-acting inhaled b 2 -agonists AND (if needed) – Oral corticosteroids 2 mg/kg/day, up to 60 mg per day, with repeated attempts to reduce systemic corticosteroids.

Medications and dosing: selected corticosteroid inhalers Medication Adult doses Pediatric doses Budesonide (Pulmocort®) 200 mcg/inhalation Administered bid Low 200 -600 Medium 600 -1200 High >1200 Low 200 -400 Medium 400 -800 High >800 Triamcinolone (Azmacort®) Low 400 -1000 Medium 1000 -2000 100 mcg/inhalation Administered bid-qid High >2000 Low 400 -800 Medium 800 -1200 High >1200 Fluticasone (Flovent®) 44, 110 or 220 mcg/puff Administered bid Low 88 -264 Medium 264 -660 High >660 Low 88 -176 Medium 176 -440 High >440 Salmeterol/fluticasone Advair Diskus ®) Low 100/50 1 puff bid Medium 250/50 1 puff bid High 500/50 1 puff bid Low 1 puff bid Medium 1 puff bid High 1 puff bid

Medications and dosing: Bronchodilators and mast cell stabilizers Medication Adult doses Pediatric doses Albuterol 90 mcg/puff (Proventil®, Ventolin ®) 2 puffs tid-qid Pirbuterol 200 mcg/puff (Maxair Autoinhaler®) 2 puffs tid-qid Salmeterol 50 mcg/dose (Serevent Diskus®) 1 blister bid Cromolyn sodium 800 mcg/puff (Intal®) 2 -4 puffs tid-qid 1 -2 puffs tid-qid Nedocromil sodium 1750 mcg/puff (Tilade ®) 2 -4 puffs tid-qid 1 -2 puffs tid-qid

Medications and dosing: Oral medications Medication Adult doses Pediatric doses Zafirlukast (Accolate ®) 20 mg bid 10 mg bid Montelukast (Singulair®) 10 mg q hs age 6 -14: 5 mg hs age 2 -5: 4 mg hs age 12 -23 mo: 4 mg hs (oral granules) Theophylline 300 mg bid Starting dose: 10 mg/kg/day; usual max: >1 year of age: 16 mg/kg/day < 1 yr: 0. 2 (age in weeks) + 5 = mg/kg/day

Regimens for quick relief of acute symptoms

Quick relief of acute symptoms in children age 5 and under • Bronchodilator prn. Intensity of rx depends on severity. – Preferred rx: Short-acting, inhaled b 2 -agonist, by • nebulizer or face mask and space/holding chamber – Alternative rx: Oral b 2 -agonist With viral respiratory infection – Bronchodilator q 4– 6 hours up to 24 hours (longer with physician consult); do not repeat < q 6 weeks – Consider systemic corticosteroid if severe or patient has hx of previous severe exacerbations

Quick relief of acute symptoms in adults and children > age 5 • • • Short-acting bronchodilator: 2– 4 puffs shortacting inhaled b 2 -agonists as needed for symptoms. Intensity of treatment depends on severity; up to 3 treatments at 20 -minute intervals or a single nebulizer treatment as needed. A course of systemic corticosteroids may be needed.

A note on intensity of treatment for acute symptoms in all age groups • • Excessive use of short-acting b 2 -agonists may indicate a need to increase long-term-control therapy Defined as: – >2 times a week in intermittent asthma – daily or increasingly in persistent asthma

Emergency room or in-hospital treatment Drug Adult dose Child dose Nebulized albuterol 2. 5– 5 mg q 20 mins x 3 doses, then 2. 5– 10 mg q 14 hr prn, or 10– 15 mg/hr continuously 0. 15 mg/kg (min= 2. 5 mg) q 20 mins x 3 doses, then 0. 15– 0. 3 mg/kg (≤ 10 mg) every 1 -4 hrs prn, or 0. 5 mg/kg/hr continuously Albuterol MDI (90 mcg/puff) 4– 8 puffs q 20 mins up to 4 4– 8 puffs q 20 mins x 3 hrs, then every 1 -4 hrs prn doses, then q 1 -4 hrs by inhalation using spacer/ holding chamber. 0. 5 mg q 30 mins x 3 doses, 0. 25 mg q 20 mins x 3 doses, then q 2 -4 hrs prn then q 2 -4 hrs Nebulized ipratropium Br (with albuterol)

Drug Adult dose Child dose levalbuterol Same as albuterol, but 5 mg albuterol=2. 5 mg levalbuterol Epinephrine 1: 1000 0. 3 -0. 5 mg sq q 20 mins x 3 0. 01 mg/kg sq (up to 0. 3– 0. 5 mg) q 20 mins x 3 (1 mg/m. L) Terbutaline mg/m. L) (1 0. 25 mg sq q 20 mins x 3 0. 01 mg/kg sq q 20 mins x 3, then q 2– 6 hrs prn Prednisone, 120– 180 mg/day in 3 or methylprednisolone, 4 divided doses x 48 hrs, prednisolone then 60– 80 mg/day until PEF reaches 70% of predicted or personal best 1 mg/kg q 6 hrs x 48 hrs, then 1 -2 mg/kg/day (max. =60 mg/day) in 2 divided doses until PEF 70% of predicted or personal best