Inhalers offer significant relief for many asthma sufferers. But they’re not the only option.
In the previous blog post, I discussed assessing control and severity of your asthmatic’s symptoms. Now we will take this stratification and translate it into clinical practice standards.
The NIH guidelines provide an algorithm whereby asthma treatment is guided in a step-wise approach. In many ways this is logical but it is not always practical. Below is a review of their step-wise approach along with commentary for real-world clinicians — not just academicians! — based on my personal experience.
Step 1 treatment (for intermittent asthmatics). This is very straightforward — prescribe a short-acting beta-agonist inhaler. A few key tips: I prefer inhalers that have dose counters so the patient doesn’t have to guess if any medicine is left in the device. For that reason I highly recommend Ventolin HFA. There are few situations more precarious than that of an asthmatic counting on their rescue inhaler only to realize they are holding nothing but air!
Step 2 treatment (for mild, persistent asthmatics). Remember the rule of 2s; two days a week of symptoms, such as wheezing, shortness of breath or coughing. The choices here are as follows: (1) a low-dose inhaled corticosteroid. (2) If you are concerned your patient will have difficulty using the inhaler, or you are concerned about long term use of an inhaled steroid, the other option is the oral monteleukast (Singulair). This is available in both adult and pediatric doses — 10 and 5 mg respectively. When going with option one, I like Flovent Diskus because it comes in two doses: 50 and 100 micrograms. I also like that it also has a dose counter and that the discus is breath activated, meaning coordination is not a factor when it comes to getting the inhaled medicine deep into the lungs.
Step 3 treatment. Here the NIH guidelines give you a few options. The one I use and find works extremely well is the combination of an inhaled corticosteroid with a long-acting beta agonist inhaler. For decades, I have used the Advair Diskus with excellent results. It comes in three strengths: 100/50, 250/50 and 500/50. I most often use the 100/50 in chronic asthmatics, and have experienced good results at that dose. I will up the dose to 250/50 if the patient has an exacerbation due to an infection or allergen exposure. I don’t find much of a need for the 500/50; a patient that severe will likely require oral steroids for control.
Step 4 treatment (for severe asthmatics). These patients have daily symptoms and their normal activities are limited. They will need a high dose inhaled corticosteroid combined with a long-acting beta agonist. A good option is the Advair 250/50 or the newer Dulera 200/50. If you confirm allergic disease, the patient may be considered for the monoclonal antibody injection (Xolair). This is where I recommend you refer to a specialist to manage the complicated disease state and specialized treatment regimen.
The other important thing to remember is the potential benefit of allergy immunotherapy for allergic asthmatics at any of these steps. All forms of allergen immunotherapy have been shown to decrease the inflammation that lies at the root of allergic asthmatics’ disease.
Dr. Dean Mitchell
Asthma is often triggered by allergies. Determining the allergy source, with a skin test, can help patients avoid extensive treatment.
This time of year brings changing weather and an uptick of respiratory viruses. For most physician offices, asthma visits rise with these trends. The diagnosis of asthma is often not the hard part; patients short of breath with coughing and wheezing make for a simple diagnosis. Other patients come in with the elusive and often undiagnosed cough, and a quick run of the spirometry can provide the answer. But navigating the art of managing and charting your asthmatic patients requires some skill.
The experts agree on the need to document two key points: severity and control. The components of severity are: intermittent, mild, moderate and severe. Begin the differentiation by stratifying the patient by the Rule of Twos using the key asthma indicators: nocturnal awakenings, use of short-acting beta-agonists inhalers, and interference in daily activities. If these indicators occur less than twice a week, then the patient is considered to have intermittent asthma; if the patient has these symptoms more than twice a week but not daily, then he/she falls into the mild persistent category. Moderate persistent is used for patients who experience the indicator symptoms daily, and severe persistent asthmatics suffer with symptoms throughout the day. It is critically important to follow and document pulmonary function tests and home peak flow levels in your moderate and severe patients. The moderate persistent asthmatic will demonstrate FEV1 values between 60-80% predicted, while more severe persistent patient values fall consistently under 60%.
The ACT (Asthma Control Test) is a standardized validated questionnaire that serves as another key component to the management process. The questionnaire provides a quick assessment of both severity and control. This form should be downloaded and printed from the back end of the AllerVision website — you will use it often! A score of less than 20 on the ACT signifies poor control, indicating that intervention or change in therapy is in order.
Always keep in mind that asthma is multi-factorial and heterogenetic; meaning there are lots of components at play. The detective work of good medicine means finding that trigger of your patient’s asthma, so the plan can center on avoiding those triggers whenever possible. Respiratory infections, especially viral, are common culprits that prove difficult to avoid. Stress and emotions also affect asthma, leading to exacerbations. However, a main trigger in most asthmatic exacerbations is allergic response. This fact is the impetus behind the NIH guideline stating that all persistent asthmatics be tested to identify their allergic triggers. The AllerVision testing program offers a comprehensive and regionally appropriate assessment. Perform the test, carefully document positive results along with correlation to the careful and detailed history, and take action to help the patient learn how to remove the offending allergen(s) from his or her environment. Because avoidance can be near-impossible, give serious consideration to allergen immunotherapy for your asthmatic patients. SLIT (sublingual immunotherapy) is a fantastic option in this case because it offers the benefits with significantly less risk than SCIT (subcutaneous immunotherapy, aka allergy shots).
Our next blog post will comment on making adjustments to asthma control through medications.
Dr. Dean Mitchell