Treating Your Asthma Patients Using NIH guidelines

Inhalers offer significant relief for many asthma sufferers. But they're not the only option.

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

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