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pathogenesis of childhood asthmaPediatr. Infect Dis J2003;22

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recurrent wheezingAm J Respir.

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Sears MR, Greene JM, Willan AR, Wiecek EM, Taylor DR,

Morgan WJ, et al. Management of asthma based on exhaled nitric

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Flannery EM, et al.A longitudinal, population-based,-cohort

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Clin Immunol2009;124:615-7, 617

CE, Wardlaw AJ, Green RH. Cluster analysis and clinical asthma

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phenotypesAm. J Respir Crit Care Med 2008;178:218-24.

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be achieved? The Gaining Optimal Asthma ControL studyAm J .

Parameswaran K, Hargreave FE. Determining asthma treatment

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by monitoring sputum cell counts: effect onEurexacerbations.

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Chen H, Gould MK, Blanc PD, Miller DP, Kamath TV, Lee JH,

Sullivan SD. Asthma control, severity, and quality of life: qua

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Education and Prevention Program. Expert Panel Report 3:

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Guidelines for the Diagnosis and Management of Asthma. August

2007. Available from:

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www.nhlbi.nih.gov/guidelines/asthma/asthgdln

NOTunderstanding, recommendations, and unanswered questions.

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American Thoracic Societym. JA Respir Crit Care Med

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clinical asthma control assessment tools and fractionalDOexhaled

nitric oxideAnn Allergy.

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Liu AH, Zeiger R, Sorkness C, Mahr T, Ostrom N, Burgess S,

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COPYRIGHTED

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Schatz M, Mosen DM, Kosinski M, Vollmer WM, Magid DJ,

O'Connor E, Zeiger RS. Validity of the Asthma Control Test

completed at homeAm. J Manag Care

2007;13:661-7.

• Medications to treat asthma can be classified as

Route of Administration

controllers or relievers. Controllers are medications

taken daily on a long-term basis to keep asthma

Asthma treatment for adults can be administered in

under clinical control chiefly through their anti-

or “wet” aerosols* . InhalerREPRODUCE!devices differ in their e

different ways—inhaled, orally or parenterally (by

inflammatory effects. Relievers are medications

used on an as-needed basis that act quickly to

subcutaneous, intramuscular, or intravenous injecti

The major advantage of inhaled therapy is that drugs are

reverse bronchoconstriction and relieve its symptoms.

delivered directly into the airways, producing highe

concentrations with significantly less risk of s

• Asthma treatment can be administered in different

ways—inhaled, orally, or by injection. The major side effects.

advantage of inhaled therapy is that drugs are

Inhaled medications for asthma are available as pressuri

delivered directly into the airways, producing higher

local concentrations with significantly lessmeteredrisk of-dose inhalers (MDIs), breath-actuated MDIs, dry

systemic side effects.

powder inhalers (DPIs), soft mist inhalers, and nebuli

OR

• Inhaled glucocorticosteroids are the most effectiveof drug delivery to the lower respiratory tract, depend

controller medications currently available.

on the form of the device, formulation of medication,

ALTER

• Rapid-acting inhaled-agonists are the

particle size, velocity of the aerosol cloud or plume (wh

applicable), and ease with which the device can be used

2

medications of choice for relief of

by the majority of patients. Individual patient pref

bronchoconstriction and for the pretreatment of

convenience, and ease of use may influence not only th

exercise-induced bronchoconstriction, in both adults

and children of all ages.

efficiency of drug delivery but also patient adheren

treatment and long-term control.

• Increased use, especially daily use, of reliever

DO

Pressurized MDIs (pMDIs) require training and skill to

medication is a warning of deterioration of asthmaNOT

control and indicates the need to reassess

coordinate activation of the inhaler and inhalation.

Medications in these devices can be dispensed as a

treatment.

-

suspension in chlorofluorocarbons (CFCs) or as a solutio

medications taken daily on MATERIALa long-term basis to keep

2

in hydrofluoroalkanes (HFAs). For a pMDI containing

CFCs, the use of a spacer (holding chamber) improves

INTRODUCTION

drug delivery, increases lung deposition, and may redu

1

local and systemic side effects. However, CFC inhaler

devices are being phased out due to the impact of CFCs

The goal of asthma treatment is to achieve and maintain

clinical control. Medications to treat asthma can be

upon the atmospheric ozone layer, and are being replaced

by HFA devices. For pMDIs containing bronchodilators,

classified as controllers or relieversControllers.are

the switch from CFC to HFA inhalers does not result in

COPYRIGHTED

change in efficacy at the same nominal. However,dose

asthma under clinical control chiefly through their anti-

for some glucocorticosteroids, the HFA formulations

inflammatory effects. They include inhaled and systemic

provide an aerosol of smaller particle size that result

glucocorticosteroids, leukotriene modifiers, long-acting

inhaled2 -agonists in combination with inhaled

less oral deposition (with associated reduction in oral

effects), and correspondingly greater lung depositio

glucocorticosteroids, sustained-release theophylline,

This may result in greater systemic efficacy at eq

cromones, and anti-IgE. Inhaled glucocorticosteroids are

ex-actuator doses, but also greater systemic exposure

the most effective controller medications currently

3-5

available.Relieversare medications used on an as-

and risk of side effects. Clinicians are advised to consult

the package inserts of each product to confirm the

needed basis that act quickly to reverse

recommended dose equivalent to currently used drugs

bronchoconstriction and relieve its symptoms. They

Some of these comparisons are providedFigurein 3-1 .

some drugs, the dose may need to be adjusted when

efficacy literature, but the categorization into dosa

switching from an MDI to 7a.DPINebulized aerosols are

categories does not imply that clear dose-response

8

inrelationadultships have been demonstrated for each drug.

rarely indicated for the treatment of chronic asthma.

The efficacy of some products varies when administe

16

CONTROLLER MEDICATIONS

via different inhaler. devicesMostof the benefit from

inhaled glucocorticosteroids is achieved in adults at

Inhaled glucocorticosteroids*

relatively low doses, equivalent to 400 ug of budesonid

per day17 . Increasing to higher doses provides little

benefit in terms of asthma control but increases th

Role in therapy- Inhaled glucocorticosteroids are currently

17,18

OR

side effects. However, there is marked individual

the most effective anti-inflammatory medications for the

variability of responsiveness to inhaled glucocortico

treatment of persistent asthma. Studies have demonstrated

9

and because of this and the recognized poor adherence to

treatment with inhaled glucocorticosteroids, many pat

their efficacy in reducing asthma, improvingsymptoms

9

9

quality of, lifeimproving lung function, decreasing airway

will require higher doses to achieve full therapeuti

10

11

NOT

ALTER

hyperresponsiveness, controlling airway inflammation, As tobacco smoking reduces the responsiveness to

12

inhaled glucocorticosteroids, higher doses may be

reducing frequency and severity of exacerbations, and

13

required in patients who smoke.

reducing asthma mortality. However, they do not cure

†

Figure 3-1. Estimated Equipotent Daily Doses of Inhaled Glucocorticosteroids for Adults

Drug

Low Daily Dose ( g)DO

Medium Daily Dose ( g)

High Daily Dose ( g) ‡

-

Beclomethasone dipropionate

200 - 500

>500 - 1000

>1000 - 2000

Budesonide*

200 - 400

>400 - 800

>800 - 1600

Ciclesonide*

80 - 160

>160 - 320

>320 - 1280

Flunisolide

500 - 1000

>1000 - 2000

>2000

Fluticasone propionate

100 - 250

>250 - 500

>500 - 1000

Mometasone furoate*

200 - 400

>400 - 800

>800 - 1200

MATERIAL

Triamcinolone acetonide

400 - 1000

>1000 - 2000

>2000

† Comparisons based upon efficacy data.

‡ Patients considered for high daily doses except for short periods should be referred to a specialist for assessment to consider altern

controllers. Maximum recommended doses are arbitrary but with prolonged use are associated with increased risk of systemic side effect

* Approved for once-daily dosing in mild patients.

Notes

• The most important determinant of appropriate dosing is the clinicianis judgment of the patientis response to therapy. The clinician m

response in terms of clinical control and adjust the dose accordingly. Once control of asthma is achieved, the dose of medication should b

theminimum dose required to maintain control, thus reducing the potential for adverse effects.

• Designation of low, medium, and high doses is provided from manufacturersi recommendations where possible. Clear demonstration of dose-r

COPYRIGHTED

relationships is seldom provided or available. The principle is therefore to establish the minimum effective controlling dose in each

may not be more effective and are likely to be associated with greater potential for adverse effects.

ASTHMA TREATMENTS

29

of inhaled glucocorticosteroids. There is, however, a

dissociating the effect of high-dose inhaled

211

clear relationship between the dose of inhaled glucoglucocorticosteroids-

from the effect of courses of

corticosteroids and the prevention of severe acute glucocorticosteroids taken by patients with severe a

exacerbations of asthma, although there appear to be

There is no evidence that use of inhaled

12

REPRODUCE!

Mouth washing (rinsing with water, gargling, and spitting

differences in response according to symptom/

glucocorticosteroids increases the risk of pulmonary

inflammation phenotype. Therefore, some patients withinfections, including tuberculosis, and inhaled gl

212

severe asthma may benefit from long-term treatmentcorticosteroidswith

are not contraindicated in patients w

higher doses of inhaled glucocorticosteroids.

active tuberculosis.

33

Side effects:Local adverse effects from inhaled

Leukotriene modifiers.

glucocorticosteroids include oropharyngeal candidiasis,

dysphonia, and occasionally coughing from upper airway

modifiers include cystei

Role in therapy Leukotriene-

irritation. For pressurized MDIs the prevalence of these

leukotriene 1 (CysLT1) receptor antagonists (montelukas

effects may be reduced by using certain spacer. devices

1

pranlukast, and zafirlukast) and a 5-lipoxygenase inhib

OR

(zileuton). Clinical studies have demonstrated that

out) after inhalation may reduce oral candidiasis. The use

leukotriene modifiers have a small and variable broncho

of prodrugs that are activated in the lungs but not in the

34

dilator effect, reduce symptoms including, improvecough

pharynx (e.g., ciclesonide), and new formulations and

ALTER

lung function, and reduce airway inflammation and ast

19

devices that reduce oropharyngeal deposition, may

exacerbations. They may be used as an alternative

35-37

minimize such effects without the need for a spacer or

38-40

mouth washing.

treatment for adult patients with mild persistent,

and some patients with aspirin-sensitive asthma res

well to leukotriene modifiers. However, when used alone

41

Inhaled glucocorticosteroids are absorbed from the lung,

as controller, the effect of leukotriene modifiers a

accounting for some degree of systemic bioavailability.

generally less than that of low doses of inhaled

The risk of systemic adverse effects from an inhaled

DO

glucocorticosteroids, and, in patients already on inhal

glucocorticosteroid depends upon its dose and potency,NOT

glucocorticosteroids, leukotriene modifiers cannot

the delivery system, systemic bioavailability, first-pass

substitute for this treatment without risking t

metabolism (conversion to inactive metabolites) in the

42,43

asthma control . Leukotriene modifiers used as add-on

liver, and half-life of the fraction of systemically-

absorbed

49-51,192

doses of 400 g or less budesonideMATERIALor equivalent daily.

20

the

therapy may reduce the dose of inhaled glucocorticostero

drug (from the lung and possibly. Therefore,gut)

44

required by patients with moderate to severe, andasthma

systemic effects differ among the various inhaled

may improve asthma control in patients whose asthma is

glucocorticosteroids. Several comparative studies have

not controlled with low or high doses of inhaled

demonstrated that ciclesonide, budesonide, and fluticasone

43,45-47

20-

glucocorticosteroids. With the exception of one

propionate at equipotent doses have less systemic effect

study that demonstrated equivalence in preventing

23 . Current evidence suggests that in adults, systemic

48

exacerbations, several studies have demonstrated that

effects of inhaled glucocorticosteroids are not a problem at

leukotriene modifiers are less effective than long

riskCOPYRIGHTEDwas considerably less than other common risk factors

inhaled2

-agonists as add-on therapy . A controlled

release formulation of zileuton allows this medicati

The systemic side effects of long-term treatment with high

used on a twice daily basis with effects equivalen

doses of inhaled glucocorticosteroids include easy

203

24

1,20

of standard zileuton used four times. a day

bruising, adrenal suppression, and decreased bone

mineral density. A meta-analysis of case-control

25,26

Side effects -Leukotriene modifiers are well tolerated,

studies of non-vertebral fractures in adults using inhaled

and few if any class-related effects have so far been

glucocorticosteroids (BDP or equivalent) indicated that in

recognized. Zileuton has been associated with liver

older adults, the relative risk of non-vertebral fractures

toxicity, and monitoring of liver tests is recommended

increases by about 12% for each 1000 µg/day increase in

204

during treatment with this medication. No associati

the dose BDP or equivalent but that the magnitude of this

found between Churg-Strauss syndrome and leukotrien

213

modifiers after controlling for asthma drug use, alt

for fracture in the older. Inhaledadult

glucocorticosteroids have also been associated with is not possible to rule out modest associations given

27

28,29

Churg-Strauss syndrome is so rare and so highly

cataractsand glaucoma in cross-sectional studies, but

52

correlated with asthma severity.

there is no evidence of posterior-subcapsular cataracts in

Long-acting inhaled

-agonists.

Side effects- Therapy with long-acting inhaled-agonists

2

2

causes fewer systemic adverse effects—such as

Role in therapy- Long-acting inhaled-agonists,

cardiovascular stimulation, skeletal muscle tremor, a

2

55,56,193

glucocorticosteroids, and this combination therapy isdeath associated with the use of salmeterol in a small

75

the preferred treatment when a medium dose of inhaledgroup of individualsled to advisories from the US Food

‡

§

glucocorticosteroid alone fails to achieve control ofand Drug Administration (FDA)and Health Canada that

asthma. Addition of long-acting inhaled-agonists to a

long-acting-agonists are not a substitute for inhaled

2

2

215

lung function, decreases the use of rapid-acting inhaledglucocorticosteroid as determined by a physician. A

57-59

12,57-62

meta-analysis of all studies of salmeterol added to in

2 -agonists, reduces the number of exacerbations,

does not increase the risk of asthma-related

glucocorticosteroids has concluded that this combina

214

hospitalizations, and achieves clinical control of asthmadoes not increase the riskREPRODUCE!for asthma-related deaths or

in more patients, more rapidly, and at a lower dose of

intubations when compared to inhaled glucocorticoster

inhaled glucocorticosteroids than inhaled

alone205 . No influence of-adrenergic receptor

63

OR2

glucocorticosteroids given. alone

phenotypes upon the efficacy or safety of long-acting

2 -agonist therapy has been observed when administere

This greater efficacy of combination treatment hasinledcombinationto

with inhaled glucocorticosteroids whe

2

ALTER

both glucocorticosteroid and long-acti-agongist

at a regular fixed dose in206adults.

64, 65

NOT

simultaneously (fluticasone propionate plus salmeterol,

budesonide plus formoterol). Controlled studies haveTheophylline.

shown that delivering this therapy in a combination inhaler

DO2

Role in therapy- Theophylline is a bronchodilator and,

is as effective as giving each drug separately.Fixed

combination inhalers are more convenient for patients,whenmaygiven in a lower dose, has modest anti-inflammato

-

properties. It is available in sustained-release

increase compliance, and ensure that the long acting-

66

MATERIAL

77-79

maintenance and provide improvements in asthma

on inhaled glucocorticosteroids .aloneAdditionally in

67,194

81-83

control at relatively low doses of treatm. (Seent

such patients the withdrawal of sustained-release

COPYRIGHTED

67-70

theophylline has been associated with deterioration of

Appendix B, GINA Pocket Guide updated 2009 for

information on Asthma Combination Medications For

control. As add-on therapy, theophylline is less effec

Adults and Children 5 Years and Older.)

84

than long-acting inhaled-agonists.

85,86

2

Long-acting 2 -agonists when used as a combination

Side effects- Side effects of theophylline, particularl

acting inhaled-agonists. Salmeterol and formoterol

generally decrease or disappear with continued use.

71

2

onset of action than salmeterol, which may make

Monitoring is advised when a high dose is started, if

72, 73

prevention.

when expected therapeutic aims are not achieved, and

68

anti-tuberculosis medicationsreduce blood levels of

the role of anti-IgE in other clinical settings.

87

207

and some macrolides increase the risk of toxicity. asthmaLower patients ages 12 years and older, who were

doses of theophylline, which have been demonstratedalreadyto

receiving treatment with glucocorticosteroid

82

89

provide the full anti-inflammatory benefit, areof this(inhaleddrug and/or oral) and long-acting-agonists, anti-

2

92-94

associated with less frequent side effects, andIgEplasmaappears to be safe as add-on therapy.

theophylline levels in patients on low-dose therapy need

not be measured unless overdose is suspected.

Systemic glucocorticosteroids.

Cromones: sodium cromoglycate and nedocromil

Role in therapy- Long-term oral glucocorticosteroid

sodium.

therapy (that is, for periods longer than two weeks as a

Role in therapy– The role of sodium cromoglycate and

glucocorticosteroid “burst”) may be required for sever

uncontrolled asthma, but its use is limited by the r

nedocromil sodium in long-term treatment of asthma in

REPRODUCE!

significant adverse effects. The therapeutic inde

adults is limited. Efficacy has been reported in patients

(effect/side effect) of long-term inhaled glucocort

with mild persistent asthma and exercise-induced

steroids is always more favorable than long-term syst

bronchospasm. Their anti-inflammatory effect is weak

OR

95,96

glucocorticosteroids in asthma.If oral glucocortico-

and they are less effective than a low dose of inhaled

88

steroids have to be administered on a long-term basis,

attention must be paid to measures that minimize th

glucocorticosteroid.

systemic side effects. Oral preparations are preferr

Side effects- Side effects are uncommon and include

parenteralALTER(intramuscular or intravenous) for long-ter

coughing upon inhalation and sore throat. Some patients

find the taste of nedocromil sodium unpleasant.

therapy because of their lower mineralocorticoid effe

relatively short half-life, and lesser effects on s

muscle, as well as the greater flexibility of dosing t

Long-acting oral 2 -agonists.

NOT

titration to the lowest acceptable dose that maintains c

Role in therapy- Long acting oral -agonists include

Side effects- The systemic side effects of long-term o

2

DO

-

slow release formulations of salbutamol, terbutaline, and

or parenteral glucocorticosteroid treatment include

bambuterol, a prodrug that is converted to terbutaline in

the body. They are used only on rare occasions when

osteoporosis, arterial hypertension, diabetes, hypothalam

pituitary-adrenal axis suppression, obesity, cataracts

additional bronchodilation is needed.

glaucoma, skin thinning leading to cutaneous striae a

easy bruising, and muscle weakness. Patients with as

Side effects- The side effect profile of long acting oral

-agonists is higher than that of-inhaledagonists, and

who are on long-term systemic glucocorticosteroids in

form should receive preventive treatment for osteopor

2

2

includes cardiovascular stimulation (tachycardia), anxiety,

. Although it is rare, withdrawal of oral

MATERIAL

(Figure 3-2 )97-99

and skeletal muscle tremor. Adverse cardiovascular

glucocorticosteroids can elicit adrenal failure or unm

reactions may also occur with the combination of oral

54,100

underlying disease, such as Churg-Strauss Syndrome.

-agonists and theophylline. Regular use of long-acting

2

Caution and close medical supervision are recommended

oral 2 -agonists as monotherapy is likely to be harmful

and these medications must always be given in

when considering the use of systemic glucocorticos

in patients with asthma who also have tuberculosis,

combination with inhaled glucocorticosteroids.

parasitic infections, osteoporosis, glaucoma, diabetes

Anti-IgE.

severe depression, or peptic ulcers. Fatal herpes viru

infections have been reported among patients who are

Role in therapy- Anti-IgE (omalizumab) is a treatment

exposed to these viruses while taking systemic

glucocorticosteroids, even short bursts.

option limited to patients with elevated serum levels of IgE.

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Its current indication is for patients with severe allergic

89

Oral anti-allergic compounds.

asthma who are uncontrolled on inhaled glucocortico-

Screening

REPRODUCE!

bodies

of

• Any patient with asthma who has been taking oral glucocorticosteroids for over 6 months duration at a mean daily dose of 7.5 mg

prednisone/prednisolone or above.

• Post-menopausal women taking over 5 mg prednisone/prednisolone daily for more than 3 months.

• Any patient with asthma and a history of vertebral or other fractures that may be related to osteoporosis.

Bone

Osteoporosis

• T-score below -2.5 (2.5 standard deviations below the mean value of young normal subjects of the same sex in patients 19-69 years

• Z-score below -1 (1 standard deviation below the predicted value for age and sex).

OR

Follow-up scanning - Repeat scanning should be done:

3.

MATERIAL

.

Sambrook PN, Diamond T, Ferris L, Fiatarone-Singh M, Flicker , MacLennan A et al. Corticosteroid induced osteoporosis. Guidelines forAusttreatmentFam

Physician 2001; 30:793-796.

4.

Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML et al. Risks and benefits of estrogen plus progestin in healthy

postmenopausal women: principal results From the Women's Health Initiative randomizedJAMA controlled.2002;288:321-33.trial.

5.

Cauley JA, Robbins J, Chen Z, Cummings SR, Jackson RD, LaCroix AZ, LeBoff M, Lewis CE, McGowan J, Neuner J, Pettinger M, Stefanick ML, Wactawski-

Wende J, Watts NB. "Effects of Estrogen Plus Progestin on Risk of Fracture and Bone MineralJAMA Density2003;290(13):1729."-1738.

6.

Brown JP, Josse RG. 2002 clinical practice guidelines for the diagnosis and management of osteoporosisCMAJ in. Canada2002;167:S1.-34.

7.

Homik J, Cranney A, Shea B, Tugwell P, Wells G, Adachi et al. Bisphosphonates for steroid induced osteoporosisCochrane Database. Syst Rev

2000;CD001347.

COPYRIGHTED

of mild to moderate allergic asthma. These include with severe asthma have been proposed. These

the long-term treatment of asthma.

overall benefit, but a relatively high frequency of a

effects. This small potential to reduce the impact of

102,103

Side effects- Sedation is a potential side effect of someglucocorticosteroidof

side effects is probably insuf

these medications.

offset the adverse effects of methotrexate.Cyclosporin

104

105

and gold106,107 have also been shown to be effective in

Other controller therapies.

some patients. The macrolide, troleandromycin, has a

small steroid-sparing effect when used with syst

ASTHMA TREATMENTS

33

108

specific immunotherapy have occurred in patients wi

remain under study. The use of intravenous

109-111

severe asthma.

immunoglobulin is not recommended. Data on a

human monoclonal antibody against tumor necrosis factor

Reliever Medications

(TNF)-alpha suggest that the risk benefit equation does

not favor the use of this class of treatments in severe

216

Reliever medications act quickly to relieve

asthma .

bronchoconstriction and its accompanying acute symptom

Side effects- Macrolide use is frequently associated with

nausea, vomiting, and abdominal pain and occasionally

Rapid-acting inhaled

2 -agonists.

liver toxicity. Methotrexate also causes gastrointestinal

symptoms, and on rare occasions hepatic and diffuse

Role in therapy- Rapid-acting inhaled-agonists are the

2

pulmonary parenchymal disease, and hematological and

medications of choice for relief of bronchospasm duri

teratogenic effects.

acute exacerbations of asthma and for the pretreatment

exercise-induced bronchoconstriction. They include

209

HFA

Allergen-specific immunotherapy.

salbutamol, terbutaline,REPRODUCE!fenoterol, levalbuterol,

reproterol, and pirbuterol. Formoterol, a long-acting-

2

agonist, is approved for symptom relief because of it

Role in therapy- The role of specific immunotherapy in

OR

adult asthma is limited. Appropriate immunotherapy rapid onset of action, but it should only be used for t

purpose in patients on regular controller therapy with

requires the identification and use of a single well-defined

inhaled glucocorticosteroids.

clinically relevant allergen. The later is administered in

progressively higher doses in order to induce tolerance.

112

Rapid-acting inhaled-agonists should be used only on

Cochrane review that examined 75 randomized controlled

ALTER

2

an as-needed basis at the lowest dose and frequency

trials of specific immunotherapy compared to placebo

required. Increased use, especially daily use, is a wa

confirmed the efficacy of this therapy in asthma in reducing

of deterioration of asthma control and indicates the ne

symptom scores and medication requirements, and improving

NOT

reassess treatment. Similarly, failure to achieve a qu

allergen-specific and non-specific airway hyperresponsiveness.

sustained response-agonistto treatment during an exacer-

Similar modest effects were identified in a systematic review of

2

196

DO

bation mandates medical attention, and may indicate the

need for short-term treatment with oral glucocorticoste

sublingual immunotherapy (SLIT). Specific immunotherapy-

has long-term clinical effects and the potential of preventing

the risk of adverse effectsMATERIALand the inconvenience of the

development of asthma in children with allergic rhinoSide effects- Use of oral -agonists given in standard

conjunctivitis up to 7 years after treatment208 . termination

2

doses are associated with more adverse systemic effe

such as tremor and tachycardia than occur with inhaled

However, in view of the relatively modest effect of

allergen-specific immunotherapy compared to other

preparations.

treatment options, these benefits must be weighed against

Systemic glucocorticosteroids.

prolonged course of injection therapy, including the

Role in therapy- Although systemic glucocorticosteroid

minimum half-hour wait required after each injection.

are not usually thought of as reliever medications, th

Specific immunotherapy should be considered only after

strict environmental avoidance and pharmacologic

important in the treatment of severe acute exacerbati

because they prevent progression of the asthma

intervention, including inhaled glucocorticosteroids, have

failed to control a patientis113ast.Thmaere are no studies

exacerbation, reduce the need for referral to emergency

departments and hospitalization, prevent early relapse

that compare specific immunotherapy with pharmacologic

after emergency treatment, and reduce the morbidity o

therapy for asthma. The value of immunotherapy using

multiple allergens does not have support.

illness. The main effects of systemic glucocortic

in acute asthma are only evident after 4 to 6 hours. Oral

COPYRIGHTED

therapy is preferred and is as effective as intraven

Side effects- Local and systemic side effects may occur in

114

hydrocortisone. A typical short course of oral gluco-

conjunction with specific immunotherapy administration.

115

corticosterods for an exacerbation is 40-50 mg

Reactions localized to the injection site may range from a