Asthma: Medication and Follow-up

00:01 Okay, let's focus on medications now.

00:04 What is the right medication for the right class of patient? For mild intermittent asthma, that is in patients who experience symptoms less than twice per month, a low dose combination of inhaled corticosteroids with formoterol is recommended.

00:18 Another option is to use low dose inhaled corticosteroids, whenever short-acting beta-agonists are used.

00:24 It is no longer recommended to use short-acting beta-agonists on their own.

00:29 This step is called anti-inflammatory reliever therapy.

00:32 Moving on to persistent asthma you need to initiate controller therapy, not just rely on reliever therapy.

00:39 For mild persistent asthma, which means the patient experiences symptoms twice a month or more but less than daily.

00:45 The recommended treatment is a daily low dose of inhaled corticosteroids.

00:49 Alternatives include a daily leukotriene receptor antagonists, such as montelukast or anti-inflammatory reliever therapy.

00:57 If patients experience symptoms most days or wake at night with asthma symptoms once a week or more, their condition is classified as moderate asthma.

01:06 For moderate asthma, we start combining medications.

01:09 The recommended treatment is a daily combination of a low to medium dose of inhaled corticosteroids plus a long-acting beta-agonist.

01:18 Alternatives include a medium to high dose of just corticosteroids or low dose steroids plus a leukotriene antagonist.

01:26 Finally, if the patient is experiencing severely uncontrolled asthma with symptoms every day and night time awakenings most nights.

01:34 For the combination of corticosteroids and a long-acting beta-agonist, the dosage needs to be raised from medium to high, add-on therapies can also be considered such as tiotropium, anti-lgE, anti-igE, anti-IL5/5R and anti-IL4R.

01:52 Alternatives include adding a low dose of oral corticosteroids.

01:56 However, you should take into account the possible side effects such as osteoporosis, glaucoma, edema, and hypertension.

02:05 Tiotropium was approved now for the management of asthma in patients who are at least 12 years old.

02:11 It's the first long-acting anti-muscarinic for asthma specifically.

02:15 It's held a approval for COPD for longer.

02:20 And in clinical trials, when added to patients already on an inhaled corticosteroid.

02:26 Tiotropium is associated with better FEV1 from baseline.

02:31 And it improved FEV1 more than sound meter.

02:34 So there is another treatment option available for patients with atleast moderate persistent asthma.

02:44 And it just a quick mention that long-acting beta-agonist should never be used alone in patients with asthma because in one trial they were associated with a higher risk of death.

02:54 But it is safe to combine them with a corticosteroid again, that's a foundational drug, so it should be automatic.

03:01 Now your PCPs like me can be helpful in managing other conditions that are associated with worse asthma outcomes and more exacerbations.

03:11 So what else can make asthma worse? GERD can (Gastroesophageal Reflux Disease), obesity can, obstructive sleep apnea certainly can, rhinitis very common at least 30% of patients with asthma also have allergic rhinitis.

03:25 Stress can make it worse as well as depression.

03:27 So, if you have a patient who's on heavy medical therapy for asthma and doing what they can for avoidance of triggers.

03:36 And yet they're not doing as well as they should.

03:38 Think about some of these other illnesses and try to you know, try to bring those under control in might have the side benefit of improving asthma.

03:48 All right, and now let's talk about follow-up for these patients.

03:51 So really it has to be close follow-up until the patient achieves control.

03:55 And like I said, it's not so important that what category of asthma they were diagnosed with initially.

04:01 Once they initiate on treatment, is this the enough to control them, in their day-to-day night tonight symptoms? And do we need to increase it? It can let go of what category they're in.

04:15 So watching for triggers and assessing that mere dose inhaler technique.

04:22 Patients get very confused particular when you start adding on inhalers, you're not necessarily covering their older inhalers versus are newer ones.

04:30 And which ones are for what and how you take them? That's why I teach back with patients showing you the inhaler.

04:36 How often they use it and then how to use it is really important.

04:40 Adjust medications at every visit, can be every two weeks.

04:44 And you want an asthma action plan to exacerbation is happening, start with your short-acting beta-agonists.

04:51 I give my patients rescue dose of prednisone at home because it can prevent them coming in the emergency department in extreme exacerbation.

04:59 If I can treat at home all the better, but that said I don't want them using prednisone all the time due the side effects.

05:06 And those treatments can be tied to their peak flows and their daily symptoms.

05:13 All right, so with that what we learned about today was a little bit about the epidemiology and the classification of asthma very important for test-taking purposes.

05:22 Important for that initial consult with the patient, but then after that it really becomes just managing the medications right and not forgetting about the basics like using the MDI appropriately and avoiding avoiding triggers and allergens.

05:36 Hope it's helpful, take care.