Okay. Let's focus on medications now.
What is the right medication
for the right class of patient?
So, for intermittent asthma,
only a short-acting beta agonist is necessary.
And it’s also first-line treatment
for exercise-induced asthma.
Whereas once you hit
the persistent category,
the key is initiate a controller therapy.
do have some systemic absorption,
and so, therefore, I try to use a
low dose if it's a mild case of asthma.
Start at the lowest dose that's tolerated
and then move up from there as needed
based on their symptomatology.
More severe symptoms, higher dose
of inhaled corticosteroid, or ICS.
Once they hit the moderate persistent category,
it’s time to consider adding another agent,
such as a long-acting beta agonist,
which is something I prefer
or a drug like montelukast can also be helpful
in addition to their medium dose ICS,
which is – again,
ICS is a mainstay of therapy for persistent asthma.
Once they hit severe persistent range,
now we are talking about a high-dose
ICS with a LABA or a montelukast.
these cases may require oral
steroids as well at a low dose.
And anyone who needs oral steroids,
this is a rare phenomenon.
It has to be very severe asthma.
One, look hard at their triggers and the allergens.
Make sure that they're doing
everything that they can with lifestyle
to be well and also refer them.
They are going to pulmonary medicine follow-up.
Tiotropium was approved now for
the management of asthma
in patients who are at least 12 years old.
It’s the first long-acting anti-muscarinic
for asthma specifically.
It’s held an approval for COPD for longer.
And in clinical trials,
when added patients are already
on an inhaled corticosteroid,
tiotropium is associated with better FEV1 from baseline
and it improved FEV1 more than salmeterol.
So, there is another treatment option available
for patients with at least moderate persistent asthma.
And just a quick mention that
long-acting beta agonists should
never be used alone
in patients with asthma because in one trial they
were associated with a higher risk of death,
but it is safe to combine them with a corticosteroid.
Again, that's a foundational drug.
So, it should be automatic.
Now, your PCPs, like me,
can be helpful in managing other conditions
that are associated with worse asthma
outcomes and more exacerbation.
So, what else can make asthma worse?
Gastroesophageal reflux disease.
Obstructive sleep apnea certainly can.
Rhinitis, very common.
At least 30% of patients with asthma
also have allergic rhinitis.
Stress can make it worse as well as depression.
So, if you have a patient who's on
heavy medical therapy for asthma and doing
what they can for avoidance of triggers,
and yet they're not doing as well as they should,
think about some of these other illnesses
and try to bring those under control.
It might have the side benefit of improving asthma.
All right. And now, let’s talk about
follow-up for these patients.
So, really, it has be close follow-up
until the patient achieves control.
And like I said, it's not so important that what
category of asthma they’re diagnosed with initially.
Once they’re initiated on treatment,
is this enough to control them
in their day-to-day, night-to-night symptoms
and do we need to increase it?
You can let go of what category they're in.
So, watching for triggers and assessing
that – the metered-dose inhaler technique.
Patients get very confused,
particularly when you start adding on inhalers.
You're not necessarily covering their
older inhalers versus their newer ones
and which ones are for what
and how you take them.
That's why a teach back with patients showing you the inhaler,
how often they use it and then
how to use it is really important.
Adjust medications at every
visit can be every two weeks
and you want an asthma action plan too.
Exacerbation is happening,
start with your short-acting beta agonist.
I give my patients a rescue dose of
prednisone at home because it can prevent
them coming to the emergency
department in extreme exacerbation.
If I can treat at home, all the better.
But that said, I don't want them using
prednisone all the time due to the side effects.
And that can – and these – those
treatments can be tied to their
peak flows and their daily symptoms.
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.
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 triggers and allergens.
Hope it's helpful. Take care.