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.