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Asthma: Medication and Follow-up

by Charles Vega, MD
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    00:02 Okay. Let's focus on medications now.

    00:04 What is the right medication for the right class of patient? So, for intermittent asthma, mild intermittent, only a short-acting beta agonist is necessary.

    00:15 And it’s also first-line treatment for exercise-induced asthma.

    00:20 Whereas once you hit the persistent category, the key is initiate a controller therapy.

    00:26 Inhaled corticosteroids do have some systemic absorption, and so, therefore, I try to use a low dose if it's a mild case of asthma.

    00:36 Start at the lowest dose that's tolerated and then move up from there as needed based on their symptomatology.

    00:42 More severe symptoms, higher dose of inhaled corticosteroid, or ICS.

    00:47 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.

    01:09 Once they hit severe persistent range, now we are talking about a high-dose ICS with a LABA or a montelukast.

    01:16 And unfortunately, these cases may require oral steroids as well at a low dose.

    01:22 And anyone who needs oral steroids, this is a rare phenomenon.

    01:26 It has to be very severe asthma.

    01:28 One, look hard at their triggers and the allergens.

    01:31 Make sure that they're doing everything that they can with lifestyle to be well and also refer them.

    01:37 They are going to pulmonary medicine follow-up.

    01:40 Tiotropium was approved now for the management of asthma in patients who are at least 12 years old.

    01:47 It’s the first long-acting anti-muscarinic for asthma specifically.

    01:50 It’s held an approval for COPD for longer.

    01:55 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.

    02:09 So, there is another treatment option available for patients with at least moderate persistent asthma.

    02:19 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.

    02:31 Again, that's a foundational drug.

    02:33 So, it should be automatic.

    02:37 Now, your PCPs, like me, can be helpful in managing other conditions that are associated with worse asthma outcomes and more exacerbation.

    02:46 So, what else can make asthma worse? GERD can.

    02:49 Gastroesophageal reflux disease.

    02:52 Obesity can.

    02:53 Obstructive sleep apnea certainly can.

    02:55 Rhinitis, very common.

    02:57 At least 30% of patients with asthma also have allergic rhinitis.

    03:00 Stress can make it worse as well as depression.

    03:03 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.

    03:17 It might have the side benefit of improving asthma.

    03:23 All right. And now, let’s talk about follow-up for these patients.

    03:26 So, really, it has be close follow-up until the patient achieves control.

    03:30 And like I said, it's not so important that what category of asthma they’re diagnosed with initially.

    03:36 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.

    03:50 So, watching for triggers and assessing that – the metered-dose inhaler technique.

    03:56 Patients get very confused, particularly when you start adding on inhalers.

    04:01 You're not necessarily covering their older inhalers versus their newer ones and which ones are for what and how you take them.

    04:07 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.

    04:15 Adjust medications at every visit can be every two weeks and you want an asthma action plan too.

    04:22 Exacerbation is happening, start with your short-acting beta agonist.

    04:26 I give my patients a rescue dose of prednisone at home because it can prevent them coming to the emergency department in extreme exacerbation.

    04:35 If I can treat at home, all the better.

    04:37 But that said, I don't want them using prednisone all the time due to the side effects.

    04:41 And that can – and these – those treatments can be tied to their peak flows and their daily symptoms.

    04:49 All right. So with that, what we learned about today was a little bit about the epidemiology and the classification of asthma.

    04:55 Very important for test taking purposes.

    04:58 Important for that initial consult with the patient.

    05:01 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.

    05:12 Hope it's helpful. Take care.


    About the Lecture

    The lecture Asthma: Medication and Follow-up by Charles Vega, MD is from the course Chronic Care.


    Included Quiz Questions

    1. Manage seasonal allergies, including identifying and avoiding triggers.
    2. Switch the short acting beta agonist for a long acting beta agonist.
    3. Start a high dose inhaled corticosteroid in addition to the short acting beta agonist, and taper the corticosteroid as symptoms are controlled.
    4. Start a daily antihistamine and an oral prednisone taper over 5 days until the full effects of antihistamine treatment are established.
    5. Start a low dose inhaled corticosteroid plus a long acting beta agonist, and instruct to use the short acting beta agonist for rescue only.
    1. Cat allergies and gastroesophageal reflux disease.
    2. Anxiety and allergies.
    3. Weight gain and anxiety.
    4. Seasonal allergies.
    5. Gastroesophageal reflux disease and obstructive sleep apnea.
    1. Rheumatic arthritis
    2. Gastroesophageal reflux disease
    3. Obesity
    4. Obstructive sleep apnea
    5. Depression
    1. In addition to the inhaled corticosteroid, start a long acting beta agonist, and follow up in 2 weeks to check for adequate control.
    2. Discontinue the inhaled corticosteroid and start a long acting beta agonist and montelukast instead, and follow up in 6 weeks to check for adequate control.
    3. Start tiotropium and follow up in 3 months to check for any need of medication adjustment.
    4. Start a high dose inhaled corticosteroid and montelukast and follow up in 4 weeks.
    5. Prescribe an as needed rescue prednisone taper to help avoid unneccessary hospitalizations in case symptoms worsen.

    Author of lecture Asthma: Medication and Follow-up

     Charles Vega, MD

    Charles Vega, MD


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