astm bronsic ghid expert panel

7/28/2019 Astm Bronsic Ghid Expert Panel

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National Heart, Lung and Blood

Institute

Expert Panel 3Guidelines for Diagnosis and

Management of Asthma


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Medications for asthma are categorized into two general classes:

KEY POINTS - Medication

1. long-term control medications used to achieve and maintaincontrol of persistent asthma

2. quick-relief medications used to treat acute symptoms and

exacerbations


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Immunomodulators:

Omalizumab (anti-IgE) is a monoclonal antibody that prevents binding of IgE to

the high-affinity receptors on basophils and mast cells.

Omalizumab is used as adjunctive therapy forpat ients >12 years o f age wh o

have allergies and severe persis tent asthm a (Eviden ce B). Clinicians who administer

omalizumab should be prepared and equipped to identify and treat anaphylaxis that may

occur.

Long-term control medications

(l is ted in alphabet ical order)

Corticosteroids:They are the most po tent and effect ive ant i-inf lamm atory medic at ion

current ly available (Evidence A).

Cromolyn sodium and nedocromil:

They are used as alternative, bu t not p referred, medication for the treatment of

mild persistent asthma (Evidence A).

They can also be used as preventive treatment prior to exercise or unavoidable

exposure to known allergens.


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Leukotriene modifiers:

Include LTRAs and a 5-lipoxygenase inhibitor. Two LTRAs are available

montelukast (for patients >1 year of age) and zafirlukast (for patients >7 years of

age). The 5-lipoxygenase pathway inhibitor zileuton is available for patients >12

years of age; liver function monitoring is essential.

LTRAs are alternative, bu t no t preferred, therapy f or the treatmen t of

m ild p ersistent asthma (Step 2 care) (Evidence A).

LTRAs can also be used as adjunctive therapy with ICSs, but for youths >12

years of age and adults they are not th e preferred adjun ct ive therapycompared to the addi t ion o f LABAs (Ev idence A).

Zileuton can be used as alternative but not preferred adjunctive therapy in

adults (Evidence D).


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LABAs:

LABAs are not to be used as mon otherapy for long -term co ntro l of asthma

(Eviden ce A).

LABAs are used in combination with ICSs for long-term control and prevention of

symptoms in moderate or severe persistent asthma (step 3 care or higher in children

>5 years of age and adults) (Evidence A for >12 years of age, Evidence B for 5-11 yearsof age).

Of the adjunctive therapies available, LABA is the preferred therapy to combine

with ICS in youths 12 years of age and adults (Evidence A).

In th e opinion of th e Expert Panel, the beneficial effects of LABA in

combination therapy for the great major i ty of pat ients who require mo re

therapy th an low-dose ICS alone to co ntrol asthm a



In the op inion of th e Expert Panel, the use of LABA for the treatment of acute

symptoms o r exacerbat ions is n ot current ly recommended (Ev idence D)


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Methylxanthines:

Sustained-release theophylline is a mild to moderate bronchodilatorused asalternative, no t preferred, adjun ctiv e therapy wit h ICS (Evidence A).

Theophylline may have mild anti-inflammatory effects.

Monitoring of serum theophylline concentration is essential.




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Quick-relief medications (listed in alphabetical order) Anticholinergics

Inhibit muscarinic cholinergic receptors and reduce intrinsic vagaltone of the airway. Ipratropium bromide provides additive benefit toSABA in moderate-to-severe asthma exacerbations. May be used asan alternat ive bronch od i lator for pat ients who do not tolerate SABA(Evid ence D).

SABAs

Albuterol, levalbuterol, and pirbuterol are bronchodilators that relaxsmooth muscle. Therapy of choice for relief of acute symptoms andprevention of EIB (Evidence A).

Systemic corticosteroids:

Although not short acting, oral systemic corticosteroids are used formoderate and severe exacerbations as adjunct to SABAs to speedrecovery and prevent recurrence of exacerbations (Evidence A).


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Safety of Inhaled Corticosteroids

KEY POINTS: SAFETY OF INHALED CORTICOSTEROIDS

ICSs are the most effective long-term therapy available formild, moderate, or severe persistent asthma; in general,ICSs are well tolerated and safe at the recommended

dosages (Evidence A).

The potential but small risk of adverse events from the useof ICS treatment is well balanced by their efficacy (Evidence

A).


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Inhaled Short-Acting Beta2-Agonists

The Expert Panel recommends that SABAs are the drugof choice for treating acute asthma symptoms and

exacerbations and for preventing EIB (Evidence A).

Quick-relief medications (listed in alphabetical order)


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Systemic Corticosteroids

The Expert Panel recommends the use of oralsystemic corticosteroids in moderate or severeexacerbations (Evidence A).

The Expert Panel recommends that multiple coursesof oral systemic corticosteroids, especially morethan three courses per year, should prompt areevaluation of the asthma management plan for apatient (Evidence C).

Quick-relief medications (listed in alphabetical order)


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Complementary and Alternative Medicine

KEY POINTS: COMPLEMENTARY AND ALTERNATIVE MEDICINE

It is recommended that the clinician ask patients about allmedications and treatments they are using for asthma and advisethe patients that complementary and alternative medicines andtreatments are not a substitute for the clinicians recommendationsfor asthma treatment (Evidence D).

Evidence is insufficient to recommend or not recommend mostcomplementary and alternative medicines or treatments.

Acupuncture is not recommended for the treatment of asthma

(Evidence B).

Patients who use herbal treatments for asthma should be cautionedthat there is the potential for harmful ingredients in herbal treatmentsand for interactions with recommended asthma medications(Evidence D).

astm bronsic ghid expert panel

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