Best strategy to treat asthma

There are 4 components of asthma –

1. Develop a patient-doctor partnership
2. Identify risk factors and reduce exposure
3. Assess, treat and monitor disease
4. Manage exacerbations

The goal of management – improve control & reduce risk – NAEPP guidelines 2007

Recurrent exacerbations and the requirement for emergency room or hospital care can be avoided.

●Reduced lung growth in children and loss of lung function in adults can be avoided.

●Pharmacotherapy optimization with few or no side effects

What is the best strategy to treat asthma?

Best strategy to treat asthma inhaled corticosteroids such as beclometasone are the drugs of choice for the long-term treatment of patients with persistent asthma. Although there is no discernible difference in efficacy among inhaled corticosteroids, beclometasone is the one with which we have the most expertise. Ciclesonide (Alvesco, Nycomed then Takeda), another inhaled corticosteroid, has been tested in three double-blind trials versus budesonide and six trials versus fluticasone but none versus beclometasone. These tests revealed the “non-inferiority” of ciclesonide, especially in terms of a surrogate endpoint: the difference in compelled expiratory volume in one second (FEV1) after 12 or 24 weeks of treatment (primary endpoint). 

Which inhaled steroid do you prefer, and why?

However, the doses of ciclesonide used in these trials were higher than the standard doses while doses of the comparator corticosteroids were lower than the standard doses, thus favoring ciclesonide. Local negative effects of inhaled corticosteroids include oral candidiasis, sore throat, and hoarseness.  Best strategy to treat asthma a routine review guided by a Cochrane group recommends that ciclesonide does not have a better adverse effect profile than other inhaled corticosteroids used at equivalent doses. Corticosteroid inhalation can also show systemic absorption. The practical benefit of once-daily dosing with ciclesonide appears minor. In practice, ciclesonide is neither more useful than the inhaled corticosteroids with which it has been compared nor does it have fewer negative effects. It is better to continue to use beclometasone, a medicine with which there is more experience.

What is an optimal dose for starting ICS

Treatment naïve patient – step 2

Already on treatment – step 3

Daily v/s intermittent dosing of ICS, which is better?

Daily ICS was only periodic ICS in several indicators of lung function, airway inflammation, asthma control, and reliever use. Both treatments seemed safe, but a fair growth suppression was associated with daily, compared to intermittent, inhaled budesonide and beclomethasone. The clinician should carefully consider the possible benefits and injury of each therapy option, taking into account the unknown long-term (> one year) effect of intermittent treatment on lung growth and lung function decline.

What are the advantages of adding LABA to ICS?

Bronchodilator action of LABA provides immediate relief, and ICS sustained relief improves control, reduces symptoms, Best strategy to treat asthma daytime as well as nocturnal, improves lung functions, reduces the risk of exacerbations, hospitalization we use formoterol + budesonide it acts as a controller as well as reliever medicine, also used in exercise-induced asthma

Can LABA monotherapy be used?

LABA should not be used as monotherapy because they are only bronchodilators with no anti-inflammatory effects. Monotherapy is associated with an increased risk of exacerbation and mortality. When used as add they are superior to LTRA and theo. They reduce symptoms, improve control, and use of SABA, and reduce exacerbations and nocturnal symptoms. Only a fixed-dose combination with ICS is to be used (which improves adherence and reduces the risk of monotherapy).

What is the role of LTRA in asthma as monotherapy, as add on

LTRA has a mild bronchodilator and anti-inflammatory effects. They may be used as monotherapy in mild asthma and aspirin-sensitive asthma. However, they are inferior to ICS and cannot replace ICS as monotherapy.

As added on they may reduce the dose of ICS needed to achieve control and improve control. However, they are inferior to LABA.

What is the role of theophylline as monotherapy, as an add-on?

Data on monotherapy are lacking. An add it improves control when control is lacking with ICS alone. However, it is inferior to LABA. In some patients on ICS + THEO, withdrawal of theo leads to deterioration of control. Usage of lower dosage has a full anti-inflammatory effect, with fewer adverse effects and blood level monitoring is not required.

Is doxycycline better than dyphylline?

It is a debatable issue. Various clinical trials have been done some supporting and others not supporting. However, meta-analysis has so far not found the superiority of doxo over deri in terms of safety and efficacy profile.

What are the benefits of using LAMA in the management of asthma?

Newer ATS/ERS guidelines published in April 2014 suggest the addition of LAMA to ICS and LABA 1. Improve FEV1 2. Reduce the use of SABA 3. Reduce the risk of exacerbation. No studies on children, so not to be used on children