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04/Jul/2022

Do asthma drugs affect pregnancy Asthma control may alter during pregnancy, so it’s important to keep an eye on it.

1/3 – same, 1/3 – deteriorate, 1/3 – improve

Risk to a fetus is more in poorly controlled asthma as compared to the risk of medications. Inhaled glucocorticoids, theophylline, beta-2 agonists, and leukotriene inhibitors are not associated with any fetal anomalies.

Do Asthma Drugs Affect Pregnancy | Can Heartburn be Worse Than Asthma?

Yes in many studies it has been shown that heartburn worsens asthma and proton pump inhibitors have been shown to improve asthma control. In severe GERD, surgery may also be need to control asthma symptoms. However, routine use of PPI in asymptomatic GERD in asthmatics is not of any benefit.

What is difficult asthma?

It was in 1998 that Peter Barnes gave the concept of difficult asthma. Most asthmatics are control with ICS. But 5% are not control. Now BTS & GINA have also defined difficult asthma.

Asthma symptoms not controlled by step 4 medications (reliever + 2 or more controllers)

  1. Recheck diagnosis of asthma
  2. Adherence
  3. Smoking history – present or past
  4. Co-morbidities – GERD, sinusitis, obesity, sleep apnea

 

What is steroid-resistant asthma?

Glucocorticoids (GCs) have potent anti-inflammatory actions and are the most effective agents in the treatment of asthma. Asthmatics have 2 spectrums of disease steroid-responsive at one end and steroid-resistant at the other end. Patients with chronic asthma who are unresponsive to high doses of GCs and are without confounding factors have been termed GC-resistant.

There is no known treatment for glucocorticoid-resistant asthma. Treatment strategies include the use of higher doses of systemic glucocorticoids for a longer duration, nonglucocorticoid agents (eg, beta-adrenergic agonists, anticholinergic agents, anti leukotriene agents, omalizumab, cromolyn) and nonpharmacologic therapies (eg, trigger avoidance, bronchial thermoplasty). Small clinical trials of anti-interleukin (IL)-5 and anti-IL-13 have showed some benefit in GC-resistant asthma patients, but many of these innovative medicines require additional evidence of clinically relevant effects.

What are allergy shots?

Allergy shots are another name for immunotherapy. Subcutaneous or sublingual administration is possible. The ideal patient for IT should be more than 5 yr, with mild to moderate disease, few dominant allergens, seasonal exacerbations, patients on daily prophylactic medicines (wants to take less), and improved QOL. Not appropriate <5yr, >60 yr, h/o anaphylaxis, lack of availability of well-tested allergens.

Long-term effects of IT persist even after IT is discontinue.

SLIT: less effective than SCIT,

Safer but not totally

Shown effective as monotherapy

Dosing issues persist

Not shown to be effective in a mixture of antigens

Not yet approved in our country

Is asthma a lifelong problem or can it be cured?

There are 2 types of asthma. Half of the children who develop asthma in childhood outgrow their symptoms when they reach the age of 14-15 y. However, they may develop symptoms in later life when exposed to heavy trigger factors.

Your message for an asthmatic?

Asthma is a controllable disease and you can lead a trouble-free life with 2 Asthma Treatment strategies. 

1. KEEP PRECAUTIONS OF TRIGGER AVOIDANCE 

2. TAKE YOUR MEDICINES REGULARLY

Intrinsic (non-atopic) asthma and extrinsic (atopic) asthma)

There is no clinical or serological evidence of IgE-mediated allergy to common environmental stimuli in intrinsic asthma. When compared to controls, bronchial biopsies from such patients demonstrate increased expression of Th2-type cytokines, CC chemokines, and I/C, similar to extrinsic asthma. These data show that in this key clinically different type of the disease, there may be local IgE production directed against unknown antigens, presumably of viral origin or even autoantigens.


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04/Jul/2022

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


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04/Jul/2022

Many cells and cellular factors play a part in this chronic inflammatory condition of the airway. Chronic inflammation is associated with airway hyperresponsiveness which is responsible for chest tightness, wheezing, and coughing, particularly at night or in the early morning. What is asthma, These article are associated with widespread but variable airway obstruction within the lung that is often reversible either spontaneously or with treatment.

What is asthma? How is asthma diagnosed?

Symptomatic asthma – PFT, Asymptomatic – provocation challenge test Symptoms: episodic breathlessness, chest tightness, wheezing, cough – incited with allergen exposure, seasonal variation. There is a family history of asthma and allergy. History of variability in symptoms. Physical examination – wheezing may be present, silent chest in severe asthma

Lung functions – FEV1, FVC, PEFR

PEFR – 1. Confirm diagnosis of asthma (>20% or >60l/min improvement post-bronchodilator or diurnal) 2. For monitoring and control

Methacholine challenge test/ histamine challenge test/ mannitol/exercise challenge test (sensitive test – negative test rules out asthma, false-positive – allergic rhinitis, CF, bronchiectasis, COPD)

Sputum eosinophilia, Feno

Total Ig E – not diagnostic of atopy

SPT – low cost and high sensitivity through false positive is high

Rule out DD –

FOREIGN BODY INHALATION

VOCAL CORD DYSFUNCTION

LVF

COPD

CF/BRONCHIECTASIS

How do u assess the severity

 Controlled
(ALL MEASURES)
Partly controlled
(1-2)
Uncontrolled
Daytime symptoms<2 /week3 OR MORE
Limitation of activityNone
Nocturnal awakeningNone
Need for reliever<2 /week
FEV1N<80%

Assessment of future risk –

  1. Poor control of symptoms
  2. Frequent exacerbations
  3. ICU admissions
  4. Low FEV1
  5. Cigarette smoke exposure
  6. High dose medications

 

Old classification of patients – intermittent, mild persistent, moderate persistent, severe persistent

It is not only the severity of symptoms but its responsiveness to treatment.

What is an asthma attack?

Many patients have stable disease and they are relatively free of symptoms. But whenever they come across trigger factors they develop an increase in their symptoms.

Asthma attack comprises the episode of progressive increase in breathlessness, cough, chest tightness, and wheezing. Treatment comprises repeated doses of rapid-acting bronchodilators, systemic steroids, and oxygen if required. Milder exacerbations can be treated in community settings

What causes these symptoms?

Asthma is an inflammatory disease with the involvement of airway cells (like mast cells, eosinophils, t lymphocytes, and dendritic cells) and structural cells (airway epithelial, endothelial cells, smooth muscle cells). Chemokines, cysteinyl leukotrienes, cytokines, histamine, and NO are mediators that act on these cells.

Airway narrowing is caused due to – smooth muscle contraction, airway edema, mucus hypersecretion, airway remodeling.

What signs tells a person that asthma is worsening ?

1. Breathlessness

2. Talks in 

3. Alertness

4. Wheeze

5. Respiratory rate

6. Accessory muscles of respiration

7. Pulse

8. Pulsus paradoxus

9. PEFR

10. SpO2

11. PaO2

12. PaCO2


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