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Stepwise approach to treatment and how it helps guide therapy.

Stepwise approach to treatment and how it helps guide therapy

• Reflect on drugs used to treat asthmatic patients, including long-term control and quick-relief treatment options for patients. Think about the impact these drugs might have on patients, including adults and children.
• Consider how you might apply the stepwise approach to address the health needs of a patient in your practice.
• Reflect on how stepwise management assists health care providers and patients in gaining and maintaining control of the disease.

Create a 6-slide PowerPoint presentation that can be used in a staff development meeting on presenting different approaches for implementing the stepwise approach for asthma treatment. Be sure to address the following:
• Describe long-term control and quick-relief treatment options for the asthma patient from your practice as well as the impact these drugs might have on your patient.
• Explain the stepwise approach to asthma treatment and management for your patient.
• Explain how stepwise management assists health care providers and patients in gaining and maintaining control of the disease. Be specific.


The benefit of the EPR-3 is it is proof-based. Each article reviewed for inclusion in the EPR-3 was graded for quality of evidence. I have alluded to the level of evidence in the body of this article, so I will give readers a brief idea of what is meant by quality of evidence. Evidence A means that the conclusion/recommendation was reached based on substantial numbers of randomized clinical trials with a substantial number of participants. Evidence B means that the conclusion/recommendation was based on fewer studies, with fewer participants. Evidence C conclusions/recommendations are based on nonrandomized trials and observational studies. Finally, evidence D means that the conclusion/recommendation was based on panel consensus judgment. So in the EPR-3, many of the conclusions/recommendations are based on evidence obtained from randomized clinical trials with many participants, meaning that these statements carry substantial support from within the research community.

As soon as a diagnosis of asthma is produced, its severity is labeled. Classification of the severity of asthma is based on two domains: impairment and risk, as seen in Figure 1. Impairment encompasses the review of symptoms the patient is currently experiencing, frequency of short-acting beta2 agonist (SABA) use, the results of spirometry (forced expiratory volume in 1 second, FEV1) and forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC)), number of nighttime awakenings, and the degree of limitation of daily activities. Risk is defined as the risk for future exacerbations of asthma, based on the number of asthma attacks/flares and the need for bursts of systemic corticosteroids. Symptoms usually included in the assessment of impairment are frequency of cough, wheeze, shortness of breath, and chest tightness.

The severity of asthma attack corresponds to probably the most frequently developing symptom or most detrimental analysis finding. For example, if a patient has daily symptoms, awakens nightly, uses SABA daily, has some limitation, and a near normal FEV1, the patient’s asthma would be classified as severe persistent (Figure 1). There is a similar chart used to classify asthma in children 5 to 11 and 0 to 4 years of age. Spirometry is introduced in the 5 to 11 years of age population, as children younger than age 5 are often not good candidates for spirometry. So the first step in caring for a patient with asthma beyond diagnosis is classification of severity. There are four levels of severity: intermittent asthma and persistent asthma split into three categories: mild, moderate, and severe, based on the symptoms and problems described above.

Before speaking about the techniques of therapy, it will be necessary to explore asthma prescription drugs. All patients with asthma, regardless of severity, need to have a rescue inhaler, which is a SABA: albuterol (ProAir, Proventil, or Ventolin), levalbuterol (Xopenex), or pirbuterol (Maxair). A SABA is used for quick relief of sudden symptoms or for the prevention of exercise-induced bronchospasm, taken 15 to 30 minutes before exercise. Patients with intermittent asthma need only a SABA. All patients with persistent asthma need an anti-inflammatory drug, since that is the nature of asthma. Most commonly, inhaled corticosteroids (ICS) are the anti-inflammatory drugs of choice, since they reduce the inflammation caused by a wide spectrum of inflammatory mediators (TNF, cytokines, histamines, etc) released from a variety of proinflammatory cells (mast cells, eosinophils, epithelial cells, etc). Inhaled corticosteroids are recommended, since they are effective and avoid the severe side effects of systemic corticosteroids. Inhaled corticosteroids include beclomethasone (Qvar), budesonide (Pulmicort), flunisolide (Aerobid), fluticasone (Flovent), mometasone (Asmanex), and triamcinolone (Azmacort). Usual dosages are found in EPR-3. Less frequently used anti-inflammatory drugs are the nonsteroidal preparations: sodium cromolyn (Intal) and nedocromil (Tilade).

Modest and significant persistent asthma attack are frequently treated with a mixture of an ICS and a lengthy-performing beta adrenergic (LABA). The two common LABAs are formoterol (Foradil) and salmeterol (Serevent). LABAs are inhaled twice daily, along with their ICS counterpart. Recently, the safety of LABAs was questioned. The EPR-3 and others have reviewed the use of LABAs and concluded that they are used as an adjunct to ICS for providing long-term control of symptoms (evidence A); LABAs are not recommended as monotherapy for asthma (evidence A), LABAs are not recommended for treating acute symptoms or exacerbations of asthma (evidence D), and LABAs may be used prior to exercise for prophylaxis of exercise-induced bronchospasm. A discussion of the safety of LABAs is found in the EPR-3 on pages 231-234. There are two combination ICS/LABA products: fluticasone + salmeterol (Advair) available as a dry powder inhaler (DPI) and hydrofluoroalkane (HFA) MDI, and formoterol + budesonide (Symbicort) available as an HFA inhaler.

Another category of drugs is definitely the leukotriene receptor antagonists (LTRAs). These drugs act to block the binding of leukotrienes to proinflammatory cells in the airways. The most frequently used drug in this category is montelukast (Singulair), which seems to be most effective in allergic asthma. Finally, the newest category of drugs is the immunomodulator. The drug omalizumab (Xolair) prevents the binding of IgE to its receptor, thereby inhibiting the IgE-mediated asthma cascade before it begins. Omalizumab is a subcutaneously injected drug, administered once or twice a month. The dose is