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Asthma
Table 2: Stepwise Management of Asthma
Adults and Children >12 Years of Age Children 5–12 Years of Age Children <5 Years of Age
Step 1: Mild intermittent asthma ’as required’ reliever therapy
Inhaled SABA as required Inhaled SABA as required Inhaled SABA as required
Step 2: Regular controller therapy
Add inhaled steroid 200–800µg/day* Add inhaled steroid 200–400µg/day* Add inhaled steroid 200–400µg/day* or
LTRA if inhaled steroid cannot be used
Step 3: Add-on therapies
Add inhaled LABA: Add inhaled LABA: In children 2–5 years of age,
• If good response, continue • If good response, continue consider addition of LTRA
• If partial but inadequate response, continue LABA and • If partial but inadequate response, continue LABA and In children <2 years of age,
increase inhaled steroids up to 800µg/day* increase inhaled steroids up to 400µg/day* consider proceeding to step 4
• If no response, stop LABA, increase inhaled steroids and • If no response, stop LABA, increase inhaled steroids and
consider other therapies such LTRA, SR theophylline consider other therapies such LTRA, SR theophylline
Step 4: Persistent poor control
Increase inhaled steroid up to 2,000µg/day* Increase inhaled steroid up to 800µg/day* Increase inhaled steroid up to 800µg/day*
Consider adding additional drug such as LTRA, Refer for specialist paediatric asthma care
SR theophylline
Step 5: Continuous oral steroids
Daily steroid tablets, maintain high-dosage inhaled Daily steroid tablets, maintain high-dosage inhaled Refer for specialist paediatric asthma care
steroids, refer for specialist care steroids, refer for specialist paediatric asthma care
SABA = short-acting β2-agonist; LABA = long-acting β2-agonist; LTRA = leukotriene receptor antagonist; SR = slow release.
*Refers to beclometasone or budesonide; equivalent dosages for fluticasone and mometasone should be halved since, clinically, these are twice as potent.
Leukotrienes are potent bronchoconstrictors and increase shown to be effective should be continued.
7,8
Patients should be
bronchial inflammation. The leukotriene receptor antagonists monitored (and treated if practical) for the development of:
montelukast and zafirlukast improve lung function and symptoms,
reduce disease exacerbation and spare inhaled corticosteroid • hypertension;
therapy.
5,6
However, response to these drugs is less predictable • diabetes;
between individuals. While not recommended as first-line add-on • osteoporosis (see guidelines of the British Osteoporosis Society,
therapy at step three, they may produce additional benefit (which www.nos.org.uk); and
should be sought objectively). They also ameliorate allergic rhinitis. • poor growth and cataracts (in children).
They are a possible substitute for controller therapy in children
below five years of age in whom it is impossible for whatever Immunosuppressive agents (methotrexate, ciclosporin and gold salts)
reason to use inhaled corticosteroids, which otherwise should have been shown to spare oral corticosteroid therapy in a minority of
always be used as first-line therapy. severe asthmatics at step five, but their effects are unpredictable and
do not persist beyond the duration of therapy.
9
They may have serious
Theophyllines are weak relaxers of bronchial smooth muscle and unwanted effects and their use must be tailored for individual
also inhibit inflammatory cells. Dosages must be individualised and patients. Omalizumab is a humanised anti–immunoglobulin E (anti-
monitored (this is often neglected in clinical practice, but essential IgE) monoclonal antibody that prevents IgE binding to its receptors on
to prevent overdosage). Addition of the inhaled anticholinergics mast cells and other immune cells. Its principal benefit is to reduce
cromoglicate and nedocromil at this stage rarely confers more than severe asthma exacerbations in unstable patients at steps four and
marginal additional benefit. five of therapy.
10
As a result of its presumed ‘anti-allergic’ action it is
currently reserved for atopic patients above 12 years of age. It must
Step Four be given by subcutaneous injection every two or four weeks in a
Few studies inform as to the best course of treatment beyond step hospital outpatient or daycare setting. Patients must be monitored
three. Options include increasing inhaled corticosteroid up to closely with spirometry and symptom diaries for the first 16 weeks of
2,000µg per day in adults or 800µg per day in children therapy to identify those patients (some 30%) who show no response,
(beclometasone equivalent) while maintaining therapy with a long- in which case treatment is discontinued. Treatment in responders is
acting β-agonist, and/or adding a leukotriene receptor antagonist, potentially life-long.
oral theophylline or oral slow-release β-agonist. Inhaled
corticosteroid dosages should not be increased over these limits: The BTS/SIGN guidelines emphasise the possible role of psychosocial
this has led to adrenal crisis on rapid withdrawal in children. Other morbidity in chronic severe asthma. Self-management of asthma may
corticosteroid systemic effects (see step five) are possible at these be neglected in the mentally ill or those living in poor social
high dosages. Drugs should be tried one at a time, while monitoring circumstances. Symptoms may be exacerbated by stress and anxiety,
efficacy, and discontinued if not objectively effective. and are occasionally used as a means of manipulating peers and
relatives. Some patients become psychologically as well as
Step Five physiologically dependent on medications, particularly oral
If patients are deemed to require oral corticosteroids long-term, corticosteroids. Management in such cases is difficult and,
maximal dosages of inhaled steroids and other add-on therapy if unfortunately, not well covered in guidelines.
22 EUROPEAN RESPIRATORY DISEASE
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