Asthma: Difference between revisions

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imported>Robert Badgett
imported>Howard C. Berkowitz
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===Chronic treatment===
===Chronic treatment===
====Drug therapy====
====Drug therapy====
=====Beta-adrenergic agonists=====
These drugs may be administered by [[inhaler]], [[nebulizer]], or oral and parenteral forms.


Short acting [[beta-agonist]] inhalers are the initial treatment. In order to comply with ozone protection, these medicines must not use chlorofluorocarbons (CFC) for a chlorofluorocarbon by January 1, 2009.<ref name="urlInformation on the Elimination of Chlorofluorocarbon-containing (CFC) Albuterol MDIs and Other Ozone-Depleting Drug Products">{{cite web |url=http://www.fda.gov/cder/mdi/albuterol.htm |title=Information on the Elimination of Chlorofluorocarbon-containing (CFC) Albuterol MDIs and Other Ozone-Depleting Drug Products |author=Anonymous |authorlink= |coauthors= |date=2008 |format= |work= |publisher=Food and Drug Administration |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="New York Times">{{cite web |url=http://www.nytimes.com/2008/05/13/health/13asth.html |title=Rough Transition to a New Asthma Inhaler |author=Tarkan L |authorlink= |coauthors= |date=May 13, 2008 |format= |work= |publisher=New York Times |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=2008-05-13}}</ref> Inhalers using hydrofluoroalkane (HFA) propellants are CFC-free. The HFA based inhalers are brand name and more expensive. They are Ventolin by GlaxoSmithKline, ProAir by Ivax, Proventil by Schering-Plough and Xopenex by Sepracor. The first three use [[albuterol]] whereas Xopenex uses [[levalbuterol]]. Financial assistance is available for patients available through the Partnership for Prescription Assistance (1-888-477-2669).<ref name="New York Times"/> As of November, 2007, the prices costs in American dollars were Ventolin 36.12, ProAir 36.72, Proventil 42.20 and Xopenex 49.75.<ref name="Medical Letter">{{cite web |url=http://en.citizendium.org/wiki?title=Asthma |title=Drugs for Chronic Obstructive Pulmonary Disease|date=Novmber, 2007|volume=5 |issue=63 |pages=95|format=pdf |publisher=Medical Letter|work= |accessdate=}}</ref>  
Short acting [[beta-agonist]] agents are the initial treatment.  
 
In order to comply with ozone protection, these medicines must not use chlorofluorocarbons (CFC) for a chlorofluorocarbon by January 1, 2009.<ref name="urlInformation on the Elimination of Chlorofluorocarbon-containing (CFC) Albuterol MDIs and Other Ozone-Depleting Drug Products">{{cite web |url=http://www.fda.gov/cder/mdi/albuterol.htm |title=Information on the Elimination of Chlorofluorocarbon-containing (CFC) Albuterol MDIs and Other Ozone-Depleting Drug Products |author=Anonymous |authorlink= |coauthors= |date=2008 |format= |work= |publisher=Food and Drug Administration |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="New York Times">{{cite web |url=http://www.nytimes.com/2008/05/13/health/13asth.html |title=Rough Transition to a New Asthma Inhaler |author=Tarkan L |authorlink= |coauthors= |date=May 13, 2008 |format= |work= |publisher=New York Times |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=2008-05-13}}</ref> Inhalers using hydrofluoroalkane (HFA) propellants are CFC-free. The HFA based inhalers are brand name and more expensive. They are Ventolin by GlaxoSmithKline, ProAir by Ivax, Proventil by Schering-Plough and Xopenex by Sepracor. The first three use [[albuterol]] whereas Xopenex uses [[levalbuterol]]. Financial assistance is available for patients available through the Partnership for Prescription Assistance (1-888-477-2669).<ref name="New York Times"/> As of November, 2007, the prices costs in American dollars were Ventolin 36.12, ProAir 36.72, Proventil 42.20 and Xopenex 49.75.<ref name="Medical Letter">{{cite web |url=http://en.citizendium.org/wiki?title=Asthma |title=Drugs for Chronic Obstructive Pulmonary Disease|date=Novmber, 2007|volume=5 |issue=63 |pages=95|format=pdf |publisher=Medical Letter|work= |accessdate=}}</ref>  


Long-acting [[adrenergic beta-agonist]]s may help<ref name="pmid17253458">{{cite journal |author=Walters EH, Gibson PG, Lasserson TJ, Walters JA |title=Long-acting beta2-agonists for chronic asthma in adults and children where background therapy contains varied or no inhaled corticosteroid |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD001385 |year=2007 |pmid=17253458 |doi=10.1002/14651858.CD001385.pub2 |url=http://dx.doi.org/10.1002/14651858.CD001385.pub2 |issn=}}</ref>; however, they should not be used ''without'' [[corticosteroid]]s and maybe should not be used in African American patients.<ref name="pmid16754916">{{cite journal |author=Salpeter SR, Buckley NS, Ormiston TM, Salpeter EE |title=Meta-analysis: effect of long-acting beta-agonists on severe asthma exacerbations and asthma-related deaths |journal=Ann. Intern. Med. |volume=144 |issue=12 |pages=904-12 |year=2006 |pmid=16754916 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=reprint&pmid=16754916 |issn=}}</ref> They might be safe in asthma as long as [[corticosteroid]]s are used. According to a [[meta-analysis|meta-analyses]] by the [[Cochrane Collaboration]], when used ''with'' [[corticosteroid]]s the relative risk for asthma-related death is increased at 1.34 although this increase was not statistically significant with a [[confidence interval]] of 0.30 to 5.97.<ref name="pmid17253458">{{cite journal |author=Walters EH, Gibson PG, Lasserson TJ, Walters JA |title=Long-acting beta2-agonists for chronic asthma in adults and children where background therapy contains varied or no inhaled corticosteroid |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD001385 |year=2007 |pmid=17253458 |doi=10.1002/14651858.CD001385.pub2 |url=http://dx.doi.org/10.1002/14651858.CD001385.pub2 |issn=}}</ref><ref name="pmid18646149">{{cite journal |author=Cates CJ, Cates MJ |title=Regular treatment with salmeterol for chronic asthma: serious adverse events |journal=Cochrane Database Syst Rev |volume= |issue=3 |pages=CD006363 |year=2008 |pmid=18646149 |doi=10.1002/14651858.CD006363.pub2 |url=http://dx.doi.org/10.1002/14651858.CD006363.pub2 |issn=}}</ref>
Long-acting [[adrenergic beta-agonist]]s may help<ref name="pmid17253458">{{cite journal |author=Walters EH, Gibson PG, Lasserson TJ, Walters JA |title=Long-acting beta2-agonists for chronic asthma in adults and children where background therapy contains varied or no inhaled corticosteroid |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD001385 |year=2007 |pmid=17253458 |doi=10.1002/14651858.CD001385.pub2 |url=http://dx.doi.org/10.1002/14651858.CD001385.pub2 |issn=}}</ref>; however, they should not be used ''without'' [[corticosteroid]]s and maybe should not be used in African American patients.<ref name="pmid16754916">{{cite journal |author=Salpeter SR, Buckley NS, Ormiston TM, Salpeter EE |title=Meta-analysis: effect of long-acting beta-agonists on severe asthma exacerbations and asthma-related deaths |journal=Ann. Intern. Med. |volume=144 |issue=12 |pages=904-12 |year=2006 |pmid=16754916 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=reprint&pmid=16754916 |issn=}}</ref> They might be safe in asthma as long as [[corticosteroid]]s are used. According to a [[meta-analysis|meta-analyses]] by the [[Cochrane Collaboration]], when used ''with'' [[corticosteroid]]s the relative risk for asthma-related death is increased at 1.34 although this increase was not statistically significant with a [[confidence interval]] of 0.30 to 5.97.<ref name="pmid17253458">{{cite journal |author=Walters EH, Gibson PG, Lasserson TJ, Walters JA |title=Long-acting beta2-agonists for chronic asthma in adults and children where background therapy contains varied or no inhaled corticosteroid |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD001385 |year=2007 |pmid=17253458 |doi=10.1002/14651858.CD001385.pub2 |url=http://dx.doi.org/10.1002/14651858.CD001385.pub2 |issn=}}</ref><ref name="pmid18646149">{{cite journal |author=Cates CJ, Cates MJ |title=Regular treatment with salmeterol for chronic asthma: serious adverse events |journal=Cochrane Database Syst Rev |volume= |issue=3 |pages=CD006363 |year=2008 |pmid=18646149 |doi=10.1002/14651858.CD006363.pub2 |url=http://dx.doi.org/10.1002/14651858.CD006363.pub2 |issn=}}</ref>
=====Corticosteroids=====
=====Methylxanthines=====
=====Mast cell stabilizers=====
=====Leukotriene antagonists=====


====Monitoring====
====Monitoring====

Revision as of 20:51, 7 October 2008

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Definition

Epidemiology

Etiology

According to the USA's National Heart, Lung, and Blood Institute of the National Institutes of Health, "atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma". [1] Atopy, although genetically predetermined, is exacerbated by environmental factors. Diesel gas emissions were shown to increase atopy in asthma in the same way as allergen exposure itself. As was emphasised by the researchers who isolated this effect, the demonstration of such a modification in the expression of genetic predispositions, which was achieved through epigenetic mechanisms, urges researchers to adopt a "new paradigm" in asthma and atopy management.[2]

Pathophysiology

Diagnosis

Prognosis

Treatment

Treatment of acute exacerbations

The U.S. National Asthma Education and Prevention Program defines exacerbations as:[3]

  • Mild. "Dyspnea only with activity (assess tachypnea in young children)"; peak expiratory flow rate ≥70 percent predicted or personal best
  • Moderate. "Dyspnea interferes with or limits usual activity"; peak expiratory flow rate 40−69 percent predicted or personal best
  • Severe. "Dyspnea at rest; interferes with conversation"; peak expiratory flow rate <40 percent predicted or personal best

Chronic treatment

Drug therapy

Beta-adrenergic agonists

These drugs may be administered by inhaler, nebulizer, or oral and parenteral forms.

Short acting beta-agonist agents are the initial treatment.

In order to comply with ozone protection, these medicines must not use chlorofluorocarbons (CFC) for a chlorofluorocarbon by January 1, 2009.[4][5] Inhalers using hydrofluoroalkane (HFA) propellants are CFC-free. The HFA based inhalers are brand name and more expensive. They are Ventolin by GlaxoSmithKline, ProAir by Ivax, Proventil by Schering-Plough and Xopenex by Sepracor. The first three use albuterol whereas Xopenex uses levalbuterol. Financial assistance is available for patients available through the Partnership for Prescription Assistance (1-888-477-2669).[5] As of November, 2007, the prices costs in American dollars were Ventolin 36.12, ProAir 36.72, Proventil 42.20 and Xopenex 49.75.[6]

Long-acting adrenergic beta-agonists may help[7]; however, they should not be used without corticosteroids and maybe should not be used in African American patients.[8] They might be safe in asthma as long as corticosteroids are used. According to a meta-analyses by the Cochrane Collaboration, when used with corticosteroids the relative risk for asthma-related death is increased at 1.34 although this increase was not statistically significant with a confidence interval of 0.30 to 5.97.[7][9]

Corticosteroids
Methylxanthines
Mast cell stabilizers
Leukotriene antagonists

Monitoring

A systematic review by the Cochrane Collaboration found that monitoring sputum eosinophils can guide treatment[10] The review identified three randomized controlled trials that found that benefit from adjusting anti-inflammatory medications to maintain less than 2 to 8% eosinophils in sputum.

Regarding peak expiratory flow rate monitoring, according to a meta-analysis of randomized controlled trials by the Cochrane Collaboration, peak flow monitoring is equivalent to symptom monitoring.[11] The U.S. National Asthma Education and Prevention Program recommends peak expiratory flow rate monitoring for selected patients.[3]

References

  1. ↑ National Heart, Lung, and Blood Institute, Guidelines for the Diagnosis and Management of Asthma, National Institutes of Health, 2002.
  2. ↑ Liu J, Ballaney M, Al-alem U, et al (March 2008). "Combined inhaled diesel exhaust particles and allergen exposure alter methylation of T helper genes and IgE production in vivo". Toxicol. Sci. 102 (1): 76-81. DOI:10.1093/toxsci/kfm290. PMID 18042818. Research Blogging.
  3. ↑ 3.0 3.1 National Asthma Education and Prevention Program: Expert Panel Report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD. National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-4051). Available from www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. (Accessed September 1, 2008).
  4. ↑ Anonymous (2008). Information on the Elimination of Chlorofluorocarbon-containing (CFC) Albuterol MDIs and Other Ozone-Depleting Drug Products. Food and Drug Administration.
  5. ↑ 5.0 5.1 Tarkan L (May 13, 2008). Rough Transition to a New Asthma Inhaler. New York Times. Retrieved on 2008-05-13.
  6. ↑ Drugs for Chronic Obstructive Pulmonary Disease (pdf) 95. Medical Letter (Novmber, 2007).
  7. ↑ 7.0 7.1 Walters EH, Gibson PG, Lasserson TJ, Walters JA (2007). "Long-acting beta2-agonists for chronic asthma in adults and children where background therapy contains varied or no inhaled corticosteroid". Cochrane Database Syst Rev (1): CD001385. DOI:10.1002/14651858.CD001385.pub2. PMID 17253458. Research Blogging.
  8. ↑ Salpeter SR, Buckley NS, Ormiston TM, Salpeter EE (2006). "Meta-analysis: effect of long-acting beta-agonists on severe asthma exacerbations and asthma-related deaths". Ann. Intern. Med. 144 (12): 904-12. PMID 16754916. [e]
  9. ↑ Cates CJ, Cates MJ (2008). "Regular treatment with salmeterol for chronic asthma: serious adverse events". Cochrane Database Syst Rev (3): CD006363. DOI:10.1002/14651858.CD006363.pub2. PMID 18646149. Research Blogging.
  10. ↑ Petsky H, Kynaston J, Turner C, et al (2007). "Tailored interventions based on sputum eosinophils versus clinical symptoms for asthma in children and adults". Cochrane database of systematic reviews (Online) (2): CD005603. DOI:10.1002/14651858.CD005603.pub2. PMID 17443604. PMID 17443604. Research Blogging.
  11. ↑ Powell H, Gibson PG (2003). "Options for self-management education for adults with asthma". Cochrane Database Syst Rev (1): CD004107. PMID 12535511. [e]
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