Asthma Recap

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Background

Asthma is primarily a chronic inflammatory disease of the airways in the lung that results from genetic and environmental conditions. In the United States, it is estimated that 25.7 million people have asthma (1). It is one of the most common chronic diseases of childhood, in which most patients are diagnosed by 5 years of age. A survey taken in California found that 13.1% of adults and 12.5% of children had been diagnosed with asthma (1,3). However, around 30% to 70% of children with asthma will improve or become symptom free by adulthood.

Emergency room visits for asthma symptoms rose by about 18% for California children ages 5-17 (4). In the Central Valley, the ER visits more than doubled: Sacramento rose by 48%, and Los Angeles county increased by 17% (4). Although the number of ER visits have been increasing, the number of asthma deaths have been decreasing over the past 10 years, with a death rate of 0.14/1000 persons with asthma reported in 2009.


Common Triggers for Asthma

Respiratory Infection
Respiratory syncytial virus (RSV), rhinovirus, influenza, Chlamydia
Emotions
Anxiety, stress, laughter
Exercise
Cold/dry climates
Drugs/Preservatives
Aspirin, Ibuprofen, Naproxen (NSAIDS), Propranolol, Nadolol
Occupational Stimuli
Flour dust, hay mold, plastics, rubber, and wood (formaldehyde, western cedar)

Signs & Symptoms of Asthma

Signs
Symptoms
●Wheezing
Dry hacking cough
●Allergic rhinitis and/or eczema
●Shortness of breath
Chest tightness
Coughing (particularly at night)

Treatment

Acute Inhalers*
Goals
Common Side Effects
Emergency Inhalers*
(Proair, Ventolin, Proventil, Xopenex ++)
●Maintain oxygen levels for proper lung functions
●Reduce & eliminate internal/external airflow obstructions
●Formulate an alternative strategy to prevent recurrence
●Throat irritation
Cough
Bad taste
Headache
Oral Steroids
(Prednisone, Prelone, Medrol, Cortel)
●Provide immediate relief of asthma symptoms
Prevent hospitalization for adults and children
Reduce inflammation in airways
●Swollen Hands
●Itching or hives
●Dizziness
●Eye Pain
Preventative Inhalers**
Goals
Common Side Effects
Inhaled Corticosteroids (ICS)
(Qvar, Flovent, Pulmicort, Symbicort ++)
●Reduce use of emergency inhalers to <2 days a week
Prevent relapse and rehospitalization
Prevent the loss of lung function
Maintain a normal lifestyle
●Nausea
Sinusitis
Rhinitis
Oral Candidiasis (oral thrush)
Leukotriene Modifiers
(Singulair, Accolate, Zyflo CR)
(Prednisone, Prelone, Medrol, Cortel)
●Decrease the frequency of asthma attacks
Reduce inflammation in airways
Provide relief in allergy-like symptoms
●Diarrhea
Restlessness
Stomach Pain
Ear ache
*Children <2 years of age respond better to nebulized albuterol solutions in ER visits
**Never used to stop asthma, only used in prevention

Conclusion

Asthma has a wide variety of symptoms that may not show up during examination. There are acute and preventative treatments. Identifying the signs and symptoms of asthma and proper inhaler technique can are essential in treating asthma. While the emergency inhalers (Ventolin, Proair, and Proventil) are the most effective first line treatment used to “stop” an asthma attack, inhaled corticosteroids (Qvar, Flovent, Advair, Symbicort, etc) are used to prevent asthma attacks. By adulthood, 30%-70% of children will have outgrown their asthma or have their symptoms greatly reduced (2).

References

(1) “Asthma and Air Pollution.” Asthma and Air Pollution. Air Resources Board, n.d. Web. 24 July 2017. <http://www.arb.ca.gov/research/asthma/asthma.htm&gt;
(2) DiPiro, Joseph T. Pharmacotherapy: A Pathophysiologic Approach 9e. New York: McGraw-Hill Medical, 2014. Electronic.
(3) Milet Meredith, Lutzker L, Flattery J. Asthma in California: A Surveillance Report. Richmond, CA: California Department of Public Health, Environmental Health Investigations Branch, May 2013. https://www.cdph.ca.gov/programs/ohsep/Documents/Asthma_in_California2013.pdf
(4) Ostrov, Barbara F. “Asthma Sending More Kids To California ERs  .” Kaiser Health News. Kaiser Family Foundation, 28 May 2015. Web. 24 July 2017. http://khn.org/news/asthma-visits-rising-among-kids-in-california-ers/

Asthma Long-term Treatments

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Preventative Inhalers – Inhaled Corticosteroids
(ICS – Qvar, Flovent, Pulmicort)

Patients that are diagnosed with persistent asthma are often treated with two asthma pumps. This may cause confusion for patients and that’s why pharmacists should clarify the major differences between the two. As mentioned before, the emergency inhalers (Ventolin, Proair, and Proventil) should be used only as needed to “stop” an asthma attack. Inhaled corticosteroids (ICS) are used for asthma prevention. Examples of ICS inhalers would be Qvar, Flovent, Aerospan, or Budesonide. They have no effect in stopping an asthma attack and should not be used as such.

Are these preventative inhalers important? Yes! If a patient’s asthma is stabilized with the correct preventative inhalers, he/she will have to use less of the emergency inhalers. One of the goals in controlling asthma, is to reduce exacerbations. A decrease in use of the emergency inhalers is a good thing!

Goals for Asthma Prevention

  • Reduce the use of emergency inhalers to less than 2 days a week
  • Prevention of an asthma relapse and rehospitalization
  • Prevent the loss of lung function
  • Maintain a normal a lifestyle

The ICS are usually dosed once to twice a day. It is very important that they are taken every day as indicated! The response time for ICS to be effective are around the first 1-2 weeks of therapy. The symptoms will improve to a maximum in 4-8 weeks. One of the most common side effects is oral candidiasis (oral thrush). It is recommended that patients brush or use mouthwash after using ICS inhalers. A simple mouthwash and brushing will prevent these creamy white lesions from forming on your tongue, mouth, or inner cheeks!

Common Side Effects

  • oral candidiasis (oral thrush)
  • nausea
  • rhinitis
  • sinusitis
  • headache
  • pharyngitis

Asthma Short-term Treatments

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Emergency inhalers (Ventolin, Proair, Proventil, Xopenex)

Now that there is an understanding on asthma, the next step is to learn what treatments are available. There are two types of inhalers, short-acting-beta-2 agonists (SABA) also known as “emergency” inhalers, and the second are long term preventative inhalers. The short-acting-beta-2-agonists are the most effective first line treatment for an asthma attack. The SABA inhalers are commonly called Albuterol inhalers which are bronchodilators used only to treat an asthma attack. The most common albuterol inhalers are Proair, Ventolin, and Proventil inhalers. A very important point to stress about these inhalers are they are to be taken only as needed. They are not to be taken every day around the clock since they do not help prevent an asthma attack.

They come in inhalation pumps as meter dosed inhalers (MDI) and nebulizer solutions. Proper inhaler technique is integral in treatment. If you’ve forgotten, you can take a look at the end of this article or check out the video under resources→video tutorials.

Children under 2 years have better responses using the nebulized albuterol solutions. In an emergency room visit, it is not uncommon to be treated with 2.5 mg doses of nebulized albuterol during an exacerbation.


Side Effects of Albuterol inhalers:

  • throat irritation
  • cough
  • bad taste
  • headache
  • heart palpitations
  • tachycardia

Corticosteroids (Prednisone, Prelone or Prednisolone syrup, Orapred, Dexamethasone, etc)

Corticosteroids are the most effective anti-inflammatories available to treat asthma. They can be used in treatment of acute severe asthma and are also recommended for severe asthma unresponsive to bronchodilators such as the albuterol inhalers. Prednisone, Prednisolone (Prelone) syrup, and dexamethasone are common corticosteroids. Patients may receive a prescription for a 3-5 day burst therapy of corticosteroids after an asthma attack to reduce another trip to the emergency room!


Goals for treating an asthma attack:

Daily monitoring and continuous diligence in one’s personal health is essential to prevent the life-threatening asthma epidemic.  Recognizing early signs of an asthma progressively worsening and early intervention is the key in preventing life-threatening asthma attacks.

The primary goals of treating an asthma attack include:

  • Stabilizing oxygen level to maintain proper lung functions
  • Reducing & eliminating internal/external airflow obstructions
  • Formulating alternative strategies to prevent similar incidents from occurring

Side effects: Corticosteroids

Short term therapy for corticosteroids should not produce the more severe side effects. Long-term therapy is where we start seeing the severe side effects. Long-term corticosteroids are never to rarely used to treat asthma attacks. So if you see a prescription for 1 month+ for an asthma attack, please double check with your pharmacist if that’s correct.


Common Side effects:

  • Nausea Vomiting
  • Elevated blood pressure
  • Acne
  • Glucose intolerance
  • Dyspepsia
  • Fluid retention
  • Insomnia

Severe Reactions:

  • Cushing syndrome
  • Diabetes
  • Seizures
  • Congestive heart failure
  • Pancreatitis
  • Tendon rupture
  • Osteoporosis.

What is Asthma?

asthmasteps

Asthma is one of the most common chronic diseases of childhood. It is a disease that is a result of genetic and environmental conditions. There are many types of asthma including: chronic ambulatory asthma, acute severe asthma, and nocturnal asthma.  Asthma is primarily a chronic inflammatory disease of the airways in the lung. It has no known cure or primary prevention. Most patients do not die from long-term asthma and their life span does not differ from the general population. (DiPiro pg. 408)

In the United States, it is estimated that 25.7 million people have asthma (1). In California, a survey found that 13.1% of adults and 12.5% of children had been diagnosed with Asthma.(1, 3) Emergency room visits for Asthma symptoms rose by about 18% for California children ages 5-14. In the Central Valley, the ER visits were more than doubled, Sacramento rose by 48%, and Los Angeles county increased by 17%. (4)

Asthma deaths have been decreasing over the past 10 years, with a death rate of 0.14/1000 persons with asthma reported in 2009. Most asthma deaths are preventable. Ethnic minorities are more prone to have asthma. African Americans are two times as likely to be hospitalized and die from asthma than whites (3). In 2007, the estimated medical cost of asthma was $14.7 billion. Most patients are diagnosed by 5 years of age. Around 30% and 70% of children with asthma will improve or become symptom free by adulthood.

Environmental Risk Factors for Developing Asthma:

  • Socioeconomic status
  • Family size
  • Exposure to secondhand tobacco smoke in infancy and in utero
  • Allergen exposure
  • Urbanization
  • Respiratory syncytial virus (RSV) infection
  • Decreased exposure to common childhood infectious agents

 

Common Triggers for Asthma
Respiratory Infection Respiratory syncytial virus (RSV), rhinovirus, influenza, parainfluenza, mycoplasma pneumonia, Chlamydia
Emotions Anxiety, stress, laughter
Exercise Cold/dry climates
Drugs/preservatives Aspirin, Ibuprofen, Naproxen (NSAIDS), Propranolol, Nadolol
Occupational Stimuli Flour dust, hay mold, spice and enzyme workers, azo dyes, plastics, rubber, and wood (formaldehyde, western cedar)

Signs & Symptoms of Asthma

Wheezing is a characteristic for asthma. However, not all wheezing is caused by asthma. Any condition that causes airway obstruction can result in wheezing. A patient may not have any signs or symptoms of asthma exacerbation at the time of examination.

 

Signs Symptoms
  • Wheezing
  • Dry hacking cough
  • Allergic rhinitis and/or eczema
  • shortness of breath
  • chest tightness
  • coughing (particularly at night)
1) “Asthma and Air Pollution.” Asthma and Air Pollution. Air Resources Board, n.d. Web. 11 July 2016. <http://www.arb.ca.gov/research/asthma/asthma.htm&gt;
2) DiPiro, Joseph T. Pharmacotherapy: A Pathophysiologic Approach 9e. New York: McGraw-Hill Medical, 2014. Electronic.
3) Milet Meredith, Lutzker L, Flattery J. Asthma in California: A Surveillance Report. Richmond, CA: California Department of Public Health, Environmental Health Investigations Branch, May 2013. https://www.cdph.ca.gov/programs/ohsep/Documents/Asthma_in_California2013.pdf
4) Ostrov, Barbara F. “Asthma Sending More Kids To California ERs  .” Kaiser Health News. Kaiser Family Foundation, 28 May 2015. Web. 11 July 2016. http://khn.org/news/asthma-visits-rising-among-kids-in-california-ers/

Guidelines for Prescribing Opioids for Chronic Pain- New CDC Guidelines 2016

The CDC recently released new guidelines for Opioid use. Pain management has become a growing issue in the United States. Last year, Hydrocodone products were reclassified into C-2. It was an effort to restrict access to it and slow down the usage of narcotics in pain management.

This year the CDC and the healthcare industry are trying to educate the patients too! When we talk about chronic pain, it involves pain management for the long term. Short term use or acute pain management like wisdom teeth and minor sports injuries are excluded from this guideline.

Healthcare professionals from doctors, nurses, to pharmacists will be asking more questions if you’re on opioids. It’s to help determine if the correct regimen is being used for you. Since long-term opioid use has led to addiction, drug abuse, and ultimately death.

Ask, have you tried non pharmacologic therapy? Are you ER/LA opioids? What are your treatment goals? How often are follow up appointments? All these questions are very important in maintaining your health!

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Opiod Guidelines PDF