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06 February 2013

How your asthma treatment will be tailored specifically for you

As soon as asthma has been confirmed by your doctor, your treatment will be initiated according to the severity of your symptoms.

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As soon as your doctor has confirmed a diagnosis of asthma, and excluded all other possible causes of your symptoms, he will initiate your treatment according to the severity of your asthma. There are two sets of guidelines: one for adults and adolescents, and one for children. These guidelines are constantly updated by asthma experts in South Africa. South African experts use international guidelines like the Global Initiative for Asthma (GINA, 2007) as a basis for children, and international guidelines from Europe and the USA as a basis for adults in South Africa. Although these guidelines are adapted for South African circumstances, the principles of these guidelines adhere to international guidelines.

In the international and South African guidelines, new management options had been implemented for children younger than five years, because they should not be treated exactly the same as older children. The much larger emphasis on the use of controllers as the foundation of asthma treatment and the major change in emphasis to assess asthma control are evident in the new guidelines. New treatment options such as combination treatment (an inhaled corticosteroid plus a long-acting beta agonist in one single inhaler), the use of new formulations of inhaled corticosteroids, and the use of leukotriene inhibitors and immunotherapy (to be used under your tongue) are also incorporated in the latest guidelines. These new advances in asthma management will benefit you as a patient because it is now possible to achieve good asthma control.

This is how your doctor will decide exactly how to manage your asthma in five main steps:

Step 1.  S/he will confirm the diagnosis of asthma (see section on diagnosis).


Step 2: S/he will identify and treat all relating conditions, aggravating factors and address the triggers.

It is important to treat (and prevent) hay fever and sinusitis, since about three quarters of people with asthma also have allergies of the nose and sinuses. It is also true that if this part of the problem is out of control, so will the asthma.
Allergies will be treated by limiting exposure to the identified allergens, and to control allergy symptoms with a new generation antihistamine.

Step 3:  S/he will classify the severity of your asthma,
based on the latest guidelines for adults/adolescents and for children (see section on Classification of asthma severity).

Step 4:  S/he will initiate your treatment based on the severity of your asthma, and your age.  The section below will explain how this will be done.

For Adults and adolescents:

Table 3: Treatment according to severity in Adults and adolescents (2007 guidelines)

Grade of severity

1. Intermittent, Mild

2. Persistent/Chronic, Mild

3. Persistent/Chronic, moderate

4. Persistent/Chronic, severe

5. Persistent/chronic, very severe

Do you need a controller?

No

Yes. Daily. Long-term.
Start with a low dose inhaled corticosteroid (ICS).(Inhaler)

Yes. Daily. Long-term.
One of the following:
1. Medium to high dose ICS (inhaler)
or
2. A combo: Low dose ICS + long-acting beta blocker inhaler (LABA) (probably a single inhaler)
or
3. Low dose ICS + Leukotriene inhibitor (inhaler + tablet)

Or
4. Low dose ICS + slow-release theophylline (only if 1st 3 options not available or not effective) (inhaler + tablet)

Yes. Daily. Long-term.
One of the following:
 Medium to high dose ICS (inhaler)
plus one of the following:
1. + LABA (inhaler)
or
or 
2. + Leukotriene inhibitor (tablet) [w2] 
3. + LABA (inhaler) + LTRA (tablet)
4. + Slow-release theophyline (tablet). Theophyllines don’t work well.  They are really only used in the public service if other more effective medication is not available.

 

Yes. Daily. Long-term.
Your doctor will add one of both to one of the treatment options on the left:
1. He will increase the dosage of your ICS inhaler

And/or
2. Add a corticosteroid tablet.

Do you need a reliever?

Yes. 
A short-acting beta agonist 

inhaler when and if needed.

Yes.
A short-acting beta agonist when and if needed.(inhaler)

Yes.
A short-acting beta agonist inhaler when and if needed (inhaler).

Yes
A short-acting beta agonist inhaler when and if needed (inhaler).

 

The medication at your bedside

One inhaler/pump

Two inhalers/pumps

Two inhalers/pumps or

Two inhalers/pumps plus daily tablets

2 Inhalers;  or
2 inhalers plus 1 – 2 different daily tablets

2 inhalers or
2 inhalers plus 2 – 3 different daily tablets


For Children

Children usually use the same medication as adults. The amount and type of medication will depend on the severity of the asthma. The approach to treatment in children (as in adults) is to "Hit Early, Hit Hard, then Step Down".

In mild cases (intermittent asthma, with less than two acute asthma attacks per week, See table 4 below), only a bronchodilator may be necessary, while any child with persistent asthma needs daily preventer medication to help prevent attacks by reducing the chronic inflammatory reaction in the airways.

In infants, management of asthma presents unique problems. But it is always better to treat a child as if he has asthma than not to treat him at all. If a parent is unsure whether the infant's wheezing is because of asthma, or whether he is suffering an acute attack, it is better to give him a bronchodilator than to withhold treatment, if he has been diagnosed with asthma.

Because an infant’s airways are so small, the smallest amount of mucus or tissue swelling can cause significant airway narrowing. Infants also have proportionately less smooth muscle around their airways, resulting in less support for the airway, but also less spasm of the airway. As a result, infants also respond less well to bronchodilators, which open up the airways and provide older asthmatics with quick relief. But there is no reason why a child's asthma cannot be managed and controlled to such an extent that he can live a normal life.

Parents often panic because they do not know whether their infant or toddler is really inhaling deep enough to get all the medication to his lungs. For infants and children, a spacer with a valve to ensure that no air escapes from the spacer, can be of great value.

A child often inhales in shallow and short breaths when using an inhaler, exhaling more than inhaling. As soon as your child can understand, you can teach him to relax before using his inhaler, and take long and slow breaths from the spacer, keeping his mouth on the spacer, while exhaling slowly through his nose, and then inhaling again. After four to five inhalations, chances are good that he inhaled all the medication he needs.

Table 4: Treatment according to severity in Children (2009 guidelines)


Grade of severity

1. Intermittent, Mild

2. Chronic, Mild

3. Chronic, moderate

4. Chronic, severe

Do you need a controller?

No

Yes. Daily. Long-term.
(listed in order of preference)
For all children:

A low dose inhaled corticosteroid (ICS) (inhaler),
or leukotriene inhibitors if ICS has failed.

Yes. Daily. Long-term
(Listed in order of preference)
For children 5 years or younger
:
1. Medium-dose ICS (inhaler).
or
2. Low-dose ICS (inhaler) + leukotriene inhibitor (tablets)
For children older than 5 years:
1. Medium dose ICS (inhaler)
or
2.Low-dose ICS + LABA (inhaler)
or
3. Low dose ICS + leukotriene inhibitor (tablet)
 

Yes. Daily. Long-term
(Listed in order of preference)
For children 5 years or younger
:
Medium-dose ICS (inhaler).
+ leukotriene inhibitor (tablets)
For children older than 5 years:
1. Medium dose ICS (inhaler)
+ LABA (inhaler)
or
2. Medium dose ICS + leukotriene inhibitor (tablet)

or
3. High dose ICS (inhaler)

Do you need a reliever? (for an acute attack, or for relieve of symptoms)

Yes.
A short-acting beta blocker when your child has an asthma attack

Yes.
 A short-acting beta blocker when your child has an asthma attack

Yes.
 A short-acting beta blocker when your child has an asthma attack

Yes.
 A short-acting beta blocker when your child has an asthma attack

The child’s medication :

One inhaler

Two inhalers, or
One inhaler + daily tablets

 

 


Step 5: Your doctor will re-assess your condition and control of your symptoms 2 – 6 weeks after you have started treatment.

Adults
After re-assessment he will classify your asthma (at this assessment and every following assessment) as either “controlled”, “partly controlled” or “uncontrolled” (see table 5).

Table 5: Classification of control in Adults


Characteristics/symptoms

Controlled
(all of the below)

Partly controlled
(if any one of the features below is present in any week)

Uncontrolled
(If more than 3 features of Partly controlled asthma are present in any week)

Daytime symptoms (wheezing, cough, difficult breathing)

2 or less per week

More than twice per week

More than twice per week

Nocturnal symptoms or waking at night

None

Any

Any

Need for reliever therapy

2 or less in any week

More than twice in any week

More than twice in any week

Lung function (with peak flow meter) as % of predicted or personal best
 

Normal

Less than 80%

Less than 80%


Based on this classification, He/she will either step up or step down your treatment (from your initial treatment – see table 3) to achieve total control (no acute attacks at all, no need for reliever therapy due to worsened symptoms) as soon as possible. Before stepping up therapy, your doctor must make sure that you are taking your medication regularly and not forgetting any doses, and that you know how to use your medications and pumps.

You should bring your medication with to the doctor and show him / her how you use it so that s/he can help you with your technique.  Spacers with your pumps (or a dry powder inhaler) are necessary in people of any age who are having very poor control.

If your asthma remains anything but well-controlled despite checking your using the medicine, your technique and stepping up therapy, S/he should refer you to a specialist physician/pulmonologist. You definitely need the help of a specialist physician or pulmonologist if you have initially been diagnosed with moderate persistent asthma (grade 3) and total control has not been achieved with initial treatment.

If total control is achieved and maintained for at least 3 months, therapy will be stepped down.

In Children:

After re-assessment, the doctor will classify your child’s asthma (at this assessment and every following assessment) as either controlled, partly controlled or uncontrolled (see table 5).

Table 6: Classification of asthma control in children

Characteristics/symptoms

Controlled
(all of the below)

Partly controlled
(if any one of the features below is present in any week)

Uncontrolled
(If more than 3 features of Partly controlled asthma are present in any week)

Daytime symptoms (wheezing, cough, difficult breathing)

Less than twice per week

More than twice per week

More than twice per week

Nocturnal symptoms or waking at night

None

Any

Any

Need for reliever therapy or rescue treatment

2 or less in any week

More than twice in any week

More than twice in any week

Lung function (with peak flow meter) as % of predicted or personal best
 

Normal

Less than 80%

Less than 80%

Acute attacks/exacerbations

None

1 or more per year

1 in any week



Based on this classification, he will either step up or step down your child’s treatment (from your initial treatment – see table 4) to achieve fully controlled asthma (no acute attacks at all, no need for relievers due to worsening of symptoms) as soon as possible.
Before stepping up therapy, your doctor must make sure that your child is taking your medication regularly and not forgetting any doses, and that you know how to use your medications and pumps.  You should bring your medication with to the doctor and show him / her how you use it so that s/he can help you with your technique. Spacers are necessary in all children to help them take their pumps effectively. Your child may do better with a mouthpiece or a mask. Ask your doctor which is best.

An acute asthma attack in any week makes that an uncontrolled asthma week. There should not even be one uncontrolled asthma week in your child’s life.

Every time you child suffers an acute attack/exacerbation, you should inform your child’s doctor, because any acute attack in any week should prompt immediate review of his/her treatment to ensure adequate control. An acute attack means that your child’s treatment is inadequate.

If your child’s asthma remains anything but well-controlled despite stepping up therapy, he will/should refer you to a paediatrician, pulmonologist or allergist.

If total control is achieved and maintained for at least 3 months, therapy should be stepped down.

Asthma should be managed on a daily basis.

When should you be referred to a specialist?

Adults should be referred to a specialist and special care taken:
•    When asthma is poorly controlled despite intensive treatment.
•    When the asthma patient suffers from other medical conditions such as a peptic ulcer, heart failure or hypertension, or if the patient is pregnant. Poor asthma control is much more dangerous to the mother and the unborn baby than the possible side-effects of any asthma medication.
•    When the patient suffers from occupational asthma.
•    When the patient is frequently absent from work.
•    When the patient needs immunotherapy.

Note that elderly asthma patients should rather not use theophyllines and oral corticosteroids due to possible adverse effects, that asthma patients with heart problems and hypertension should rather not use beta agonists because it may affect their heart and blood pressure, that diabetics should rather not use oral corticosteroids, and that asthma patients with pulmonary tuberculosis should not take isoniazid (a TB medication) while using inhaled or oral corticosteroids.

Children should be referred to a specialist and special care taken:

•    When asthma is poorly controlled despite treatment, or has shown no or merely slight improvement in control over the past year.
•    When a child regularly requires oral corticosteroids.
•    When a child has had one or more life-threatening episode.
•    When the child is frequently absent from school.
•    When the child needs immunotherapy.

(Reviewed and updated May 2011 by Dr Mike Levin, paediatrician, Red Cross Children's Hospital, Cape Town)

 





 
 
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