Treatment for asthma in 4 year old,herpes vision problems,alternative treatment adhd adults jokes - 2016 Feature

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On occasion, patients or their clinicians may wish to change from one combination product to another. In the absence of clinical equivalency data, the approved prescribing information for each product should be used. Following the prescription of an alternative therapeutic regimen, careful patient monitoring is necessary because individual patient response to different drugs and devices may vary.
Once asthma control is achieved and maintained, patients should be assessed at regular intervals. Asthma and chronic obstructive pulmonary disease (COPD) are the most common obstructive airway diseases [1]. The National Asthma Education and Prevention Expert Panel Report 3 (NAEPP EPR-3) provides guidelines for the stepwise pharmacological management of asthma based on disease severity (Figure) [7].
Reprinted from the National Asthma Education and Prevention Program Expert Panel Report [7] with permission from the National Heart, Lung, and Blood Institute, part of the National Institutes of Health and the US Department of Health and Human Services. Once adequate asthma control is achieved, the NAEPP recommends that step-down therapy be initiated, with the goal of identifying the minimum medication necessary to maintain control [7].
Recently, the FDA issued a safety communication highlighting updated recommendations for LABA therapy due to concerns of an increased risk of severe exacerbation of asthma symptoms leading to hospitalization in pediatric and adult patients, as well as death in some patients using LABAs for the treatment of asthma [9]. Similar to asthma management, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest that pharmacological treatment of COPD should reduce symptoms and complications with minimal side effects [10]. 13.Kavuru M, Melamed J, Gross G, Laforce C, House K, Prillaman B, Baitinger L, Woodring A, Shah T. 14.Shapiro G, Lumry W, Wolfe J, Given J, White MV, Woodring A, Baitinger L, House K, Prillaman B, Shah T. 18.Pearlman DS, Peden D, Condemi JJ, Weinstein S, White M, Baitinger L, Scott C, Ho SY, House K, Dorinsky P. 31.Anzueto A, Ferguson GT, Feldman G, Chinsky K, Seibert A, Emmett A, Knobil K, O'Dell D, Kalberg C, Crater G. 32.Calverley PM, Anderson JA, Celli B, Ferguson GT, Jenkins C, Jones PW, Yates JC, Vestbo J.
Gabriel Ortiz serves as the American Academy of Physician Assistants (AAPA) liaison to the American Academy of Allergy, Asthma & Immunology (AAAAI) and as the AAAAI liaison to the AAPA. He has served previously as the AAPA liaison to the National Asthma Education and Prevention Program. Summary Information for Inhaled Corticosteroid and Long-Acting β2-Adrenergic Agonist Combination Product Use in Patients in the United States Who Have Asthma or Chronic Obstructive Pulmonary Disease. Applying the 2009 Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines for the Pharmacological Management of Chronic Obstructive Pulmonary Disease in Clinical Practice. Both asthma and chronic obstructive pulmonary disease (COPD) are obstructive respiratory disorders characterized by airflow limitation and inflammation. Establishing a diagnosis of asthma, COPD, or both may be challenging because of overlapping disease characteristics and the possibility for both diseases to coexist; however, an accurate diagnosis is necessary because disease management strategies and treatment approaches are different for each disease.
Assess the patient’s history and identify key disease indicators and demographic, clinical, and pathophysiological features. Once diagnosed, disease severity (or level of asthma control for patients already receiving treatment) should be determined and corresponding treatments should be prescribed according to current guideline recommendations (eg, National Asthma Education and Prevention Program [NAEPP] guidelines for asthma; Global initiative for chronic Obstructive Lung Disease [GOLD] guidelines for COPD). Both asthma and COPD are obstructive respiratory disorders that are characterized by inflammation and airway limitation and associated with varying degrees of severity [1, 2].
Early recognition of suggestive symptoms may help clinicians establish diagnoses of chronic respiratory diseases [6]. Differences between asthma and COPD also exist in the types of infiltrating cells and inflammatory markers present, age at onset, persistency of symptoms, exercise capacity, and smoking history [1, 2]. Asthma and COPD have many overlapping features [12], and distinguishing between the 2 diseases may be more difficult in the elderly and in patients with a long history of asthma [2, 12]. Spirometry: The diagnosis of asthma is determined in part by the presence of airway hyperresponsiveness or episodic symptoms of airflow obstruction that is at least partially reversible [1]. Spirometry also is recommended to make a confident diagnosis of COPD through measurement of airflow limitation and should be undertaken in all patients who may have COPD [2]. Questionnaires: Symptom-based questionnaires may be useful for improving the diagnostic accuracy of obstructive lung diseases when used together with spirometry [20].
Alternative diagnoses also should be considered during patient evaluation for COPD or asthma (Figure 2) [1, 2].
Sources: the National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program.
Once a diagnosis of asthma, COPD, or both has been made, disease severity should be determined to establish appropriate therapy (Figure 3, Table 3) [1, 2].
The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity.
Source: the National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program.
At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. Review adherence to medication, inhaler technique, environmental control, and comorbid conditions.
If an alternate treatment option was used in a step, discontinue and use the preferred treatment for that step.
Goals for treatment of COPD include prevention and control of symptoms, reduction of the frequency and severity of exacerbations, and improvement of health status and exercise tolerance [2]. Overlapping features of asthma and COPD may make confident diagnosis of either disease challenging for clinicians. Calverley PMA, Burge PS, Spencer S, Anderson JA, Jones PW; for the ISOLDE Study Investigators. Martinez FJ, Raczek AE, Seifer FD, et al; on behalf of the COPD-PS Clinician Working Group. Yawn BP, Mapel DW, Mannino DM, et al; on behalf of the Lung Function Questionnaire Working Group.
The best way to improve your condition and live your life on your terms is to learn all you can about your asthma and what you can do to make it better. Asthma is a chronic, inflammatory disease of the airways affecting 22 million Americans, of whom 6 million are children. In 2007, the National Asthma Education and Prevention Program (NAEPP) published its third report, Guidelines for the Diagnosis and Management of Asthma, based on the findings of the Expert Panel Report-3 (EPR-3). The severity of asthma corresponds to the most frequently occurring symptom or worst assessment finding.
Moderate and severe persistent asthma are often treated with a combination of an ICS and a long-acting beta adrenergic (LABA).
The stepwise approach for managing asthma in youths =12 years of age and adults is depicted in Figure 3. When assessing control, the clinician will use many of the same markers as are used in the initial assessment: symptoms, nighttime awakenings, interference with normal activities, SABA use, and FEV1 or peak flow.
Risk is assessed by noting the number of exacerbations requiring OCS, loss of lung function, and treatment-related adverse effects. Use of the EPR-3 to guide the diagnosis and therapy of asthma has improved from the EPR-2 by providing an evidence base.
Tim Op’T Holt, EdD, RRT, AE-C, FAARC, is professor, cardiorespiratory care, University of South Alabama, Mobile. Asthma is a common long-term condition that can cause coughing, wheezing, chest tightness and breathlessness. Severe attacks may require hospital treatment and can be life threatening, although this is unusual. Asthma is caused by inflammation of the small tubes, called bronchi, which carry air in and out of the lungs. When you come into contact with something that irritates your lungs – known as a trigger – your airways become narrow, the muscles around them tighten, and there is an increase in the production of sticky mucus (phlegm).
The reason why some people develop asthma is not fully understood, although it is known that you are more likely to develop it if you have a family history of the condition.
While there is no cure for asthma, there are a number of treatments that can help control the condition. For most people, this will involve the occasional – or, more commonly, daily – use of medications, usually taken using an inhaler. You should have a personal asthma action plan agreed with your doctor or nurse that includes information about the medicines you need to take, how to recognise when your symptoms are getting worse, and what steps to take when they do so.
For many people, asthma is a long-term condition – particularly if it first develops in adulthood. Asthma symptoms are usually controllable and reversible with treatment, although some people with long-lasting asthma may develop permanent narrowing of their airways and more persistent problems.
For children diagnosed with asthma, the condition may disappear or improve during the teenage years, although it can return later in life.
With an account you can keep track of pages on the site and save them to this tab, which you can access on every page when you are logged in. Control: the degree to which the manifestations of asthma are minimized by therapeutic intervention and the goals of therapy are met.
Asthma severity and asthma control include the domains of current impairment and future risk. Impairment: frequency and intensity of symptoms and functional limitations the patient is currently experiencing or has recently experienced. Risk: the likelihood of either asthma exacerbations, progressive decline in lung function (or, for children, reduced lung growth), or risk of adverse effects from medication. For mild persistent asthma, one daily long-term control medication (inhaled corticosteroids are preferred therapy) is necessary. For moderate persistent asthma, inhaled corticosteroids with or without additional long-term control medications are indicated.
For severe persistent asthma, multiple long-term control medications are required, including high-dose inhaled corticosteroids and, if needed, oral corticosteroids.


With an accurate diagnosis and classification, the child's asthma can then be managed using best practices and a stepwise approach. The Expert Panel recommends the following actions for managing exacerbations due to viral respiratory infections, which are especially common in children. If the symptoms are mild, short-acting inhaled ß2–agonists (every 4–6 hours for 24 hours, longer with a physician consult) may be sufficient to control symptoms and improve lung function. For those patients who have a history of severe exacerbations with viral respiratory infections, consider initiating oral systemic corticosteroids at the first sign of the infection.
Referral to an asthma specialist for consultation or co-management if patient requires step 3 for children 0–4 years of age.
It may be necessary to increase anti-inflammatory medication to regain control of a patient's asthma. Medication delivery devices should be selected based on the child's ability to use them well. Nebulizer therapy is one option for administering short-acting inhaled ß2-agonists or inhaled corticosteroids in children. Adapted from the Guidelines for the Diagnosis and Management of Asthma, National Asthma Education and Prevention Program of the National Heart, Lung and Blood Institute, Expert Panel Report 3, 2007. This entry was posted in Diagrams, Disease and tagged asthma, asthma chart, asthma diagram, asthma symptoms by admin.
They should not be used for patients whose asthma is adequately controlled on low- or medium-dose ICS and are not indicated for the relief of acute bronchospasm. However, clinical equivalency data outlining the appropriate dosing to use when prescribing an alternative combination therapy are not available.
The first dose was administered under the supervision of the physician assistant and the patient stated that she felt it working and did not object to the taste. Onset of effect of budesonide and formoterol administered via one pressurized metered-dose inhaler in patients with asthma previously treated with inhaled corticosteroids.
Down-titration from high-dose combination therapy in asthma: removal of long-acting beta(2)-agonist. Asthma diagnosis and management: A review of the updated national asthma education and prevention program treatment guidelines.
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Efficacy and safety of budesonide and formoterol in one pressurised metered-dose inhaler in adults and adolescents with moderate to severe asthma: a randomised clinical trial. Twelve-week, randomized, placebo-controlled, multicenter study of the efficacy and tolerability of budesonide and formoterol in one metered-dose inhaler compared with budesonide alone and formoterol alone in adolescents and adults with asthma.
Salmeterol and fluticasone propionate combined in a new powder inhalation device for the treatment of asthma: a randomized, double-blind, placebo-controlled trial.
Combined salmeterol 50 microg and fluticasone propionate 250 microg in the diskus device for the treatment of asthma. The safety of twice-daily treatment with fluticasone propionate and salmeterol in pediatric patients with persistent asthma. Efficacy and safety of budesonide and formoterol in one pressurized metered-dose inhaler in patients with moderate to very severe chronic obstructive pulmonary disease: results of a 6-month randomized clinical trial. Effectiveness of fluticasone propionate and salmeterol combination delivered via the Diskus device in the treatment of chronic obstructive pulmonary disease.
Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease: a randomised controlled trial.
Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. However, the pathogenesis of each disease is distinct, and each disease has distinguishing characteristics.
In 2008, the estimated prevalence in the United States was 23 million for asthma and 12 million for COPD [3, 4].
Although eosinophils are the predominant effector cell, other prominent infiltrating cells and inflammatory markers during asthma pathogenesis include neutrophils, lymphocytes, activated mast cells, injured epithelial cells, interleukin-5 (IL-5), IL-4, IL-13, immunoglobulin E, and nitric oxide [1].
COPD often develops during middle age [2]; current prevalence rates are highest among adults at least 45 years old [4]. Data from the US National Health and Nutrition Examination III survey indicate that a substantial number of patients in the United States are diagnosed with both asthma and COPD (chronic bronchitis or emphysema) [13]. Spirometry, which measures forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and other lung function parameters, is used to demonstrate airflow obstruction and assess reversibility [1].
In particular, spirometry is required to establish an accurate diagnosis in patients with symptoms, risk factors, or suspicion of COPD [15].
Clinical application of a simple questionnaire for the differentiation of asthma and chronic obstructive pulmonary disease. Beeh et al designed and validated a simple, 4-item questionnaire to assist health care providers in distinguishing between asthma and COPD (Table 2) [21]. These alternative diagnoses are generally distinct for asthma and COPD; however, congestive heart failure may be considered in the differential diagnosis for both COPD and asthma [1, 2]. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthmaa€”Full Report 2007. For patients diagnosed with asthma who are already receiving treatment, the level of control should be assessed for adjustments to therapy (Figure 4) [1].
In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or intensive care unit admission) indicate greater underlying disease severity. Assess impairment domain by patient’s recall of previous 2a€“4 weeks and by spirometry or peak flow measures. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or intensive care unit admission) indicate poorer disease control.
A goal of asthma therapy for patients 12 years and older is to maintain control of asthma, defined as reduction of impairment and risk, with the least amount of medication and minimal risk for adverse events [1]. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. International primary care respiratory group (IPCRG) guidelines: diagnosis of respiratory diseases in primary care.
Pulmonary function tests, sputum induction, and bronchial provocation tests: diagnostic tools in the challenge of distinguishing asthma and COPD phenotypes in clinical practice. The proportional venn diagram of obstructive lung disease: two approximations from the United States and the United Kingdom.
Development and initial validation of a self-scored COPD population screener questionnaire (COPD-PS).
Pharmacist-led intervention study to improve inhalation technique in asthma and COPD patients.
You have a better chance of controlling your asthma if it is diagnosed early and treatment is begun right away.
Current treatments for asthma, if followed closely, allow most people with asthma to limit the number of attacks they have. It is the leading cause of missed school days and lost productivity for the caregiver who must leave work to care for the child. Classification of the severity of asthma is based on two domains: impairment and risk, as seen in Figure 1. 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).
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). These drugs act to block the binding of leukotrienes to proinflammatory cells in the airways. Once the patient has been started on the appropriate step and has received education on triggers, environmental controls, symptoms, etc, control is assessed at 2- to 6-week intervals with regular follow-up contacts at 1- to 6-month intervals. In addition, the patient (>12 years of age) will be asked to complete a validated quality of life questionnaire. As with classifying severity, classifying control is based on the most frequent or worst assessment finding, or questionnaire score. Clinicians may be assured that when following the EPR-3 guidelines, therapy is being administered based on the best evidence available at the time the guidelines were written.
Asthma can be controlled well in most people most of the time, although some people may have more persistent problems.
This is known as an "asthma attack", although doctors sometimes use the term "exacerbation". You should also talk to your doctor or asthma nurse if you have been diagnosed with asthma and you are finding it difficult to control your symptoms. Severity is most easily and directly measured in a patient who is not receiving long-term control therapy. During a patient's initial presentation, if the patient is not currently taking long-term control medication, asthma severity is assessed to guide clinical decisions for initiating the appropriate medication and other therapeutic interventions.
If this therapy needs to be repeated more frequently than every 6 weeks, consider a step up in long-term care.
Find out about cotinine levels, which can help track exposure to tobacco smoke and its toxic constituents using a saliva, blood or urine test. After 2 weeks, the patienta€™s response to therapy was monitored based on a formal assessment of asthma control (ie, frequency of symptoms, nocturnal awakenings, rescue medication use, interference with daily activities, and, ideally, an assessment of lung function). FDA Drug Safety Communication: drug labels now contain updated recommendations on the appropriate use of long-acting inhaled asthma medications called Long-Acting Beta-Agonists (LABAs). He was previously diagnosed with moderate persistent asthma and is being treated accordingly.
Although both diseases share common characteristics, each is associated with distinct pathophysiological mechanisms mediated by specific cell types and factors (Figure 1) [1-5]; therefore, each disease has distinguishing features. Establishment of a firm diagnosis of asthma or COPD may be particularly challenging because of overlapping disease characteristics [7]. Onset of asthma and persistence most commonly occur early in life [1], with rates of asthma prevalence higher in children than in adults [11]. Although considered a disease that primarily affects men, current data suggest almost equal prevalence rates between genders, possibly reflecting the increased rate of smoking among women [2].


In patients with coexisting chronic asthma and COPD, the GOLD guidelines suggest disease management according to the asthma component [2].
Total scores range from 0 to 15; high and low scores support diagnoses of COPD and asthma, respectively [21].
Suggestive features for alternative diagnoses for COPD were reviewed in a previous article in this series. NIH Publication Number 08-4051, 2007 [1] and the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD). For adolescents (at least 12 years old) and adults diagnosed with asthma, levels of severity and asthma control are assessed based on measures of impairment and risk (Figures 3 and 4) [1].
For treatment purposes, patients who had at least 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient’s asthma is better or worse since the last visit.
For treatment purposes, patients who had at least 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma. Assessment of patient inhaler technique is recommended as part of regular follow-up for adults with asthma and COPD [1, 2]. However, these diseases have distinct pathogenic mechanisms and require different strategies for appropriate management.
Without treatment, they will have more frequent and more severe asthma attacks and can even die. With the help of your health-care provider, you can take control of your care and your life. Hospitalizations remain high, at more than 497,000 annually, and there is a disparate impact on African-Americans and Puerto Ricans.
The EPR-2, while helping greatly with the treatment of asthma, was a report based on expert opinion. 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. There is a similar chart used to classify asthma in children 5 to 11 and 0 to 4 years of age. 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. The most frequently used drug in this category is montelukast (Singulair), which seems to be most effective in allergic asthma. Questionnaires also are available for children, but are not part of the EPR-3 control charts for younger children (<12 years of age).
As can be seen in Figure 4, control is classified as well controlled (the goal), not well controlled, or very poorly controlled.
Asthma is characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation [1].
Identification of key indicators (Table 1) may help to distinguish asthma or COPD from other respiratory diseases and from each other [1, 2].
Symptoms of asthma are often variable and may be aggravated by environmental allergens, viral respiratory infections, and other irritants [1].
COPD is associated with chronic symptoms and risk of continual lung function decline [2, 8]. The extent to which airflow obstruction is reversible in patients with COPD has not been determined definitively; however, several clinical studies have reported significant bronchodilator responsiveness in a substantial proportion of patients with COPD [16-19]. Patient recall of increased impairment (asthma symptoms, nighttime awakenings, short-acting β2-adrenergic use, and interference with normal activity) within 2a€“4 weeks, decreased lung function as measured by spirometry (or peak flow when assessing asthma control), and increased frequency and intensity of exacerbations imply greater disease severity or worse asthma control [1].
Patients may also benefit from supplemental instruction on inhaler technique by community-based pharmacists [26]. The addition of an inhaled corticosteroid to long-acting inhaled bronchodilator therapy is recommended in patients with GOLD stage III (severe) or IV (very severe) COPD with a history of repeated exacerbations [2]. Therefore, it is critically important that clinicians make an accurate diagnosis of asthma, COPD, or both upon patient presentation with symptoms. The good news is that deaths from asthma have decreased, fewer patients who have asthma report limitations to activities, and an increasing proportion of people who have asthma receive formal patient education. 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. For patients with mild persistent asthma, the patient should take a low-dose ICS daily and SABA prn. Reducing risk is defined as prevention of recurrent exacerbations and progressive loss of lung function, as well as provision of optimal pharmacotherapy.
These questionnaires include the Asthma Therapy Assessment Questionnaire (ATAQ), the Asthma Control Questionnaire (ACQ), and the Asthma Control Test (ACT: page 80 of EPR-3). Recurrent airflow limitation may be caused by bronchoconstriction, airway edema, airway hyperresponsiveness, or airway remodeling [1]. Reduced exercise capacity is often apparent at moderate and severe stages of disease and is a result of airway hyperinflation [2]. Degree of airflow limitation is no longer recommended for determination of a COPD diagnosis [2]. During the study, patients with scores of 6 to 8 included COPD patients with atopy and greater bronchodilator reversibility and nonallergic patients with asthma who smoked more heavily [21]. Ortiz’s e-newsletter on the GOLD guidelines) Differential diagnosis may be based on results of routine evaluation (medical history, physical examination, and pulmonary function testing) or additional studies if needed (additional pulmonary function testing [lung volume, inspiratory flow-volume loops, diffusing capacity], bronchoprovocation when spirometry results are normal or near normal, chest X ray, computed tomography, allergy testing, or measurement of inflammatory biomarkers [1, 2]. Worse scores on validated asthma control questionnaires also indicate worse asthma control [1]. Spirometry, supported by other screening and diagnostic tools, is strongly recommended for differentiation between these obstructive respiratory diseases in clinical practice. Symptoms usually included in the assessment of impairment are frequency of cough, wheeze, shortness of breath, and chest tightness. So the first step in caring for a patient with asthma beyond diagnosis is classification of severity.
All patients with persistent asthma need an anti-inflammatory drug, since that is the nature of asthma. 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.
The drug omalizumab (Xolair) prevents the binding of IgE to its receptor, thereby inhibiting the IgE-mediated asthma cascade before it begins. COPD is characterized by chronic and progressive airflow limitation that is not fully reversible, resulting from a combination of inflammatory small airway disease (obstructive bronchiolitis) and parenchymal destruction (emphysema) [2]. A history of smoking, combined with specific respiratory symptoms (described above), suggests COPD since most cases occur in long-time smokers [2, 9]. A validated 9-item differential diagnosis questionnaire showed utility in identifying patients likely to have COPD in a population of patients at least 40 years old with previous evidence of obstructive lung disease [20, 22].
The level of severity or asthma control should be assigned according to the most severe category in which any impairment or risk feature occurs [1]. 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). If control is maintained for at least 3 months, the clinician may consider going down one step in therapy (eg, from step 4 to step 3).
Upon evaluation, he reveals a previous 20a€“pack-year smoking history, although he quit several years ago.
COPD also is associated with significant pathological lung changes, extrapulmonary effects, and comorbidities [2].
Treatment algorithms for asthma based on disease severity and level of control are cited in the National Asthma Education and Prevention Program guidelines [1] and previously reviewed. Inhaled corticosteroids are recommended, since they are effective and avoid the severe side effects of systemic corticosteroids. It is very important to remember that ICS is the treatment of choice and the evidence is overwhelmingly in favor of ICS over the alternative. If the asthma is not well controlled, therapy is stepped up by one step and reevaluated in 2 to 6 weeks. Each disease also has predisposing risk factors, most commonly atopy for asthma [1] and smoking for COPD [2]. Inhaled corticosteroids include beclomethasone (Qvar), budesonide (Pulmicort), flunisolide (Aerobid), fluticasone (Flovent), mometasone (Asmanex), and triamcinolone (Azmacort).
Lung inflammation in severe asthma and COPD may be similar [2]; however, distinct attributes of these diseases can be used to distinguish between them. If the asthma is very poorly controlled, a short course of OCS is considered and therapy is increased by one to two steps, and reevaluated in 2 weeks. Because disease management strategies and treatment approaches are different for asthma and COPD [1, 2], an accurate diagnosis should be established as early as possible to avoid potential adverse outcomes and health care costs associated with inappropriate disease management. Less frequently used anti-inflammatory drugs are the nonsteroidal preparations: sodium cromolyn (Intal) and nedocromil (Tilade). This newsletter reviews characteristic features, diagnostic tools, and management approaches for asthma and COPD. While the medications used at each step are important, they represent only part of the plan of care.
Before stepping up therapy, the clinician should review adherence to medication, inhaler technique, environmental control, and comorbid conditions.
If care at or beyond step 4 is required, consultation with an asthma specialist (pulmonologist, allergist, or immunologist) is recommended. Accompanying each step, the patient must receive appropriate education about asthma, steps in environmental control, and how to manage comorbidities (sinusitis, rhinitis, gastroesophageal reflux, obstructive sleep apnea, or allergic bronchopulmonary aspergillosis). Also, if patients require steps 2 to 4, the care team must consider subcutaneous allergen immunotherapy (allergy shots) for patients who have allergic asthma. Neither of those approaches includes omalizumab, since it is not approved for children under age 12.



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