Patient information: Asthma treatment in adolescents and adults

ASTHMA TREATMENT OVERVIEW

Asthma is a common lung disease affecting millions of people worldwide. It is caused by narrowing of the airways (tubes) in the lungs. This narrowing is partially or completely reversible. Symptoms of asthma include wheezing, coughing, chest tightness, and shortness of breath. These symptoms tend to come and go, and are related to the degree of airway narrowing in the lungs. The airways are sensitive to a variety of stimuli, which may include viral illnesses (eg, the common cold), allergens, exercise, foods, or environmental conditions.

Asthma can usually be treated successfully. This requires being well educated about the disease and being an active player in managing it.

This topic will review asthma treatment in adolescents and adults (adolescents defined asß children 12 years and older). Other topics about asthma are also available. (See "Patient information: How to use a peak flow meter" and "Patient information: Asthma inhaler techniques in adults" and "Patient information: Pregnancy and asthma" and "Patient information: Exercise-induced asthma".)

Topics about asthma in children are also available. (See "Patient information: Asthma symptoms and diagnosis in children" and "Patient information: Asthma treatment in children" and "Patient information: Asthma inhaler techniques in children" and "Patient information: Trigger avoidance in asthma".)

CONTROLLING ASTHMA TRIGGERS

The factors that set off and worsen asthma symptoms are called "triggers." Identifying and avoiding asthma triggers are essential steps in preventing asthma flare-ups. Common asthma triggers generally fall into several categories:

• Allergens (including dust, pollen, and furred animals)
• Respiratory infections
• Irritants (such as tobacco smoke or chemicals)
• Physical activity
• Emotional stress
• Menstrual cycle in some women

A small number of patients will develop asthmatic symptoms after exposure to aspirin or other nonsteroidal antiinflammatory medications, like ibuprofen or naproxen. (See "Patient information: Trigger avoidance in asthma" and "Allergen avoidance in the treatment of asthma and allergic rhinitis".)

After identifying potential asthma triggers, you and your clinician should develop a plan to deal with the triggers. There are three main options:

• Avoid the trigger entirely (eg, if allergic to animals, do not own pets, if sensitive to aspirin or related medications, avoid all forms of these medications).
• Limit exposure to the asthma trigger if it cannot be completely avoided (eg, move to another seat if someone with strong perfume is seated nearby, have someone else do house cleaning if allergic to dust mites)
• Take an extra dose of bronchodilator medication before exposure to an asthma trigger. Talk with a healthcare provider before using this approach; it should only be used if the first two options are not possible. Be careful not to use more than twice the amount of medication normally used.

MONITORING SYMPTOMS AND LUNG FUNCTION

Successful asthma treatment relies on your ability to monitor your condition over time. This is done by recording the frequency and severity of symptoms (such as wheezing, coughing, and shortness of breath) and by measuring lung function with a peak expiratory flow rate meter.

Asthma diary — A healthcare provider may recommend keeping a daily asthma diary when symptoms are not well controlled or when starting a new treatment. In the diary, your peak flow readings, asthma symptoms (eg, coughing, wheezing) and medications are recorded (algorithm 1).

A periodic diary may be recommended if you have stable symptoms and your medications have not changed recently. This type of diary can be completed before visiting the healthcare provider, and helps you and your healthcare provider to determine if the asthma treatment plan needs to be adjusted (graph 1).

Peak expiratory flow rate (PEFR) — PEFR measures the rate at which you can exhale. This rate is dependent on the degree of airway narrowing. PEFR monitoring can be used to monitor your lung function and response to treatment, assess the severity of asthma attacks, and guide decisions regarding treatment.

Peak flow meters are inexpensive and easy to use. Adults with persistent asthma may, at times, use a peak flow meter once or twice daily to monitor their lung function. For more information, (see "Patient information: How to use a peak flow meter".

Review of treatment — Adolescents and adults with asthma are usually seen by their healthcare provider every one to six months to evaluate symptom severity and frequency and response to treatment. If your control has been adequate for at least three months, your medication dose may be decreased. If control is not adequate, your medication schedule, delivery technique, and trigger avoidance will be reviewed and your medication dose may be increased.

CATEGORIES OF ASTHMA SYMPTOMS

The medications used for asthma treatment vary according to your age, the severity of asthma, and the level of symptom control. The asthma treatment plan must be reviewed and adjusted on a regular basis. If symptoms are well controlled, medication can often be reduced. As symptoms worsen, medication should be increased.

Intermittent asthma — People with intermittent asthma are defined as those who have the following characteristics (see "Treatment of intermittent and chronic mild asthma in adolescents and adults":

• Symptoms of asthma occur two or fewer times per week
• Asthma does not interfere with daily activities
• Nighttime symptoms awaken you two or fewer nights per month
• Oral steroid treatment (eg, prednisone) is needed no more than once per year to treat increased asthma symptoms

If your asthma is triggered only by vigorous exercise (exercise-induced bronchoconstriction), you might fit into this category, even if you have episode of asthma with exercise more than twice per week. (See "Patient information: Exercise-induced asthma".)

Persistent asthma — People with persistent asthma have symptoms regularly. There may be days when your activities are limited due to symptoms, and you may be awakened from sleep. Lung function is usually normal between episodes but becomes abnormal during an asthma attack.

Based on how frequently you have symptoms and the severity of your asthma flares, the clinician will determine whether your persistent asthma is mild, moderate, or severe. Treatment plans will vary based upon the severity of your asthma as well as your level of symptom control (graph 2). (See "Treatment of moderate persistent asthma in adolescents and adults".)

The symptoms that are used to determine your asthma severity include the number of days per week that you have one or more of the following:

• Symptoms such as cough, wheeze, and shortness of breath
• Nighttime symptoms that awaken the person
• Uses a bronchodilator (reliever medication)
• Symptoms that affect your ability to participate in normal activities

ASTHMA RELIEVER MEDICATIONS

Bronchodilators — Short-acting bronchodilators (usually beta-2 agonists) relieve asthma symptoms rapidly, by temporarily relaxing the muscles around narrowed airways. In the United States, albuterol (Ventolin®, Proventil®, and ProAir® plus generic albuterol) is the most commonly used short-acting bronchodilator (table 1). These medications are sometimes referred to as "quick-acting relievers". People with intermittent asthma, the mildest form of asthma, will require these symptom-relieving medications only occasionally.

The preferred way of taking medication for mild intermittent asthma is by inhalation with a metered dose inhaler. This method allows the medication to take effect rapidly with maximum strength and minimal side effects. (See "Patient information: Asthma inhaler techniques in adults".)

There is no benefit to using short-acting bronchodilators on a regular basis. If your asthma symptoms are consistently occurring more than twice per week, you should review your treatment plan with a healthcare provider. Other medications are more effective for persistent symptoms in this situation.

Side effects of bronchodilators — Some people feel shaky, have a rapid heart rate, and/or feel anxious after using an inhaled short-acting bronchodilator. Using a single puff rather than the usual two puffs may limit these side effects and only minimally decrease their benefit. In addition, these side effects usually become less noticeable over time.

ASTHMA CONTROLLER MEDICATIONS

People with persistent asthma need to take medication on a daily basis to keep their asthma under control, even if there are no symptoms of active asthma on a given day. Medications taken daily for asthma are called "long-term controller" medicines.

Some controller medicines are delivered by inhaler while others are taken as a pill or liquid. The doses and types of controller medications prescribed depend upon your asthma severity and level of symptom control (graph 2).

Inhaled glucocorticoids — Inhaled glucocorticoids (or steroids, for short) act to decreased inflammation (swelling) of the airways over time. Regular treatment with an inhaled corticosteroid reduces the frequency of symptoms (and the need for inhaled bronchodilators for symptom relief), improves quality of life, and decreases the risk of serious attacks.

A number of inhaled glucocorticoids are available, most of which are taken once or twice a day (table 2). An inhaled bronchodilator is still used as needed for relief of symptoms and before exposure to asthma triggers.

Side effects of inhaled glucocorticoids — Unlike glucocorticoids that are taken as tablet or liquid by mouth, very little of the inhaled glucocorticoid is absorbed into the bloodstream and there are few side effects. However, as the dose of inhaled glucocorticoids is increased, more of the medication is absorbed into the bloodstream and the risk of side effects increases.

The most common side effect of low-dose inhaled glucocorticoids is oral candidiasis (thrush). This can usually be prevented by taking inhaled glucocorticoids with a spacer (which helps to deliver medication to the lungs rather than the mouth). You should rinse your mouth or brush your teeth and tongue immediately after inhalation. A hoarse voice and sore throat (without thrush) are less common side effects that are usually managed by changing to a different steroid preparation.

Rare but possible side effects of long-term high dose inhaled glucocorticoids treatments include cataracts, increased pressure in the eye (glaucoma), and increased bone loss (osteoporosis).

The risk of these complications is far less with inhaled glucocorticoids compared to oral glucocorticoids (eg, prednisone). Nevertheless, every effort should be made to use the lowest possible dose that controls asthma and minimizes the risk of an asthma attack.

Long-acting bronchodilators — A long-acting inhaled bronchodilator is often recommended, in combination with an inhaled corticosteroid, to adults with persistent asthma. Long-acting bronchodilators (salmeterol, formoterol) are recommended because they work for a longer period than short-acting bronchodilators (for 12 or more hours, (table 3). A device that contains both an inhaled corticosteroid and a long-acting bronchodilator is usually preferred (Advair®, Symbicort®, Seretide® in Europe). A short-acting bronchodilator is still used as needed for immediate relief of asthma symptoms.

Cromolyn and nedocromil — Cromolyn (Intal®) and nedocromil may be recommended as an alternative to low-dose inhaled glucocorticoids (table 4); however nedocromil is not available in the United States. These medicines work by decreasing the activity of allergy cells. They are taken by metered dose inhaler, but are generally less effective than inhaled glucocorticoids. They are also less convenient because they must be used three or four times daily.

Cromolyn can be used to prevent symptoms before exposure to an asthma trigger or before exercising. (See "Patient information: Exercise-induced asthma".)

Leukotriene modifiers — Leukotriene modifiers, such as montelukast (Singulair®), zafirlukast (Accolate®), or zileuton (Zyflo®) are an alternative to inhaled glucocorticoids (table 5). Leukotriene modifiers work by opening narrowed airways, decreasing inflammation, and decreasing mucus production. They are taken by mouth as a pill once or twice daily, and have very few side effects. However, compared to inhaled glucocorticoids, leukotriene modifiers are generally somewhat less effective in controlling asthma.

Leukotriene modifiers can be used to prevent symptoms before exposure to a trigger or before exercising. (See "Patient information: Exercise-induced asthma".)

Oral glucocorticoids — If symptoms are not controlled with the above medications, an oral glucocorticoid (eg, prednisone) may be added to the treatment regimen. Most healthcare providers recommend a one to two week course of oral glucocorticoids.

EXERCISE-INDUCED ASTHMA

If exercise is a trigger for asthma, an extra dose of bronchodilator medication, leukotriene modifier, or cromolyn can be used to prevent asthma symptoms before exercise. A topic review that discusses exercise-induced asthma is available separately. (See "Patient information: Exercise-induced asthma".)

ASTHMA IN PREGNANCY

Asthma is the most common chronic medical condition that affects the lungs during pregnancy. About 4 percent of pregnant women have asthma. With good asthma treatment during pregnancy, most women can breathe easily, have a normal pregnancy, and give birth to a healthy baby. It is essential to keep asthma well-controlled during pregnancy to ensure that optimal levels of oxygen reach the baby.

Before becoming pregnant, women with asthma should learn as much as they can about the condition and talk with their healthcare providers about asthma treatment during pregnancy. More information about asthma during pregnancy is presented separately. (See "Patient information: Pregnancy and asthma".)

ASTHMA ATTACK TREATMENT

The term asthma "attack" is somewhat confusing because it does not distinguish between a mild increase in symptoms and a life-threatening episode. Symptoms may be aggravated by changes in air quality, common colds, exercise, exposure to allergens, or changes in the weather. These triggers can cause mild, moderate, or severe symptoms to develop. Any of these changes could be considered an asthma "attack."

Some people have periodic, mild asthma attacks that never require emergency care, while others have severe and sudden asthma attacks that require a call for emergency medical services.

Asthma action plan — You should work with your healthcare provider to develop personalized directions (also called an asthma action plan) to follow when symptoms increase or your peak flow rate begins to decrease. An asthma action plan for adolescents and adults is shown in figure 5 (figure 1), and a school asthma action plan is shown in figure 6 (figure 2A-C).

Peak expiratory flow rates can be divided into three zones, which are assigned colors similar to those of a traffic light. These zones can be used to make decisions about the need for treatment:

Green — Green signals that the lungs are functioning well. When symptoms are not present or are well controlled, you should continue your regular medicines and activities.

Yellow — Yellow is a sign that the airways in the lungs are somewhat narrowed, making it difficult to move air in and out; asthma symptoms may be more frequent or more severe. A short-term change or increase in medication is generally required. You should change or increase your medication according to the plan that was discussed with your provider.

Red — Red is a sign that the airways are severely narrowed and requires immediate treatment; symptoms are usually more severe and frequent. The quick-acting reliever inhaler should be used according to the plan discussed with your provider.

Emergency care plan — You should work with your healthcare provider to formulate an emergency care plan that explains specifically what to do if symptoms worsen. This may include more frequent use of a reliever medication and starting or increasing the dose of a long-term controller medication.

However, if symptoms are severe and worsen or do not improve after use of a quick-acting reliever medication, someone should immediately call for emergency medical assistance. Severe asthma attacks can be fatal if not treated promptly. In most areas of the United States, emergency medical assistance is available by calling 911. You should not attempt to drive yourself to the hospital and you should not ask someone else to drive. Calling 911 is safer than driving for two reasons:

• From the moment EMS personnel arrive, they can begin evaluating and treating your asthma. When driving in a car, treatment cannot begin until you arrive in the emergency department.
• If a dangerous complication of asthma occurs on the way to the hospital, EMS personnel may be able to treat the problem immediately.

Following an asthma attack, most people are given a five to ten day course of an oral glucocorticoid medication (eg, prednisone). This treatment helps to reduce the risk of a second asthma attack.

Wear medical identification — Many people with medical conditions wear a bracelet, necklace, or similar alert tag at all times. If an accident occurs and you cannot explain your condition, the identification will help responders provide appropriate care.

The alert tag should include a list of major medical conditions and allergies, as well as the name and phone number of an emergency contact. One device, Medic Alert® (www.medicalert.com), provides a toll-free number that emergency medical workers can call to find out a person's medical history, list of medications, family emergency contact numbers, and healthcare provider names and numbers.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: A guide to asthma
Patient information: How to use a peak flow meter
Patient information: Asthma inhaler techniques in adults
Patient information: Pregnancy and asthma
Patient information: Exercise-induced asthma
Patient information: Asthma symptoms and diagnosis in children
Patient information: Asthma treatment in children
Patient information: Asthma inhaler techniques in children
Patient information: Trigger avoidance in asthma

Professional Level Information:
Agents affecting the 5-lipoxygenase pathway in the treatment of asthma
Allergen avoidance in the treatment of asthma and allergic rhinitis
An overview of asthma management
Diagnosis of asthma in adolescents and adults
Evaluation of severe asthma in adolescents and adults
Identifying patients at risk for fatal asthma
Natural history of asthma
Severe asthma: Evidence for heterogeneity of the disease
Treatment of acute exacerbations of asthma in adults
Treatment of intermittent and chronic mild asthma in adolescents and adults
Treatment of moderate persistent asthma in adolescents and adults
Treatment of severe asthma in adolescents and adults
Patient information: A guide to asthma

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• The National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Heart, Lung, and Blood Institute

      (www.nhlbi.nih.gov/)

• American Lung Association

      (www.lungusa.org)

• What's Asthma All About?

      (www.whatsasthma.org)

• The Asthma and Allergy Foundation of America

      (www.aafa.org)

• American Academy of Allergy, Asthma, and Immunology

      (www.aaaai.org/patients.stm)

• American College of Allergy, Asthma, and Immunology

      (www.acaai.org/public/)

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