38. FDA pregnancy risk categories for asthma medications
Agent Risk category
Albuterol (Ventolin)
C
Pirbuterol (Maxair)
C
Levalbuterol (Xopenex)
C
Terbutaline (Bricanyl)
B
Salmeterol (Serevent)
Formoterol (Foradil Oxis)
C
C
Ipratropium bromide (Atrovent) B
Cromolyn sodium (Intal)
B
Nedocromil sodium (Tilade)
B
39. Zafirlukast (Accolate)
Montelukast sodium (Singulair)
Zileuton (Zyflo)
B
B
C
Budesonide (pulmicort)
Beclomethasone dipropionate (Becotide)
Fluticasone propionate (Flixotide)
Triamcinolone acetate (Azmacort)
Flunisolide (AeroBid)
Ciclesenoide (Alvesco)
B
C
C
C
C
C
Oral Corticosteroids C
Theophylline C
Omalizumab (Xolair) B
41. DDeeffiinniittiioonn ooff AAsstthhmmaa
AAsstthhmmaa,, iirrrreessppeeccttiivvee ooff tthhee sseevveerriittyy,, iiss
aa cchhrroonniicc iinnffllaammmmaattoorryy ddiissoorrddeerr ooff tthhee aaiirrwwaayyss..
AAiirrwwaayy iinnffllaammmmaattiioonn iiss aassssoocciiaatteedd wwiitthh::
● AAiirrwwaayy hhyyppeerr rreessppoonnssiivveenneessss..
● AAiirrffllooww lliimmiittaattiioonn..
● RReessppiirraattoorryy ssyymmppttoommss..
((GINA, the Global Strategy for Asthma Management and Prevention, 2002.)
45. Asthma can be effectively controlled in most
patients, although it can not be cured
The major factors contributing to asthma morbidity
mortality are under-diagnosis and inappropriate
treatment.
The most effective management is to prevent airway
inflammation by eliminating the causal factors.
99. SSuussttaaiinneedd rreelleeaassee tthheeoopphhyylllliinnee
RRoollee iinn tthheerraappyy::
As monotherapy is an alternative, but not preferred
tthheerraappyy ffoorr mmiilldd ppeerrssiisstteenntt aasstthhmmaa..
For moderate or severe persistent asthma, theophylline
mmaayy bbee ccoonnssiiddeerreedd aass aalltteerrnnaattiivvee,, bbuutt nnoott pprreeffeerrrreedd
ooppttiioonn ffoorr LLAABBAA..
As add on therapy , theophylline is less effective
tthhaann LLAABBAA..
((NNAAEEPPPP 22000044))
101. TThheeoopphhyylllliinnee iinn pprreeggnnaannccyy
Pregnancy iiss aassssoocciiaatteedd wwiitthh hhyyppoo--aallbbuummiinneemmiiaa,,
tthhee pprrootteeiinn bbiinnddiinngg ooff tthheeoopphhyylllliinnee ddeeccrreeaasseess bbyy
1100 –– 1155 %% dduurriinngg pprreeggnnaannccyy ..
Theophylline clearance may be reduced by 30% during
tthhee 33rrdd ttrriimmeesstteerr ..
((NNAAEEPPPP 11999933))
It is important to closely monitor the theophylline serum
concentration and the patient for signs of toxicity during
pregnancy .
102. TThheeoopphhyylllliinnee iinn pprreeggnnaannccyy
c Clinical experience coonnffiirrmm tthhee ssaaffeettyy ooff
tthhyyoopphhyylllliinnee aatt rreeccoommmmeennddeedd ddoosseess (( 55--1122 μμccgg // mmll ))..
Theophylline crosses the placenta.
The new born may have jitteriness, increased heart
rraattee,, eevveenn vvoommiittiinngg aatt bbiirrtthh ((iiff tthhee mmaatteerrnnaall bblloooodd
lleevveell 12 μcg / ml ))
((NNAAEEPPPP 11999933))
103. Theophylline is not contraindication to breast feeding.
((NNAAEEPPPP 11999933))
nnuurrssiinngg iinnffaanntt,, tthhiiss iiss uussuuaallllyy nnoott cclliinniiccaallllyy ssiiggnniiffiiccaanntt ..
1% or less of the maternal theophylline does reaches the
Theophylline iiss eexxccrreetteedd iinnttoo bbrreeaasstt mmiillkk
TThheeoopphhyylllliinnee iinn llaaccttaattiioonn
105. OOrraall ccoorrttiiccoosstteerrooiiddss
RRoollee iinn tthheerraappyy::
Short bursts for acute asthma episodes when the
ppaattiieenntt’’ss ccoonnddiittiioonn hhaass nnoott rreessppoonndd ttoo sshhoorrtt
aaccttiinngg BB22 aaggoonniissttss..
For the long term in severe persistent asthma.
((PPoossttggrraadduuaattee MMeeddiicciinnee MMaayy 22000044))
106. Oral corticosteroids in pprreeggnnaannccyy
It has been known for decades that administration of
ccoorrttiiccoosstteerrooiiddss ttoo ssuusscceeppttiibbllee ssttrraaiinnss ooff mmiiccee aanndd rraattss
wwiillll iinnccrreeaassee ppaallaattaall cclleeffttiinngg..
Oral corticosteroid use during the first trimester of
pprreeggnnaannccyy iiss aassssoocciiaatteedd wwiitthh aann iinnccrreeaasseedd rriisskk ffoorr
iissoollaatteedd cclleefftt lliipp wwiitthh oorr wwiitthhoouutt cclleefftt ppaallaattee..
((tthhee rriisskk iinn tthhee ggeenneerraall PPooppuullaattiioonn iiss 00..11 ppeerrcceenntt;; tthhee rriisskk iinn
wwoommeenn oonn oorraall ccoorrttiiccoosstteerrooiiddss iiss 00..33 ppeerrcceenntt))..
((NNAAEEPPPP 22000044))
107. ((CChhaammbbeerrss.. IImmmmuunnooll AAlllleerrggyy cclliinn NN AAmmeerr 22000066))
aassssoocciiaattiioonnss))
Preeclampsia and prematurity (independent
tthhrroouugghhoouutt pprreeggnnaannccyy))
Lower infant birth weight (prednisone 10mg daily
Oral clefts (33 –– 66 ffoolldd iinnccrreeaasseedd rriisskk))..
during pregnancy
Adverse associations with oral steroids
108. OOrraall ccoorrttiiccoosstteerrooiiddss iinn pprreeggnnaannccyy
The available ddaattaa mmaakkee iitt ddiiffffiiccuulltt ttoo sseeppaarraattee tthhee
aaddvveerrssee eeffffeeccttss ooff oorraall sstteerrooiiddss oonn mmaatteerrnnaall ffeettaall
oouuttccoommeess ffrroomm tthhee eeffffeeccttss ooff sseevveerree oorr
uunnccoonnttrroolllleedd aasstthhmmaa..
Although the data are uncertain about some risks of
oorraall ccoorrttiiccoosstteerrooiiddss dduurriinngg pprreeggnnaannccyy,,
sseevveerree uunnccoonnttrroolllleedd aasstthhmmaa ppoosseess aa ddeeffiinniittee rriisskk
ttoo tthhee mmootthheerr aanndd ffeettuuss..
((NNAAEEPPPP 22000044))
109. OOrraall ccoorrttiiccoosstteerrooiiddss iinn pprreeggnnaannccyy
The risk-benefit considerations favor the use of
oorraall ccoorrttiiccoosstteerrooiidd mmeeddiiccaattiioonn wwhheenn iinnddiiccaatteedd iinn
tthhee lloonngg--tteerrmm mmaannaaggeemmeenntt ooff sseevveerree ppeerrssiisstteenntt
aasstthhmmaa aaccuuttee eexxaacceerrbbaattiioonnss dduurriinngg pprreeggnnaannccyy..
((NNAAEEPPPP 22000044))
Asthma Management
There are two main ways to pharmacologically manage this chronic inflammatory disease of the airways
Medication Overview
Rescue Meds
Bronchoconstriction and acute airflow obstruction are typically treated with “rescue medication,” which primarily includes short-acting beta2-agonists, but also includes anticholinergics and systemic corticosteroids
Rescue medications are an important part of appropriate asthma management, and everyone with asthma should have rescue medication on hand.
Controller Meds
People with persistent asthma, should be on controller medication, which is taken on a daily, long-term basis.
They are primarily corticosteroids, but also include cromolyn, nedocromil, leukotriene modifiers, and long-acting Beta2-agonists.
Vertical Growth – The NEAPP Recommendations:
Despite the reassuring findings from studies examining long-term effects of inhaled corticosteroids, it may still be prudent that
providers:
Weigh the benefits of asthma control against the possibility of growth suppression or delay.
Keep in mind that growth rates in children are highly variable.
Understand that children with asthma tend to have longer periods of reduced growth rates prior to puberty (males > females).
Monitor the growth of children and adolescents taking corticosteroids.
Use the lowest dose of corticosteroids necessary to maintain control.
Administer medications with age-appropriate devices, such as spacers/holding chambers.
Advise patients to rinse and spit following inhalation.
Spacers come in many shapes and sizes.
The only bad spacer is the one that isn’t used.
All people with asthma, adults and children, should be using spacers.
Steroid Phobia
Background
Many patients and parents of children with asthma have heard about potential growth-stunting effects or other adverse events associated with corticosteroids and are therefore reluctant to agree to treatment with corticosteroids.
In a recent Canadian survey of 603 patients with asthma, more than 50% of the patients reported they were ‘very’ or ‘somewhat’ concerned about using inhaled corticosteroids on a regular basis. Despite their concerns, two-thirds of these patients had never discussed their apprehensions with their physician.
The most common concerns are those of vertical growth, bone mineral density, cataracts and glaucoma, skin problems, and glucose metabolism