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A Long-Term Control Medications
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Anti-inflammatory agents, long-acting bronchodilators, and leukotriene modifiers comprise the important medications in this group of agents (Table 9 4) Other classes of agents are mentioned briefly below 1 Anti-inflammatory agents Corticosteroids are the most potent and consistently effective anti-inflammatory agents currently available They reduce both acute and chronic inflammation, resulting in fewer asthma symptoms, improvement in airflow, decreased airway hyperresponsiveness, fewer asthma exacerbations, and less airway remodeling These agents may also potentiate the action of -adrenergic agonists Inhaled corticosteroids are preferred for the long-term control of asthma and are first-line agents for patients with persistent asthma Patients with persistent symptoms or
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Table 9 3 Stepwise approach for managing asthma1
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Long-Term Control Step 1: Mild intermittent No daily medication needed Short-acting bronchodilator: inhaled 2-agonists as needed for symptoms Intensity of treatment will depend on severity of exacerbation Use of short-acting inhaled 2-agonists > 2 times a week may indicate the need for long-term control therapy Teach basic facts about asthma Teach inhaler/inhalation chamber technique Discuss roles of medications Develop self-management and action plans Discuss appropriate environmental control measures Step 1 actions plus: Teach self-monitoring Refer to group education if available Review and update self-management plan Step 1 actions plus: Teach self-monitoring Refer to group education if available Review and update self-management plan Quick Relief Education
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Step 2: Mild persistent One daily medication: Anti-inflammatory: either inhaled corticosteroid (low doses) or cromolyn or nedocromil Less desirable alternatives: sustained-release theophylline or leukotriene modifier Step 3: Moderate persistent Daily medication: Either Anti-inflammatory: inhaled corticosteroid (medium dose) or Inhaled corticosteroid (low-medium dose) and a long-acting bronchodilator (long-acting inhaled 2-agonist, sustained-release theophylline or long-acting 2-agonist tablets) If needed: Anti-inflammatory: inhaled corticosteroid (medium-high dose) and Long-acting bronchodilator (long-acting inhaled 2-agonist, sustained-release theophylline or long-acting 2-agonist tablets) Daily medication: Anti-inflammatory: inhaled corticosteroid (high dose) and Long-acting bronchodilator (long-acting inhaled 2-agonist, sustained release theophylline or long-acting inhaled 2-agonist tablets) and Corticosteroid tablets or syrup (1 2 mg/kg/d, generally not to exceed 60 mg/d) As for step 2 Step 1 actions plus: Use of short-acting inhaled 2-agonists on a daily basis, or increasing use, indicates the need for additional long-term control therapy
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Step 4: Severe persistent As for step 2 Step 2 and 3 actions plus: Refer to individual education, counseling
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Step down: Review treatment every 1 6 months; a gradual stepwise reduction in treatment may be possible Step up: If asthma control is not maintained, consider step up to next treatment level after reviewing medication technique, adherence, and environmental control
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Preferred treatments are in bold text; however, specific medication plans should be tailored to individual patients Modified from National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma National Institutes of Health Pub No 97-4051 Bethesda, MD, 1997
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Table 9 4 Long-term control medications for asthma1
Drug Inhaled corticosteroids Beclomethasone dipropionate (QVAR) Budesonide (Pulmicort Turbuhaler) Flunisolide (AeroBid) Fluticasone (Flovent HFA) Triamcinolone acetonide (Azmacort)
Important Formulations 40 mcg/puff 80 mcg/puff Dry powder delivery system: 200 mcg/puff; 200 puffs/inhaler MDI: 250 mcg/puff; 100 puffs/inhaler MDI: 44, 110, or 220 mcg/ puff; 120 puffs/inhaler MDI: 100 mcg/puff; 240 puffs/inhaler
Usual Adult Dosage Two or three puffs twice a day One to two puffs twice a day One inhalation twice a day
Cost2 $6575/ 730 g $8286/ 730 g $17022/ inhaler $8222/7 g $12004/ 12 g (110 g) $11344/ 20 g
Comments Chlorofluorocarbon-free; hydrofluoroalkane propellant
Dry powder
Two to four puffs twice a day Two or three puffs (of 110 mcg) twice a day Two or three puffs four times a day, or four to six puffs twice daily 5 60 mg daily to every other day as needed 5 60 mg daily to every other day as needed 5 60 mg daily to every other day as needed One puff twice a day of 250/50; cannot use more than one puff twice a day due to salmeterol component 2 4 puffs 4 times a day 20 mg (2 mL) four times a day Two puffs four times a day
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