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DOCUMENT CONTROL SHEET

Development
And Consultation

Dissemination

Originally developed in 2015 by the NCD Working Group which


included PHCC Health Center Physicians and members from the
Service Development and Health Promotion, Operations, Clinical
Affairs and Workforce Training departments. The guideline has
been developed in reference to the implementation of NCD
Services across all PHCC health centers. External peer review
was obtained from HMC. Review and ratified by PHCC Guideline
Review Committee (PGRC), and approved by the Executive
Director of Clinical Affairs.
This guideline will be disseminated to all Primary Health Care
Corporation (PHCC) Directorates and Health Centre Managers
and clinicians through announcements, memos and training. It will
also be available to view and download from Primary Health Care
Corporation (PHCC) intranet web site.

Target Audience

This document targets PHCC staff working at all health centers


including but not limited to physicians, nurses, health educators,
pharmacists and nutritionists.

Implementation

The NCD Pilot Working Group is responsible for ensuring that this
Guideline is implemented and all required staff receives the
training in the application of the guideline.

Training

The NCD Pilot Working Group will work with health center
managers to ensure that all required staff receives appropriate
training and support in implementing this guideline.

Audit

The Quality Improvement or Accreditation Management Team and


the guideline issuing Directorate are responsible for auditing this
Guideline and verifying that the management is based on the
available best practices it is produced to a high standard.

Review

The issuing Directorate in consultation with necessary group(s)


will review this Guideline after 1 year for the first revision cycle and
then every 3 years.

This Guideline complies with National Health Strategy 2011-2016


Compliance
with
Goal 2.1.2 and other accreditation bodies such as Accreditation
National Guidance and
Canada International (ACI) and national standards where
Accreditation Standards
applicable.

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Table of Contents
1.

Introduction .................................................................................................................................... 1

2.

Purpose /Objective Of The Guideline ............................................................................................. 1

3.

Definitions / Abbreviation................................................................................................................ 2

4.

Clinical Specialty ............................................................................................................................ 3

5.

Intended Users ............................................................................................................................... 3

6.

Target Population ........................................................................................................................... 3

7.

Guideline ........................................................................................................................................ 3

8.

Indications for Referral to Secondary Care .................................................................................. 12

9.

Recommendation ......................................................................................................................... 12

10. Guideline Linked .......................................................................................................................... 12


11. Appendices .................................................................................................................................. 12
12. References ................................................................................................................................... 12

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Date issued
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Management of Asthma
Date Reviewed 02/10/2014
Clinical Practice Guidelines Next revision 02/10/2015
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REVISION CONTROL SUMMARY


Edited By

Version

Paragraph No

Description of Change

Ossama Mansy

All

Pasted into clinical affairs


template

1.

Date Approved

Introduction
Asthma is a major cause of chronic morbidity and mortality throughput the world and there
is evidence that its prevalence has increased considerably over the past 20 years,
especially in children. According to WHO about 235 million people currently suffer from
asthma around the world. Like other countries in the world Asthma is also common in GCC,
it is particularly common among children. According to one study the prevalence of Asthma
in Qatari school children stands at around 19.8%1 which is comparatively higher than in
some of the neighboring Gulf countries. Asthma is occasionally under-diagnosed and
under-treated. It creates substantial burden to individuals and families and often restricts
individuals activities for a lifetime. Minimizing the risk factor, proactively controlling the
symptoms through medication and avoiding the triggers can result in better outcome and
quality of life for individuals suffering with the disease.
These Clinical Practice Guidelines (CPGs) and Recommendations are based upon the best
information available at the time of preparation. They are designed to provide information
and assist decision-making. They are not intended to define a standard of care, and should
not be construed as one. Neither should they be interpreted as prescribing an exclusive
course of management.
Variations in practice will inevitably and appropriately occur when clinicians take into
account the needs of individual patients, available resources, and limitations unique to an
institution or type of practice. Every health-care professional making use of these CPGs
and Recommendations is responsible for evaluating the appropriateness of applying them
in the setting of any particular clinical situation.

2.

Purpose /Objective Of The Guideline


The purpose of this guideline is to standardize the management of Asthma within all PHCC
health centers according to current evidence based best practice.

Prevalence of Asthma Among Qatari Schoolchildren, Pediatric Pulmonology, Prevalence of Asthma Among Qatari School children

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Date Reviewed 02/10/2014
Clinical Practice Guidelines Next revision 02/10/2015
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3.

Definitions / Abbreviation
Asthma

Wheezing
Cough-variant asthma

Exercise-induced
bronchoconstriction.
Occupational asthma.

Airway Obstruction
Revisable obstruction
Exacerbation

Asthma is a common chronic disorder of the airways that is complex and


characterized by variable and recurring symptoms, airflow obstruction,
bronchial hyper responsiveness, and an underlying inflammation
High-pitched whistling sounds when breathing.
Some patients with asthma have chronic cough (frequently occurring at
night) as their principal, if not only, symptom.
For these patients, documentation of lung function variability and airway
hyper-responsiveness are particularly important
is an important cause of asthma symptoms for most asthma patients, and
for some (including many children) it is the only cause
an absence of asthma symptoms before beginning of employment; and a
documented relationship between symptoms and the workplace
(improvement in symptoms away from work and worsening of symptoms
upon returning to work)
The airways become inflamed and produce excess mucus and the muscles
around the airways tighten making the airways narrower.
Improved airflow obstruction and bronchospasm accompanied with
clinical improvement of asthma patient and spirometry reading.
Suddenly development of an acute episode of severe asthma

Bronchial
hyper Where the bronchial airways are extra sensitive or hyper reactive. It is a
responsiveness
state characterized by easily triggered bronchospasm.
ACQ
ACT
C-ACT
COPD
FEV1
GCC
GINA
IgE
LABAs
PEF
PHCC
SABAs
WHO
NCD

Asthma Control Questionnaire


Asthma Control Test
Childhood Asthma Control test
Chronic obstructive pulmonary disease
Forced Expiratory Volume in 1 Second.
Gulf Cooperation Council
Global Initiative for Asthma
Immunoglobulin E
Long-Acting Beta Agonists
Peak expiratory flow
Primary Health Care Corporation
Short-Acting Beta Agonists
World Health Organization
Non communicable Disease.

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4.

Clinical Specialty
Allergy and Immunology
Emergency Medicine
Family Practice
Internal Medicine
Pediatrics
Pharmacology
Pulmonary Medicine

5.

Intended Users
All Health Care Providers in PHCC.

6.

Target Population
This guideline applies to all patients diagnosed with Asthma aged 5 years and above of
both genders attending PHCC health centers. Patient less than 5 years should be treated
as per the Emergency Guideline.

7.

Guideline2

7.1.

Patient Evaluation: (Assessment & Diagnosis )


7.1.1. Detailed medical history including personal and family history
7.1.2. Physical examination: Focusing on the upper respiratory tract, chest, and skin.
7.1.3. To establish a diagnosis of asthma, the clinician should determine that:
1. History of Episodic symptoms of airflow obstruction or airway hyper
responsiveness is present including wheeze, cough and breathing difficulty.
2. Airflow obstruction is at least partially reversible.
3. Alternative diagnoses are excluded.
4. Specific Tests:
a) Spirometry: Is the preferred method to diagnose asthma. Spirometry
demonstrates obstruction and assesses reversibility in all patients including
children aged 5 years and above. Reversibility is determined either by an
increase in FEV1 of 12 percent from baseline or by an increase 10 percent
of predicted FEV1 after inhalation of a short-acting bronchodilator.
b) Peak Expiratory Flow (PEF): An important aid in both diagnosis and
monitoring of
asthma. PEF measurements are ideally compared to the

This guideline has been developed based on the Global Institute for Asthma Pocket Guide for Asthma Management and
Prevention. http://www.ginasthma.org/local/uploads/files/GINA_Pocket2013_May15.pdf

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patients own previous best measurements using his/her own peak flow
meter. An improvement of 60 L/min (or 20% of the pre-bronchodilator PEF)
after inhalation of a bronchodilator, or diurnal variation in PEF of more than
20% (with twice-daily readings, more than 10%), suggests a diagnosis of
asthma.
5. Other Tests: (if indicated and applicable)
a) Skin Prick tests with allergens or measurement of specific IgE in serum:
The presence of allergies increases the probability of a diagnosis of asthma
and can help to identify risk factors that cause asthma symptoms in individual
patients.
b) Exercise challenging test
c)

Meth choline stress Test

d) FENO test (Fractional exhaled nitric oxide)


6. Additional studies as necessary to exclude alternate diagnoses.
For patients with symptoms consistent with asthma, but normal lung function,
measurements of airway responsiveness to meth choline and histamine, or
exercise challenge may help establish a diagnosis of asthma (this is currently
carried out by secondary care
7. Following can be counted as Key Symptom Indicators for Considering a
Diagnosis of Asthma:
a) Wheezing: High-pitched whistling sounds when breathing out especially in
children. A lack of wheezing and a normal chest examination do not exclude
asthma.
b) History of any of the following:
-

Cough (worse particularly at night)

Recurrent wheeze

Recurrent difficulty in breathing

Recurrent chest tightness

c) Symptoms occur or worsen in the presence of:


-

Exercise

Viral infection

Inhalant allergens (e.g. animals with fur or hair, house-dust mites, mold,
pollen)

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-

Irritants (tobacco or wood smoke, airborne chemicals)

Changes in weather

Strong emotional expression (laughing or crying hard)

Stress

d) Eczema, hay fever, or a family history of asthma or atopic diseases is often


associated with asthma, but they are not key indicators.
7.2.

Treatment/Management :
7.2.1. Four components considered essential to effective asthma management:
a) Obtained measures by objective tests, physical examination, patient history
and patient report can determine the characteristics and severity of asthma
and accordingly if control is achieved and maintained or not.
b) Education for a partnership in asthma care.
c) Control of environmental factors and comorbid conditions that affect asthma.
d) Pharmacologic therapy.
7.2.2. The assessment of asthma control
a) Each patient should be assessed to establish his or her current treatment
regimen, adherence to the current regimen, and level of asthma control.
b) A simplified scheme for recognizing controlled, partly controlled, and
uncontrolled asthma is provided in Table 1 below.
c) Lung function is not a reliable test for children younger than 5 years of age.
d) Measures for assessing clinical control of asthma include:
e) Asthma Control Test (ACT): www.asthmacontrol.com (Appendix 6)
f) Childhood Asthma Control test (C-Act)

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TABLE 1: ASSESSMENT OF CURRENT CLINICAL CONTROL (PREFERABLY OVER 4 WEEKS)


Characteristics

Controlled
(All of the following)

Partly Controlled
(Any
measure
presented)

Uncontrolled

Daytime symptoms

None
(twice
less/week)

More
twice/week

Limitation of activities

None

Any

Three
or
more
features of partly
controlled asthma*

Nocturnal
symptoms/awaking

None

Any

Need for reliever/


rescue inhaler

None
(twice
less/week)

Lung function (PEF or


FEV )

Normal

or

or

More
twice/week

than

than

< 80% predicted or


personal
best
(if
known)

Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side
effects)
Features that are associated with increased risk of adverse events in the future include:
Poor clinical control, frequent exacerbations in past year*, ever admission to critical care for
asthma, low FEV , exposure to cigarette smoke, high dose medications
* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate
By definition, an exacerbation in any week makes that an uncontrolled asthma week
Without administration of bronchodilator
7.2.3. Pharmacological Treatment
Management Approach based on control
a) Each patient is assigned to one of five treatment steps. Figure 1 below
details the treatments at each step for adults and children age 5 and over.
b) At each treatment step, reliever medication should be provided for quick relief
of symptoms as needed (regular or increased use indicates that asthma is not
well controlled.)

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c) At Steps 2 through 5, patients also require one or more regular controller
Inhaled glucocorticosteroids medications, which keep symptoms and
attacks from starting (see appendix 2 and appendix 3 for details).
d) For most patients newly diagnosed with asthma or not yet on medication,
treatment should be started at Step 2 (or if the patient is very symptomatic, at
Step 3). If asthma is not controlled on the current treatment regimen,
treatment should be stepped up until control is achieved.

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e) Patients who do not reach an acceptable level of control at Step 4 can be


considered to have difficult-to-treat asthma. Referral to an asthma specialist is
advisable.
7.2.4. Asthma Control
a) To improve control of asthma and reduce medication needs, patients should take
steps to avoid the risk factors that cause their asthma symptoms.
b) Physical activity is a common cause of asthma symptoms but patients should not
avoid exercise. Symptoms can be prevented by taking a rapid-acting inhaled agonist before strenuous exercise (a leukotriene modifier or cromones are
alternatives).
c) Inhalation Technique:
Advantages of inhaled therapy in respiratory disease are well recognized.
However despite these advantages, inhaler technique problem can lead to
ineffective inhalation therapy. All patients should learn how to inhale
effectively. Please see inhaler technique, Appendix 5.
Patients with asthma should be advised to receive an influenza vaccination
every year, or at least when vaccination of the general population is advised.
Inactivated influenza vaccines are safe for adults and children over age 3.
Refer to appendix 1 for special considerations in managing asthma and
appendix 2 for strategies for avoiding common allergens and pollutant.
7.2.5. Medications:
Medications for asthma are categorized into two general classes:
1. Short Term Control:
a) Short-Acting Inhaled Beta Agonists (SABAs): are bronchodilators that
relax smooth muscle and are therapy of choice for relief of acute symptoms.
b) Anticholinergics: provides additive benefit to short-acting beta agonists
(SABAs) in moderate-to-severe asthma exacerbations. May be used as an
alternative bronchodilator for patients who do not tolerate SABA.
c) Oral corticosteroids: are used for moderate and severe exacerbations as
adjunct to SABAs to speed recovery and prevent recurrence of exacerbations.
Refer to Appendix 3 and Appendix 4 for additional details about dosages and side effects
of controller and reliever medications.

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2. Long term control medications: According to the case and treatment flow
sheet.
a) Inhaled Corticosteroids: They are the most potent and effective antiinflammatory medication currently available.
b) Long-Acting Beta Agonists (LABAs): have duration of bronchodilation of at
least 12 hours after a single dose. LABAs are not to be used as monotherapy
for long-term control of asthma.
c) Combines. (Long acting Beta agonist & ICS).
d) Leukotriene modifiers: Are alternatives, but not necessarily preferred, therapy
for the treatment of mild persistent asthma.
e) Cromolyn sodium and nedocromil: They are used as alternative, but not
preferred, medication for the treatment of mild persistent asthma.
f) Immunomodulators: Are used as adjunctive therapy for patients 12 years of
age that have allergies and severe persistent asthma.
3. Special Considerations in Managing Asthma:
a) Pregnancy: During pregnancy the severity of asthma often changes and
patients may require close follow-up and adjustment of medications. Pregnant
patients with asthma should be advised that the greater risk to their baby lies
with poorly controlled asthma, and the safety of most modern asthma
treatments should be stressed. Acute exacerbations should be treated
aggressively to avoid fetal hypoxia.
b) Obesity: Management of asthma in the obese should be the same as patients
with normal weight. Weight loss in the obese patient improves asthma control,
lung function and reduces medication needs.
c) Rhinitis, Sinusitis, and Nasal Polyps: can often coexist in the same patient,
and treatment of rhinitis may improve asthma symptoms. Both acute and
chronic sinusitis can worsen asthma, and should be treated. Nasal polyps are
associated with asthma and rhinitis, often with aspirin sensitivity and most
frequently in adult patients. They are normally quite responsive to topical
glucocorticosteroids.
d) Respiratory infections: can provoke wheezing and increased asthma
symptoms in many patients.
e) Gastro esophageal reflux: is more common in patients with asthma
compared to the general population. However, treatments with proton pump
inhibitors, H2 antagonists or surgery fail to improve asthma control.

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f) Aspirin-induced asthma: Up to 28 percent of adults with asthma, but rarely
children, suffer from asthma exacerbations in response to aspirin and other
nonsteroidal anti-inflammatory drugs. The diagnosis can only be confirmed by
aspirin challenge, which must be conducted in a facility with cardiopulmonary
resuscitation capabilities. Complete avoidance of the drugs that cause
symptoms is the standard management.
g) Anaphylaxis: is a potentially life-threatening condition that can both mimic
and complicate severe asthma. Prompt treatment is crucial and includes
oxygen, intramuscular epinephrine, injectable antihistamine, intravenous
hydrocortisone, and intravenous fluid.
4. Establishment of Witten ASTMA ACTION PLAN
a) Like inhaler technique, asthma action plans (AAPs) are seen by many
guidelines as an essential component of asthma care. Guidelines such as
BTS/SIGN (2010) recommend AAPs for all patients who have exacerbated as
a minimum. As most patients, even those who are well controlled may
experience some loss of control 6-7 times per year (Partridge et al, 2007), this
may be interpreted as all asthma patients should have an AAP please refer to
b) Refer to My Asthma Plan in Appendix 6

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7.2.6. Manage Exacerbations: Refer to the primary urgent care guidelines.
Severity of Asthma Exacerbation:

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8.

Indications for Referral to Secondary Care


1) Severe uncontrolled Asthma, refer it to ED.
2) Treatment goals are not being met after three weeks to six months of treatment, or
asthma is not responding to current therapy.
3) Atypical signs and symptoms make asthma diagnosis unclear, or other conditions are
complicating asthma or its diagnosis
4) Patient history suggests asthma is being provoked by unknown occupational factors, an
environmental inhalant, or an ingested substance.
5) Additional diagnostic testing if indicated.

9.

Recommendation
1) Before changing a patients treatment due to poor control try to eliminate any possible
trigger factors
2) Review inhaler use periodically, checks their compliance with medication treatment.
3) Engage and educate patients and caregivers regarding asthma management, to follow
asthma action plan.
4) Spirometry should be made available as tools for diagnosing asthma at all PHCC and
appropriate training should be provided.

10.

Guideline Linked
My Asthma Plan.

11.

Appendices
Appendix 1 Strategies for Avoiding Common Allergens and Pollutants
Appendix 2 Estimated Equipotent Daily Doses of Inhaled Glucocoticosteroids
Appendix 3 Glossary of Asthma Medications
Appendix 4 Questions for Monitoring Asthma Care
Appendix 5 Asthma Control Test (ACT)
Appendix 5 How to teach inhaler technique
Appendix 6 My Asthma Plan

12.

References
1) Prevalence of Asthma Among Qatari Schoolchildren,
Prevalence of Asthma Among Qatari School children

Pediatric

Pulmonology,

2) Global Institute for Asthma Pocket Guide for Asthma Management and Prevention.
http://www.ginasthma.org/local/uploads/files/GINA_Pocket2013_May15.pdf

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3) National Heart, Lung and Blood Institute. Expert Panel Report 3 (EPR3): Guidelines for
the Diagnosis and Management of Asthma Component 4: Medication.
http://www.nhlbi.nih.gov/guidelines/asthma/07_sec3_comp4.pdf

Appendix 1 Strategies for Code


Avoiding Common
Allergens and Pollutants Pages

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Appendix 1 Strategies for Avoiding Common Allergens and Pollutants


Strategies for Avoiding Common Allergens and Pollutants
Avoidance measures that improve control of asthma and reduce medication needs:
Tobacco smoke: Stay away from tobacco smoke. Patients and parents should not smoke.
Drugs, foods, and additives: Avoid if they are known to cause symptoms.
Occupational sensitizers: Reduce or, preferably, avoid exposure to these agents
Reasonable avoidance measures that can be recommended but have not been shown to have
clinical benefit
House dust mites: Wash bed linens and blankets weekly in hot water and dry in a hot dryer or sun.
Encase pillows and mattresses in air-tight covers. Replace carpets with hard flooring, especially in
sleeping rooms. (If possible, use vacuum cleaner with filters. Use a caricides or tannic acid to kill
mites--but make sure the patient is not at home when the treatment occurs.
Animals with fur: Use air filters. (Remove animals from the home, or at least from the sleeping
area. Wash the pet.)
Cockroaches: Clean home thoroughly and often. Use pesticide spray--but make sure the patient is
not at home when spraying occurs.
Outdoor pollens and mold: Close windows and doors and remain indoors when pollen and
mold counts are highest.
Indoor mold: Reduce dampness in the home; clean any damp areas frequently

Appendix 2 Estimated Code


Equipotent Daily Doses of
Inhaled
Pages
Glucocorticosteroids

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Appendix 2 Estimated Equipotent Daily Doses of Inhaled Glucocorticosteroids

Appendix 3 Glossary of
Asthma Medications

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Appendix 3 Glossary of Asthma Medications


Glossary of Asthma Medications - Controllers
Name and Also known Usual Doses
As
Glucocorticosteroids
Inhaled:
Beginning
Adrenocorticoids
dose dependent on
Corticosteroids
asthma control then
Glucocorticoids
titrated down over 2-3
months to lowest
Inhaled (ICS):
effect dose once
Beclomethasone
control is achieved.
Budesonide Ciclesonide
Flunisolide
Tablets or syrups: For
Fluticasone Mometasone daily control use
Triamcinolone
lowest effective dose
5-40mg of prednisone
Tablets or syrups:
equivalent in a.m. or
Hydrocortisone
qod.
Methylprednisolone
Prednisolone
For acute attacks 40Prednosone
60 mg daily in 1 or 2
divided doses for
adults or 1-2 mg/kg
daily in children.

Sodium Cromoglycate
Cromolyn

Side Effects

Comments

Inhaled: High daily


doses
may
be
associated with skin
thinning are bruises,
and rarely adrenal
suppression. Local side
effects are hoarseness
and
oropharyngeal
candidiasis. Low to
medium doses has
produced minor growth
delay or suppression
(av. 1 cm) in children.
Attainment of predicted
adult height does not
appear to be affected.

Inhaled: Potential but


small risk of side effects is
well balanced by efficacy.
Valved holding- chambers
with MDIs and mouth
washing with DPIs after
inhalation decrease oral
Candidiasis. Preparations
note equivalent on per
puff or g basis.

Tablets or syrups:
Long term use: alternate
day a.m. dosing produces
less toxicity. Short term:
3- 10 day bursts are
Tablets or syrups: Used effective for gaining
long term, may lead to prompt control.
osteoporosis,
hypertension, diabetes,
cataracts,
adrenal
suppression,
growth
suppression,
obesity,
skin thinning or muscle
weakness.
Consider
coexisting
conditions
that could be worsened
by
oral
glucocorticosteroids,
e.g.
herpes
virus
infection,
Varicella,
tuberculosis,
hypertension, diabetes
and osteoporosis.
MDI 2 mg or 5 mg 2-4 Minimal side effects. May take 4-6 weeks to
inhalations 3-4 times Cough may occur upon determine
maximum

Appendix 3 Glossary of
Asthma Medications

cromones

Nedocromil
cromones
Long-acting 2- agonists
Beta-adrenergis
Sympathomimetics
LABAs
Inhaled:
Formoterol (F)
Salmeterol (Sm)
Sustainedrelease
tablets:
Salbutamol (S)
Terbutaline(T)
Aminophylline
Methylxanthine
Xanthine

daily.
Nebulizer 20 mg 3-4
times daily
MDI 2 mg/puff 2-4
inhalations 2-4 times
daily.
Inhaled:
DPI F: 1 inhalation
(12 g) bid.
MDI F: 2 puffs bid.
DPI Sm: 1 inhalation
(50 g) bid.
MDI Sm: 2 puffs bid.

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inhalation.

effects. Frequent daily


dosing required.

Cough may occur upon Some patients unable to


inhalation
tolerate the taste.
Inhaled: fewer and less
significant, side effects
than tablets. Have been
associated with an
increased risk of severe
exacerbations
and
asthma deaths when
added to usual therapy.

Inhaled: Salmeterol NOT


to be used to treat acute
attacks. Should not use as
mono
therapy
for
controller
therapy.
Always use as adjunct to
ICS therapy. Formoterol
has onset similar to
Tablets:
salbutamol and has been
S: 4 mg q 12h.
Tablets: may cause used as needed for acute
T: 10 mg q 12h.
tachycardia,
anxiety, symptoms.
Starting
does
10 skeletal muscle tremor,
mg/kg/day with usual headache, hypokalemia. Tablets: As effective as
800 mg maximum in Nausea and vomiting sustainedrelease
1-2 divided doses.
are most common. theophylline. No data for
Serious
effects use as adjunctive therapy
occurring at higher with
inhaled
serum concentrations glucocorticosteroids.
include
seizures, Theophylline
level
tachycardia,
and monitoring
is
often
arrhythmias.
required. Absorption and
metabolism
may
be
affected by many factors,
including febrile illness.

Appendix 3 (A): Glossary of Asthma Medications Controllers (continued..)


Name and Also Known Usual Doses
Side Effects
Comments
As
Antileukotrienes
Adult: M 10mg qhs
No specific adverse Antiliukotrienes
are
Leukotriene modifiers
P 450 mg bid
effects to date at most effective for
Montelukast (M)
Z 20 mg bid;
recommended doses. patients with mild
Pranlukast (P)
Zi 600 mg qid.
Elevation
of
liver persistent
asthma.
Zafirlukast (Z)
enzymes
with They provide additive
Zileuton (Zi)
Children: M 5 mg qhs Zafirlukast and Zileuton benefit when added to

Appendix 3 Glossary of
Asthma Medications

(6-14 y)
M 4 mg qhs (2-5 y)
Z 10 mg bid (7-11 y)

Immunomodulators
Omalizumab
Anti-IgE

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and
limited
case
reports of reversible
hepatitis
and
hyperbilirubinemia
with Zileuton and
hepatic failure with
afirlukast.
Adults:
Dose Pain and bruising at
administered
injection site (5-20%)
subcutaneously every and
very
rarely
2-4 weeks dependent anaphylaxis (0.1%)
on weight and IgE
concentration.

ICSs though not as


effective as inhaled
long
acting
2agonists.

Need to be stored
under refrigeration 2-8
degree Celsius and
maximum of 150 mg
administered
per
injection site.

Appendix 3 (B): Combination medications for Asthma

Formulation
Fluticasone
Propionate/
salmeterol
Fluticasone
Propionate/
salmeterol
Budesonide/
formoterol
Budesonide/
formoterol
Beclomethasone/
formoterol
Mometasone/
formoterol

Inhaler Devices

DPI

pMDI
(Suspension)

DPI
pMDI
(Suspension)
pMDI
(Solution)
pMDI

Doses Available
(g) ICS/LABA
100/50
250/50
500/50
50/25
125/25
250/25
80/4.5
160/4.5
320/9.0
100/6
200/6

Inhalations/day

1 inhalation x 2

2 inhalations x 2

Therapeutic Use

Maintenance

Maintenance

1-2 inhalations x Maintenance


2
and relief
2 inhalations x 2

Maintenance

100/6

1-2 inhalations x
Maintenance
2

100/5
200/5

2 inhalations x 2

Maintenance

ICS = inhaled corticosteriod; LABA = long-acting 2-agonist; pDMI = pressurized metered dose inhaler; DPI
= dry powder inhaler

Appendix 3 Glossary of
Asthma Medications

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1 Refers to metered dose. For additional information about doses and products available in specific
countries, please consult www.gsk.com to find a link to your country website or contract your local
company representatives for products approved for use in your country.
2 Refers to delivered dose. For additional information about doses and products available in specific
countries, please consult www.astrazeneca.com to find a link to your country website or contract your
local company representatives for products approved for use in your country.
3 Refers to metered dose. For additional information about doses and products available in specific
countries, please consult www.chiesigroup.com to find a link to your country website or contract your local
company representatives for products approved for use in your country.

Appendix 3 (c) Glossary of Asthma Medications Relievers


Name and Also Known Usual Doses
Side Effects
As
Short-acting
2- Differences
in Inhaled: tachycardia,
agonists
potency exist but all skeletal
muscle
products
are tremor, headache and
Adrenergics
essentially
irritability. At very
2- Sitmulants
comparable on a per high
dose
Sympathomimetics.
puff basis for pre hyperglycemia,
symptomatic use and hypokalemia.
Albuterol/salbutamol
pretreatment before
Fenoterol
exercise 2 puffs MDI Systemic
Levalbuterol
or 1 inhalation DPI. administration
as
Metaproterenol
For asthma attacks 4- Tablets or syrup
Pirbuterol
8 puffs q2-4h, may increases the risk of
Terbutaline
administer q20 min x these side effects.
3
with
medical
supervision or the
equivalent of 5 mg
salbutamol
by
nebulizer.

Anticholinergics

IB MDI 4-6 puffs Minimal

Comments
Drug of choice for
acute bronchospasm.
Inhaled route has
faster onset and is
more effective than
tablets or syrup.
Increasing use, lack of
expected effect, or
use of 1 canister a
month indicate poor
asthma
control;
adjust long term
therapy accordingly.
Use of 2 conisters
as per month is
associated with an
increased risk of a
severe,
lifethreatening asthma
attack.

mouth May provide additive

Appendix 3 Glossary of
Asthma Medications

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Ipratropium
bromide q6h or q20 min in the dryness or bad taste effects to 2-agonst
(IB)
emergency
in the mouth.
but has slower onset
Oxitropium bromide
department.
of action. Is an
Nebulizer 500 g
alternative
for
q20min x 3 then q2
patients
with
4hrs for adults and
intolerance to 2250 - 500 g for
agonists.
children.
Short-acting
theophylline
Aminophylline

7 mg/kg loading dose


over 20 min followed
by
0.4mg/kg/hr
continuous infusion.

Nausea,
vomiting,
headache. At higher
serum
concentrations:
seizures, tachycardia
and arrhythmias.

Theophylline
level
monitoring
is
required.
Obtain
serum levels 12 and
24
hours
into
infusion.
Maintain
between 10-15 g/ml.

Epinephrine/adrenaline 1: 1000 solution


injection
(1mg/ml) .01mg/kg
Up to 0.3 0.5 mg,
can give q20min x 3.

Similar but more


significant
effects
than selective 2agonist. In addition
hypertension,
vomiting in children
and hallucinations.

In
general,
not
recommended
for
treating
asthma
attacks if selective 2agonists are available.

Appendix 4 Questions for


Monitoring Asthma Care

Code

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Appendix 4 Questions for Monitoring Asthma Care


Is the asthma management plan meeting expected goals?
Action to consider:
Adjust medications and management plan as needed (step up or down).
But first, compliance should be assessed.
Is the patient using inhalers, spacer, or peak flow meters correctly?
Ask the patient:
Please show me how you take your medicine.
Action to consider: Demonstrate correct technique. Have patient demonstrate back.
Is the patient taking the medications and avoiding risk factors according to the asthma
management plan?
Action to consider:
Adjust plan to be more practical.
Problem solve with the patient to overcome barriers to following the plan.
Does the patient have any concerns?
Ask the Patient:
What concerns might you have about your asthma, medicines, or management plan?
Action to consider: Provide additional education to relieve concerns and discussion to
overcome barriers.

Appendix 5 Asthma
Control Test (Act)
Appendix 5 Asthma Control Test (Act)

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Appendix 6 My Asthma
Plans

Appendix 6 My Asthma Plans.

Code

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