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PaulaKauppi

Long-Term Management of Asthma

Essentials

  • Teach the patient self-management in the follow-up and treatment Self-Management Education and Regular Practitioner Review for Adults with Asthma.
  • The patient's own primary care physician checks the adequacy of the treatment regularly.
  • The treatment aims at
    • minimal symptoms
    • normal functional ability
    • minimal need for an on-demand bronchodilator drug
    • no adverse effects of drugs
    • normal or the patient's best possible pulmonary function evaluated with spirometry and PEF monitoring
    • prevention of exacerbations.

Principles

  • Inhaled glucocorticoids treat and suppress the asthmatic airway inflammation. They are an essential part of the treatment.
  • All patients with asthma should also have a bronchodilator drug to be used as needed.
  • Teaching and follow-up of the inhalation technique of drugs is important.
  • The treatment should be tailored for each patient according to the severity of the disease and modified flexibly step-by-step. Self-management of drug dosing is encouraged (written instructions!).
    • Provide advice on local information sources.
  • As necessary, inhaled glucocorticoid is combined with a long-acting beta2 agonist, long-acting anticholinergic or leukotriene receptor antagonist.
  • Short courses of oral glucocorticoids are occasionally needed.
    • In association with a viral infection, a symptom-relieving drug (usually a short-acting beta2 agonist) is used regularly. If this is not sufficient, an oral glucocorticoid course is started. A combination of budesonide and formoterol may also be used as symptomatic therapy. If the patient uses anti-inflammatory medication only periodically (e.g. during the pollen season), the anti-inflammatory medication should be, however, used regularly also in the event of a viral infection.
  • High allergen concentrations may increase symptoms in a patient with allergic asthma. For example, it is not recommended for a person who has asthma and is allergic to cats to have a cat as a home pet.
  • High concentrations of airway irritants (dusts, fumes, chemicals) usually increase the occurrence of asthmatic symptoms.
  • It should be noted that people who are hypersensitive to NSAIDs cannot use aspirin or other NSAIDs (including metamizole). Approximately 10-20% of patients with asthma are hypersensitive to these drugs.
  • Non-selective beta-blockers often exacerbate the symptoms of asthma.
  • Smoking cessation is actively supported.
  • Allergen immunotherapy Allergen Immunotherapy may help some patients Allergen Immunotherapy for Asthma.

Implementation Intermittent Versus Daily Inhaled Corticosteroids for Persistent Asthma, Intermittent Inhaled Corticosteroid Versus Placebo for Persistent Asthma

  1. The patient has asthma symptoms only occasionally (less frequently than once a week and nightly symptoms not more frequently than twice a month) and the pulmonary function tests are normal:
  2. If the symptoms are more frequent and inhaled bronchodilator drugs are needed more often than once a week or if sleep is disturbed by asthma, adding regular anti-inflammatory medication is indicated.
  3. If the symptoms continue daily, if the need for an on-demand bronchodilator drug is frequent, and obstruction is present according to PEF monitoring:
  4. If the symptoms are not controlled adequately with a combination of a daily dose of inhaled glucocorticoid corresponding to 800 µg of budesonide (table T1) and a long-acting bronchodilator drug, added with a short-acting inhaled bronchodilator drug when needed, add one or more of the following:
  5. During exacerbation, an oral glucocorticoid course is used (more details below).

Clinically comparable doses of inhaled glucocorticoids

DrugForm*Daily dose µg
LowMediumHigh
Source: Global strategy for asthma management and prevention. Global Initiative for Asthma (GINA) 2019 http://www.ginasthma.org/ (the doses have been adjusted to the pharmaceutical preparations on the market in Finland) and Chung KF, Wenzel SE, Brozek JL ym. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J 2014;43(2):343-73. [PubMed]. The doses have been estimated according to clinical comparability. They are only indicative and may vary from patient to patient. Most of the clinical benefit of the medication is usually seen at low doses already, and evidence on dose-response relationships is limited. The risk of adverse effects is usually increased with high doses in long-term use.
* Nebulizer suspensions are not included in the table.
** HFA = hydrorofluoroalkane propellant
*** Mometasone and ciclesonide can be administered once daily.
BeclomethasonePowder200-500500-1 000> 1 000
HFA** solution100-200200-400> 400
BudesonidePowder200-400400-800> 800
BudesonideAs part of a combination preparation160-320320-640> 640
Fluticasone propionatePowder
HFA suspension
100-250250-500> 500
Fluticasone furoate (only in combined preparation)Powder-92HASH(0x2f82cc8) 184
Mometasone***Powder200200-400> 400
Ciclesonide***HFA solution80-160160-320> 320

Tapering down of medication Initial Starting Dose of Inhaled Corticosteroids for Asthma

  • With regard to systemic adverse effects, the low-medium doses of inhaled glucocorticoids as presented in table T1 are considered safe in maintenance therapy in adults.
  • As the symptoms alleviate, the medication can be tapered down gradually.
  • If the symptoms are minimal, if the need for inhaled bronchodilating medication is small, if the PEF values are normal, and if there is no diurnal variation, the dose of anti-inflammatory medication can be halved about 6 months after the disease has stabilized. Symptoms, periods of exacerbation and PEF values should be monitored.
  • In chronic asthma it is often not possible to stop all anti-inflammatory medication and this need not even be the aim, but pauses in medication may be tried every now and then.

Other aspects to be noted The Effect of Treatment for Gastro-Oesophageal Reflux on Asthma

  • Antimicrobial drugs are only prescribed if clear signs of bacterial infection are present.
  • Cough medicines have no place in the treatment of asthma.
  • Consider the need for pneumococcal, COVID-19 and influenza vaccination. Influenza Vaccination in Asthma: Efficacy and Side Effects
  • Note possible allergic or non-allergic rhinosinusitis or gastro-oesophageal reflux disease. Provide actively guidance on weight management if the patient is overweight, and giving up smoking if the patient smokes. It is not recommended for people who are allergic to animal dust to keep a domestic animal that increases allergy symptoms.

Course of oral glucocorticoids

Indications

  • Increasing symptoms
  • The effect duration of inhaled bronchodilating medication is shortening.
  • If PEF values are used in the assessment of a period of exacerbation, they are usually less than 80-70% of the patient's best values.
  • Sleep is disturbed by asthma.
  • Morning symptoms persist until noon.
  • Maximal medication without oral glucocorticoids shows no sufficient effect.
  • An acute exacerbation for which the patient has received nebulised bronchodilating medication in an emergency setting Corticosteroids for Preventing Relapse Following Acute Exacerbations of Asthma.

Dosage

  • Prednisolon is given (30-)40 mg daily usually for 5-7 days.
  • If the course of an oral glucocorticoid has lasted for 1 to 2 weeks it can be stopped at once without tapering the dose gradually.

Guided self-management Breathing Exercises for Adults with Asthma, Physical Training for Asthma, Self-Management of Asthma by Adjustment of Anti-Inflammatory Therapy, Increased Versus Stable Doses of Inhaled Corticosteroids for Exacerbations of Chronic Asthma, Caffeine for Asthma, Ionisers for Chronic Asthma, Beta2-Agonists for Exercise-Induced Asthma

  • The patient should have good knowledge of self-management.
  • The components of successful self-management are
    • acceptance and understanding of asthma and its treatment
    • effective and compliant use of drugs
    • an own PEF meter at home and follow-up of results as necessary (provide the patient with instructions and a tracking chart)
    • written instructions for different problems.
  • As a part of guided self-management the patient may receive individually tailored medication instructions in writing and, as necessary, PEF alarm thresholds.
    • If there is an increase in symptoms, the patient takes a short-acting bronchodilator (or budesonide-formoterol) regularly 1-6 times a day in addition to the maintenance medication.
    • If symptoms persist or worsen, self-management instructions may include a prednisolone course (e.g. 30-40 mg/day) for 5-7 days.
    • The PEF thresholds to consider in association with a period of exacerbation are the following: if the morning PEF values are repeatedly less than 80-70% of the optimal value, the patient starts a course of oral prednisolone 30-40 mg daily for 5-7 days.
    • If symptoms persist or worsen despite the prednisolone treatment or if the PEF value is less than 50% of the optimal, the patient should seek emergency help or contact the treating unit in addition to starting the oral prednisolone course.
  • During a respiratory tract infection, it is recommended to take short-acting bronchodilator 3-4 times daily on a regular basis or to increase the dose of budesonide-formoterol medication and follow other individual medication instructions.
  • Increasing the dose of anti-inflammatory medication may be indicated, for example, during pollen season or respiratory infection.

Referral

  • Specialist consultation may be needed in the situations listed below.
    • Diagnostic problems
    • Recurrent exacerbations
    • Assessment of working ability
    • Suspected cases of occupational asthma
    • Severe exacerbation
    • Symptoms in spite of a large dose of inhaled glucocorticoids
    • Nebuliser for home use is considered.
    • Biological drug therapy, thermoplasty or other special treatment is considered.
    • Pregnant women with increased symptoms
    • Assessment for hyposensitization therapy
    • Asthma interferes with the patient's way of living (e.g. sports activities).

Follow-up Interventions Based on Sputum Eosinophils for Asthma

  • Asthma is mainly treated and followed up by a general practitioner.
  • A patient on medication should meet his/her own doctor regularly.
  • In mild cases one assessment of the situation yearly, either with a specialized asthma nurse Nurse Versus Physician-Led Care for the Management of Asthma or with a doctor depending on the local arrangement and remotely if deemed appropriate, is sufficient but with worsening severity of asthma more frequent follow-up visits are needed.
  • In addition to symptom history and lung auscultation, a one-week recording of PEF values at home can be considered for follow-up.
  • Spirometry Pulmonary Function Tests in order to assess the adequacy of asthma treatment is recommended for all patients every 3 to 5 years and more frequently for those who have problems in the management of their asthma.
  • In some patients the determination of exhaled nitric oxide (FeNO) may be useful for the adjustment of the dose of inhaled glucocorticoid in order to prevent exacerbations Exhaled Nitric Oxide Levels to Guide Treatment for Adults with Asthma; at the same time the average glucocorticoid dose may be slightly reduced.

References

  • Global strategy for asthma management and prevention. Global Initiative for Asthma (GINA) 2022. http://ginasthma.org/gina-reports/
  • [Asthma]. A Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim, Finnish Respiratory Society, Finnish Paediatric Society and Finnish Society of Clinical Physiology. Helsinki: Finnish Medical Society Duodecim 2022 (accessed 10 Jan 2023). Available in Finnish at:

Evidence Summaries