Pharmacist Disease State Guides
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      Asthma

      Disease State Overview

      Asthma is a chronic lung disease associated with inflammation, airflow obstruction, and bronchospasm. Symptoms of asthma can be variable and include wheezing, shortness of breath, chest tightness, and a cough. Asthma can be related to different types of demographic, clinical and/or pathophysiological traits. Lung function can be used to diagnosis and monitor therapy. Lung function can vary when a patient has asthma especially when it is uncontrolled. Once a patient is on asthma treatment variability should decrease.   

      Risk of Condition 

      Uncontrolled asthma increases risk of exacerbations, irreversible airway damage, decline in lung function, and asthma-related death. 

      Medication 

      Role of Medication 

      Asthma treatment goals include achieving control over symptoms, preventing asthma exacerbations, and preventing asthma mortality. The Global Initiative for Asthma (GINA) guidelines recommend a stepwise approach to adjust treatment up or down based on asthma control. General asthma treatment includes short-acting medication to provide quick relief of symptoms along with controller medications to reduce exacerbations and prevent symptoms. The GINA guidelines recommend the following tracks for medication treatment. 

       

      Track 1 (preferred track)

      Reliever: As-needed low dose ICS- formoterol 

      Step 1 & 2: As-needed low dose ICS-formoterol  

      Step 3: Low dose maintenance ICS-formoterol

      Step 4: Medium dose maintenance ICS-formoterol  

      Step 5: Add on LAMA. Refer for phenotypic assessment. Consider high dose ICS-formoterol.  

      Track 2

      Step 1: Take ICS whenever SABA is taken 

      Step 2: low dose maintenance ICS 

      Step 3: Low dose maintenance ICS-LABA 

      Step 4: Medium/high dose maintenance ICS-LABA 

      Step 5: Add on LAMA. Refer for phenotypic assessment. Consider ICS-LABA 

      Choice of therapy should be based on multiple factors including the patient’s willingness and ability to use the medication, medication side effect profile, insurance coverage, age, comorbid conditions, and concurrent medications. 

      Asthma Medication Classes 

      Short-Acting Medications

      • Short-acting inhaled beta2 agonist bronchodilators (SABA)* 
        • Example: Albuterol (ProAir, Proventil, Ventolin), Levalbuterol (Xoponex) 
      • Low dose ICS-formoterol 
        • Example: Budesonide and Formoterol (Symbicort), Mometasone and Formoterol (Dulera) 
      • Short-acting anticholinergic 
        • Example: Ipratropium (Atrovent) 

      Long-Acting Medications

      • Inhaled corticosteroids (ICS) 
        • Example: Beclomethasone (Qvar), Budesonide (Pulmicort), Fluticasone Furoate (Arnuity), Fluticase Propionate (Flovent), Mometasone (Asmanex) 
      • ICS and long-acting beta2 agonist combinations (ICS-LABA) 
        • Example: Budesonide and Formoterol (Symbicort), Fluticasone and Salmeterol (Advair, AirDuo, Wixela), Fluticasone and Vilanterol (Breo), Mometasone and Formoterol (Dulera) 
      • Leukotriene modifiers 
        • Example: Montelukast (Singulair), Zafirlukast (Accolate), Zileuton (Zyflo) 
      • Long-acting inhaled beta2 agonist bronchodilators (LABA)
        • Example: Aformoterol (Brovana), Formoterol (Perforomist), Olodaterol (Striverdi), Salmeterol (Serevent) 
      • Immunomodulators (Anti-IgE, Anti-IL5, Anti-IL5R, Anti-IL4R) 
        • Example: Omalizumab (Xolair), Mepolizumab (Nucala), Reslizumab (Cinqair), Benralizumab (Fasenra), Dupilumab (Dupixent) 
      • Methylxanthine 
        • Example: Theophylline (Uniphyl) 
      • Oral corticosteroids (OCS) 
        • Example: Prednisone, Methylprednisolone (Medrol), Dexamethasone (Decadron) 

      *SABA as monotherapy for asthma is no longer recommended due to risk of asthma-related death and urgent asthma-related healthcare. 

      Adherence 

      Using short-acting and controller medications correctly is essential for asthma symptom control. Discuss the differences and when to use each type of medication. Discuss barriers to adherence and provide appropriate solutions. You may use the DRAW tool within the Worksheets & Forms category in this Knowledge Base.

      • Short-acting medications should be used on an as-needed basis; assess for overuse. 
      • Long-acting medications should be used on a regular basis as prescribed; assess for underuse.  

      Administration 

      Pharmacists play a key role in the training and education of inhaler use, priming, technique, and cleaning for patients with asthma.  

      • Inhaler technique (refer to package insert) 
      • Ensure the patient knows how to correctly administer the medication. 
      • Inhaler priming (refer to package insert) 
      • If applicable, ensure the patient knows when to prime their inhaler. 
      • Most rescue inhalers should be primed when not used within the last 2 weeks. 
      • Inhaler cleaning (refer to package insert) 
      • Ensure the patient knows how to properly clean the inhaler. 
      • Use of nebulizer, spacer, or mask devices if applicable 
      • Advise patient to rinse mouth and spit after using ICS medications. 

      Monitoring 

      The GINA Guidelines recommend patients be seen by their provider 1-3 months after starting new therapy and every 3-12 months thereafter. If an asthma exacerbation occurs it is recommended to be seen within 1 week. Best practice is to assess asthma control, adherence, and inhaler technique at every visit to ensure adequate management. In addition, patients should be educated on asthma self-management including symptom or peak flow monitoring and should have an asthma action plan created in partnership with their prescriber. 

      Self-monitoring of symptoms 

      • Frequency of daytime symptoms (daily, weekly, monthly) 
      • Rescue inhaler use (especially if using ≥1 per month) 
      • Nighttime sleep awakenings due to asthma (daily, weekly)  
      • Trouble performing activities due to asthma 
      • Using a peak flow meter 

      Asthma action plan 

      • Use of daily asthma medications and treatment goals 
      • How to adjust medications for worsening symptoms 
      • When to seek medical care 
      • If you would like to provide an asthma action plan use this tool 

      Stepping Down Asthma Treatment  

      • After 3+ months with well-controlled asthma and stable lung function consider stepping down therapy  
      • ICS doses can be reduced by 25-50% at 3-month intervals for most patients.  
      • Educate the patient on the process and a new asthma action plan for stepping down therapy 

      Lifestyle Education 

      Lifestyle changes can play an important role in asthma management. Some helpful hints for patients include3: 

      • Minimize triggers that can worsen asthma, including allergens, irritants, certain foods and/or tobacco  
      • Immunizations are recommended for all patients with asthma (e.g. influenza and pneumonia).
      • Educate on quitting smoking (if applicable). 
      • Educate on the importance of regular physical activity and the use of appropriate preventative medications if exercise induces asthma symptoms. 

       

       

      Resources 

      1. 2024 Gina Main Report - Global Initiative for asthma. Global Initiative for Asthma (GINA).https://ginasthma.org/2024-report/.