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دا British guideline on the management of asthma. A national clinical guideline.
وبالنسبة لي
RECOMMENDATIONS
EVIDENCE SUPPORTING THE RECOMMENDATIONS
IDENTIFYING INFORMATION AND AVAILABILITY
DISCLAIMER
وكل التفاصيل عن الموضوع دا موجودة في الرابط دا
اضغط هنا
ودي بعض النقاط المهم بخصوصاmangment زي ما جت في guideline
Step 1: Mild Intermittent Asthma
Adults: A; Children aged 5 to 12 years: B; Children under 5 years: C - Prescribe an inhaled short acting beta2 agonist as short term reliever therapy for all patients with symptomatic asthma.
Adults: B; Children aged 5 to 12 years: D; Children under 5 years: D - Patients with high usage of inhaled short acting beta2 agonists should have their asthma management reviewed.
Step 2: Introduction of Regular Preventer Therapy
Adults: A; Children aged 5 to 12 years: A; Children under 5 years: A - Inhaled steroids are the recommended preventer drug for adults and children for achieving overall treatment goals.
Inhaled Steroids
Inhaled steroids should be considered for patients with any of the following asthma related features
Adults: B; Children aged 5 to 12 years: C; Children under 5 years: Recommendation does not apply to this age group; exacerbations of asthma in the last two years
Adults: B; Children aged 5 to 12 years: C; Children under 5 years: GPP - using inhaled beta2 agonists three times a week or more
Adults: B; Children aged 5 to 12 years: C; Children under 5 years: GPP- symptomatic three times a week or more
Adults: B; Children aged 5 to 12 years: C; Children under 5 years: GPP - waking one night a week
Starting Dose of Inhaled Steroids
GPP - Start patients at a dose of inhaled steroids appropriate to the severity of disease.
GPP - In adults, a reasonable starting dose will usually be 400 micrograms per day and in children 200 micrograms per day. In children under five years, higher doses may be required if there are problems in obtaining consistent drug delivery.
GPP - Titrate the dose of inhaled steroid to the lowest dose at which effective control of asthma is maintained.
Frequency of Dosing of Inhaled Steroids
Adults: A; Children aged 5 to 12 years: D; Children under 5 years: D - Give inhaled steroids initially twice daily, except ciclesonide which is given once daily.
Adults: A; Children aged 5 to 12 years: D; Children under 5 years: D - Once a day inhaled steroids at the same total daily dose can be considered if good control is established.
Safety of Inhaled Steroids
Adults
GPP - Titrate the dose of inhaled steroid to the lowest dose at which effective control of asthma is maintained.
Children
GPP - Monitor height of children on high doses of inhaled steroids on a regular basis.
GPP - The lowest dose of inhaled steroids compatible with maintaining disease control should be used.
For children treated with ≥800 micrograms per day of beclomethasone dipropionate (BDP) or equivalent:
GPP - Specific written advice about steroid replacement in the event of a severe intercurrent illness should be part of the management plan.
GPP - The child should be under the care of a specialist paediatrician for duration of the treatment.
Smoking
Adults: B; Children aged 5 to 12 years: Recommendation does not apply to this age group; Children under 5 years: Recommendation does not apply to this age group Clinicians should be aware that higher doses of inhaled steroids may be needed in patients who are smokers/ex-smokers.
Step 3: Initial Add-on Therapy
Adults: A; Children aged 5 to 12 years: B; Children under 5 years: Recommendation does not apply to this age group. - The first choice as add-on therapy to inhaled steroids in adults and children (5-12 years) is an inhaled long-acting beta2 agonist, which should be considered before going above a dose of 400 micrograms (BDP) or equivalent per day and certainly before going above 800 micrograms BDP.
Adults: D; Children aged 5 to 12 years: D; Children under 5 years: Recommendation does not apply to this age group. - If asthma control remains sub-optimal after the addition of an inhaled long acting beta2 agonist, then the dose of inhaled steroids should be increased to 800 micrograms/day in adults or 400 micrograms/day in children (5 to 12 years, if not already on these doses.
GPP - If control remains inadequate after stopping a long-acting inhaled beta2 agonist (LABA) and increasing the dose of inhaled steroid, consider sequential trials of add-on therapy (i.e., leukotriene receptor antagonists, theophyllines, slow-release beta2 agonist tablets [this in adults only]).
GPP - Long-acting inhaled beta2 agonists should only be started in patients who are already on inhaled corticosteroids.
Step 4: Poor Control on Moderate Dose of Inhaled Steroid + Add-on Therapy: Addition of Fourth Drug
Adults: D; Children aged 5 to 12 years: D; Children under 5 years: Recommendation does not apply to this age group. - If control remains inadequate on 800 micrograms daily (adults) and 400 micrograms daily (children) of an inhaled steroid plus a long acting beta2 agonist, consider the following interventions:
Increasing inhaled steroids to 2,000 micrograms/day (adults) or 800 micrograms/day (children 5-12 years)*
Leukotriene receptor antagonists
Theophyllines
Slow release beta2 agonist tablets, though caution needs to be used in patients on long acting beta2 agonists.
* At high doses of inhaled steroid via metered-dose inhaler (MDI), a spacer should be used.
GPP - If a trial of an add-on treatment is ineffective, stop the drug (or in the case of increased dose of inhaled steroid, reduce to the original dose).
GPP - Before proceeding to step 5, consider referring patients with inadequately controlled asthma, especially children, to specialist care.
Step 5: Continuous or Frequent Use of Oral Steroids
GPP - For the small number of patients not controlled at step 4, use daily steroid tablets in the lowest dose providing adequate control.
Steroid Tablet-Sparing Medication
Adults: A; Children aged 5 to 12 years: D; Children under 5 years: Recommendation does not apply to this age group. - In adults the recommended method of eliminating or reducing the dose of steroid tablets is inhaled steroids, at doses of up to 2,000 micrograms/day if required. In children aged 5 to 12, consider very carefully before going above a dose of 800 micrograms/day.
Adults: D; Children aged 5 to 12 years: D; Children under 5 years: D - There is a role for a trial of treatment with long acting beta2 agonists, leukotriene receptor antagonists, and theophyllines for about six weeks. They should be stopped if no improvement in steroid dose, symptoms, or lung function is detected.
GPP - Immunosuppressants (methotrexate, ciclosporin and oral gold) may be given as a three month trial, once other drug treatments have proved unsuccessful. Their risks and benefits should be discussed with the patient and their treatment effects carefully monitored. Treatment should be in a centre with experience of using these medicines.
دا British guideline on the management of asthma. A national clinical guideline.
وبالنسبة لي
RECOMMENDATIONS
EVIDENCE SUPPORTING THE RECOMMENDATIONS
IDENTIFYING INFORMATION AND AVAILABILITY
DISCLAIMER
وكل التفاصيل عن الموضوع دا موجودة في الرابط دا
اضغط هنا
ودي بعض النقاط المهم بخصوصاmangment زي ما جت في guideline
Step 1: Mild Intermittent Asthma
Adults: A; Children aged 5 to 12 years: B; Children under 5 years: C - Prescribe an inhaled short acting beta2 agonist as short term reliever therapy for all patients with symptomatic asthma.
Adults: B; Children aged 5 to 12 years: D; Children under 5 years: D - Patients with high usage of inhaled short acting beta2 agonists should have their asthma management reviewed.
Step 2: Introduction of Regular Preventer Therapy
Adults: A; Children aged 5 to 12 years: A; Children under 5 years: A - Inhaled steroids are the recommended preventer drug for adults and children for achieving overall treatment goals.
Inhaled Steroids
Inhaled steroids should be considered for patients with any of the following asthma related features
Adults: B; Children aged 5 to 12 years: C; Children under 5 years: Recommendation does not apply to this age group; exacerbations of asthma in the last two years
Adults: B; Children aged 5 to 12 years: C; Children under 5 years: GPP - using inhaled beta2 agonists three times a week or more
Adults: B; Children aged 5 to 12 years: C; Children under 5 years: GPP- symptomatic three times a week or more
Adults: B; Children aged 5 to 12 years: C; Children under 5 years: GPP - waking one night a week
Starting Dose of Inhaled Steroids
GPP - Start patients at a dose of inhaled steroids appropriate to the severity of disease.
GPP - In adults, a reasonable starting dose will usually be 400 micrograms per day and in children 200 micrograms per day. In children under five years, higher doses may be required if there are problems in obtaining consistent drug delivery.
GPP - Titrate the dose of inhaled steroid to the lowest dose at which effective control of asthma is maintained.
Frequency of Dosing of Inhaled Steroids
Adults: A; Children aged 5 to 12 years: D; Children under 5 years: D - Give inhaled steroids initially twice daily, except ciclesonide which is given once daily.
Adults: A; Children aged 5 to 12 years: D; Children under 5 years: D - Once a day inhaled steroids at the same total daily dose can be considered if good control is established.
Safety of Inhaled Steroids
Adults
GPP - Titrate the dose of inhaled steroid to the lowest dose at which effective control of asthma is maintained.
Children
GPP - Monitor height of children on high doses of inhaled steroids on a regular basis.
GPP - The lowest dose of inhaled steroids compatible with maintaining disease control should be used.
For children treated with ≥800 micrograms per day of beclomethasone dipropionate (BDP) or equivalent:
GPP - Specific written advice about steroid replacement in the event of a severe intercurrent illness should be part of the management plan.
GPP - The child should be under the care of a specialist paediatrician for duration of the treatment.
Smoking
Adults: B; Children aged 5 to 12 years: Recommendation does not apply to this age group; Children under 5 years: Recommendation does not apply to this age group Clinicians should be aware that higher doses of inhaled steroids may be needed in patients who are smokers/ex-smokers.
Step 3: Initial Add-on Therapy
Adults: A; Children aged 5 to 12 years: B; Children under 5 years: Recommendation does not apply to this age group. - The first choice as add-on therapy to inhaled steroids in adults and children (5-12 years) is an inhaled long-acting beta2 agonist, which should be considered before going above a dose of 400 micrograms (BDP) or equivalent per day and certainly before going above 800 micrograms BDP.
Adults: D; Children aged 5 to 12 years: D; Children under 5 years: Recommendation does not apply to this age group. - If asthma control remains sub-optimal after the addition of an inhaled long acting beta2 agonist, then the dose of inhaled steroids should be increased to 800 micrograms/day in adults or 400 micrograms/day in children (5 to 12 years, if not already on these doses.
GPP - If control remains inadequate after stopping a long-acting inhaled beta2 agonist (LABA) and increasing the dose of inhaled steroid, consider sequential trials of add-on therapy (i.e., leukotriene receptor antagonists, theophyllines, slow-release beta2 agonist tablets [this in adults only]).
GPP - Long-acting inhaled beta2 agonists should only be started in patients who are already on inhaled corticosteroids.
Step 4: Poor Control on Moderate Dose of Inhaled Steroid + Add-on Therapy: Addition of Fourth Drug
Adults: D; Children aged 5 to 12 years: D; Children under 5 years: Recommendation does not apply to this age group. - If control remains inadequate on 800 micrograms daily (adults) and 400 micrograms daily (children) of an inhaled steroid plus a long acting beta2 agonist, consider the following interventions:
Increasing inhaled steroids to 2,000 micrograms/day (adults) or 800 micrograms/day (children 5-12 years)*
Leukotriene receptor antagonists
Theophyllines
Slow release beta2 agonist tablets, though caution needs to be used in patients on long acting beta2 agonists.
* At high doses of inhaled steroid via metered-dose inhaler (MDI), a spacer should be used.
GPP - If a trial of an add-on treatment is ineffective, stop the drug (or in the case of increased dose of inhaled steroid, reduce to the original dose).
GPP - Before proceeding to step 5, consider referring patients with inadequately controlled asthma, especially children, to specialist care.
Step 5: Continuous or Frequent Use of Oral Steroids
GPP - For the small number of patients not controlled at step 4, use daily steroid tablets in the lowest dose providing adequate control.
Steroid Tablet-Sparing Medication
Adults: A; Children aged 5 to 12 years: D; Children under 5 years: Recommendation does not apply to this age group. - In adults the recommended method of eliminating or reducing the dose of steroid tablets is inhaled steroids, at doses of up to 2,000 micrograms/day if required. In children aged 5 to 12, consider very carefully before going above a dose of 800 micrograms/day.
Adults: D; Children aged 5 to 12 years: D; Children under 5 years: D - There is a role for a trial of treatment with long acting beta2 agonists, leukotriene receptor antagonists, and theophyllines for about six weeks. They should be stopped if no improvement in steroid dose, symptoms, or lung function is detected.
GPP - Immunosuppressants (methotrexate, ciclosporin and oral gold) may be given as a three month trial, once other drug treatments have proved unsuccessful. Their risks and benefits should be discussed with the patient and their treatment effects carefully monitored. Treatment should be in a centre with experience of using these medicines.
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