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Subsections
Asthma: NAEPP Stepwise Guide and Long Term Drug Dosing Guide

Asthma: NAEPP Stepwise Guide and Long Term Drug Dosing Guide

Background

  1. Evaluation protocols
  2. Screening
    • Ask
      • Q1: Has your child been to a doctor, an emergency room, or a hospital for wheezing during the last year?
      • Q2: Has your child ever had episodes of wheezing in the last 12 months?
      • Q3: Does your child wheeze or cough after active playing?
      • Q4: Other than a cold, in the last 12 months, has your child had a dry cough at night?
      • Q5: Has a doctor ever diagnosed your child as having asthma?
    • Answer key
      • Negative
        • No to questions 1, 5, and two other questions
      • Possible asthma
        • No to question 5
        • Yes to questions 1 & 2 or more other questions
      • Asthma
        • Yes to question 5

NAEPP Stepwise Guide

  • For all Steps
    • All ages: Education patient on proper medication use and environmental controls
      • Ages 5-11: Patient education, environmental controls, AND manage comorbidities
        • Steps 2-4 (ages > 4 years): consider subcutaneous allergen immunotherapy if persistent, allergic asthma
    • Frequent or increasing use of SABA indicates need to step up treatment
    • Ages ≥ 12 years old:
      • If alternative treatment response is inadequate, discontinue and use preferred treatment before stepping up
      • Zileuton is a less desirable alternative due to
        • Limited studies as adjunctive therapy
        • Need to monitor liver function
      • Theophylline requires monitoring of serum concentration levels
      • Clinicians: be prepared to identify and treat possible anaphylaxis if administering immunotherapy or omalizumab
      • In step 6, before oral corticosteroids are introduced
        • Give a trial of high-dose ICS + LABA + (consider LTRA, theophylline, or zileuton)
          • This approach has not been studied
    • See also exacerbation management
  • Step 1
    • SABA PRN
  • Step 2
    • Low-dose ICS
      • Alternative: Cromolyn, Leukotriene receptor antagonists (LTRA), Nedocromil, or Theophylline
  • Step 3
    • (Low-dose ICS + LABA) or (Medium-dose ICS)
      • Alternative: Low-dose ICS + (LTRA, Theophylline, or Zileuton)
      • Consider asthma specialist consult
  • Step 4
    • Medium-dose ICS + LABA
      • Alternative: Medium-dose ICS + (LTRA, Theophylline, or Zileuton)
      • Consult asthma specialist
  • Step 5
    • High-dose ICS + LABA AND consider Omalizumab if allergies
      • Consult asthma specialist
  • Step 6
    • High-dose ICS + LABA + Oral corticosteroids AND consider Omalizumab if allergies

Treatment

  1. Initial/Prep/Goals
    • No or minimal symptoms
      • Maintain normal or near normal lung function
      • No limitations on activities
      • Includes exercise
    • No or minimal exacerbations
      • Minimize need for ED visits
      • Optimize pharmacology
        • Minimal adverse effects
      • Ease of taking meds
      • Minimal use of short-acting inhaled beta 2-agonist
        • Use < 1 puff per day; < 1 canister per month
    • See also:
  2. Medical/Pharmaceutical
    • Long-acting beta 2-agonists
      • Salmeterol DPI (50 mcg/blister)
        • Age approval: ≥ 4 years old
        • Dose: 1 blister q12h
      • Formoterol DPI (12 mcg/capsule)
        • Age approval: ≥ 5 years old
        • Dose: 1 capsule q12h
    • Long-acting beta 2-agonists with steroids
      • Fluticasone/salmeterol DPI (100, 250, 500 mcg/50 mcg per puff)
        • Age approval: ≥ 5 years old
        • 1 inhalation BID
        • Dose depends on severity or control
      • Budesonide/formoterol DPI (80 or 160 mcg/4.5 mcg per puff)
        • Age approval: ≥ 5 years old
        • 2 puffs BID
        • Dose depends on severity or control
    • Inhaled Corticosteroids
      • Beclomethasone HFA MDI (40 or 80 mcg/puff)
        • ≥ 12 years old
          • Low dose: 80-249 mcg/day
          • Medium dose: > 240-480 mcg/day
          • High dose: > 480 mcg/day
      • Budesonide DPI (90, 180, or 200 mcg/puff)
        • ≥ 12 years old
          • Low dose: 180-600 mcg/day
          • Medium dose: > 600-1200 mcg/day
          • High dose: > 1200 mcg/day
      • Budesonide (suspension for nebulizer)
        • 5-11 years old
          • Low dose: 0.5 mg
          • Medium dose: 1.0 mg/day
          • High dose: 2.0 mg/day
      • Flunisolide MDI (250 mcg/puff)
        • ≥ 12 years old
          • Low dose: 500-1000 mcg/day
          • Medium dose: > 1000-2000 mcg/day
          • High dose: > 2000 mcg/day
      • Flunisolide HFA (80 mcg/puff)
        • ≥ 12 years old
          • Low dose: 320 mcg/day
          • Medium dose: > 320-640 mcg/day
          • High dose: > 640 mcg/day
      • Fluticasone HFA/MDI (44, 110, or 220 mcg/puff)
        • ≥ 12 years old
          • Low dose: 88-264 mcg/day
          • Medium dose: > 264-440 mcg/day
          • High dose: > 440 mcg/day
      • Fluticasone DPI (50, 100, or 250 mcg/inhalation)
        • ≥ 12 years old
          • Low dose: 100-300 mcg/day
          • Medium dose: > 300-500 mcg/day
          • High dose: > 500 mcg/day
      • Triamcinolone acetonide MDI (75 mcg/puff)
        • ≥ 12 years old
          • Low dose: 300-750 mcg/day
          • Medium dose: > 750-1500 mcg/day
          • High dose: > 1500 mcg/day
      • Mometasone DPI (200 mcg/inhalation)
        • Age approval: ≥ 12 years old
        • Low dose: 200 mcg/day
        • Medium dose: 400 mcg/day
        • High dose: > 400 mcg/day
    • Mast-cell stabilizers
      • Cromolyn: MDI (0.8 mg/puff)
        • Age approval: ≥ 5 years old
        • Dose: 1-2 puffs TID-QID
        • One dose of cromolyn before exercise/allergen exposure is effective prophylaxis for 1-2 hrs
          • Not as effective as inhaled beta2-agonists for Exercise-Induced Bronchospasms as SABA
      • Cromolyn nebulizer (20 mg/ampule)
        • Age approval: ≥ 2 years old
        • Dose: 1 ampule TID-QID
        • 4-6 week trial of cromolyn or nedocromil may be needed to determine maximum benefit
      • Nedocromil (1.75 mg/puff)
        • Age approval: ≥ 6 years old
        • Dose: 1-2 puffs BID-QID
        • 4-6 week trial of cromolyn or nedocromil may be needed to determine maximum benefit
          • MDI dose may be inadequate
        • If control achieved, reduce frequency of dosing
    • Leukotriene modifiers
      • Montelukast
        • > 14 years old
          • 10 mg qhs
        • Notes
          • Flat dose-response curve
            • Doses > 10 mg will not produce a greater response
          • No more efficacious than placebo in infants ages 6-24 months**
          • Long-term therapy may attenuate exercise-induced bronchospasm in some patients
            • However, less effective than ICS therapy
      • Zafirlukast
        • ≥ 12 years old
          • 40 mg daily
        • Notes
          • Administration with meals decreases bioavailability
            • take ≥ 1 hour before or 2 hours after meals
          • Microsomal P450 enzyme inhibitor that can inhibit the metabolism of warfarin
            • Doses of these drugs should be monitored accordingly
          • Monitor hepatic enzymes (ALT)
            • Discontinue use if signs/symptoms of liver dysfunction
      • Zileuton
        • Age approval: ≥ 12 years old
        • Dose: 600 mg PO QID (2,400 mg daily)
        • Notes
          • Monitor hepatic enzymes (ALT)
          • Microsomal P450 enzyme inhibitor that can inhibit the metabolism of warfarin and theophylline
            • Monitor accordingly
    • Theophylline
      • ≥ 12 years old
        • Starting dose: 10 mg/kg/day (max up to 300 mg)
        • Usual max dose: 800 mg/day
      • Recommendations
        • Adjust dosage to achieve serum concentration of 5-15 mcg/mL at steady state (≥ 48 hrs on same dosage)
        • Due to wide interpatient variability in theophylline metabolic clearance, routine serum theophylline level monitoring is essential
        • Patients should be told to discontinue if they experience toxicity
        • Various factors can affect serum concentrations (e.g., diet, food, febrile illness, age, smoking, and other medications)
    • Monoclonal antibodies
      • Do not administer more than 150 mg per injection site
      • Monitor patients following injections
        • Be prepared and equipped to identify and treat anaphylaxis that may occur
      • Whether patients will develop significant antibody titers to the drug with long-term administration is unknown
      • Indications
        • Moderate-severe persistent asthma patients that:
          • React to perennial allergens
          • Have symptoms not controlled by/refractory to inhaled corticosteroids
      • Omalizumab
        • Age approval: ≥ 12 yo
        • Dose: 150-375 mg SC every 2-4 weeks
          • Max: 150 mg/injection site
          • Inject over 5-10 sec (viscosity)

References

  1. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma- Full Report 2007. Available at: https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf. [Accessed August 2019]
  2. Baren JM, Zorc JJ. Contemporary approach to the emergency department management of pediatric asthma. Emergency Medicine Clinics of North America, February 2002;20(1):pp.115-138
  3. Bolte RG. Emergency department management of pediatric asthma. Clinical Pediatric Emergency Medicine, Dec 2004;5(4):pp.256-269
  4. Kliegman RM, Stanton BMD, St. Geme J, et al. Childhood Asthma. Nelson's Textbook Of Pediatrics: Expert Consult, 19th ed., Elsevier-Saunders:Philadelphia, PA, 2011;Chapter138

Contributor(s)

  1. Ballarin, Daniel, MD

Updated/Reviewed: August 2019