By: Jeremy Mesias, PharmD Candidate c/o 2022
It starts with a simple cough or a wheeze. Suddenly, it escalates to tightness in the chest. Breathing gets quicker but shallower, making you feel short of breath. These are the most common and recognizable symptoms of an asthma attack. Around the world, nearly 300 million people suffer from asthma and about 250,000 people die from it each year. So, what is asthma and why is it so deadly? Asthma is a common and often times, serious chronic respiratory disease that can cause various respiratory symptoms and carry the possibility of becoming fatal.1,2,3 Fortunately, it can be effectively treated. Most patients are able to achieve control of their condition and live long, healthy lives.
While the exact causes of asthma are unknown, scientists continue to explore the various factors that play a key role in determining its etiology. As we learn more about the disease, we have found that the following factors are associated with the development of asthma: genetics, allergies, respiratory infections, and environmental irritants.4 Each of these factors aid in triggering a complex cascade of mechanisms throughout the body that lead to airway inflammation, excess mucus secretion, airway constriction, and bronchial hyperresponsiveness. The principal cells involved in the inflammatory response include mast cells, eosinophils, macrophages, and activated T-lymphocytes. First, the irritant is carried by an antigen presenting cell, such as a dendritic cell, and exposed to native T-lymphocytes. The lymphocytes are then activated into T-helper cells (Th2), or CD4+ cells. The increased level of Th2 then generates a family of various cytokines, such as IL-4 and IL-13, that mediate allergic inflammation of the airways and cause various asthma symptoms. These responses, when occurring acutely and together, come to form an asthma exacerbation, or asthma attack.1
A patient who presents with asthma may present with a number of various symptoms. Wheezing is usually a key indicator of asthma and is defined as “a musical, high-pitched, whistling sound produced by airflow turbulence.” However, wheezing is not necessary for the diagnosis of asthma, since it can occur without wheezing in cases when the obstruction involves the small airways of the lung. Additionally, due to the inflammation of the airways and increased mucus production, a patient with asthma may also present with an increased feeling of chest tightness and nonproductive cough, oftentimes leaving them unable to breathe efficiently. Many asthmatics also report experiencing nocturnal symptoms once or twice a month. Furthermore, some patients only experience symptoms at night and have normal pulmonary function in the daytime. Nocturnal asthma is reported to have increased morbidity and mortality when compared to its normal counterpart and should be taken just as seriously, if not more to daytime asthma.2
When asthma symptoms continue to worsen over a short amount of time, the patient may be experiencing an acute exacerbation, more commonly known as an asthma attack. Classified from a mild episode to an imminent respiratory arrest, symptoms can range depending onthe severity of the attack. During mild episodes, the patient may be breathless, moderately wheezing, or breathing faster after light physical activity, such as walking. If the patient is experiencing imminent respiratory arrest, in addition to an increased intensity of the aforementioned symptoms, the patient would also be struggling for air. They would begin to experience episodes of confusion or increased agitation, inability to speak coherently, and potentially unconsciousness due to lack of oxygen. Considered a medical emergency, a patient experiencing imminent respiratory arrest must be treated immediately or they may undergo respiratory failure, which can become fatal.2
The guidelines to treat asthma are published by the Global Initiative for Asthma (GINA), which were established “to increase awareness about asthma among health professionals, public health authorities, and the community, and to improve prevention and management through a coordinated worldwide effort.” To treat asthma, GINA recommends utilizing the control-based asthma management cycle of assess-adjust treatment-review response. Assessment of a patient’s asthma does not only include symptom control, but also addresses risk factors and other comorbidities that could exacerbate the disease or increase the risk of poor health outcomes. Both pharmacological and nonpharmacological treatment is necessary to prevent exacerbations, control symptoms, and treat modifiable risk factors. Finally, the response of the patient to the prescribed medication must be assessed to evaluate if it is working optimally or if it needs to be adjusted. Altogether, the asthma management cycle is used to personalize asthma management therapy, thus preventing exacerbations through effective symptom control.3
The GINA guidelines present a 5-step treatment guideline for adults and adolescents greater than 12 years old. The guidelines are divided based on the preferred controller medication, which is used frequently to prevent exacerbations and control symptoms, and the preferred reliever, which is used to quickly treat asthma symptoms or for quick relief during an asthma attack. Depending on whether the patient is responding well or responding inadequately to treatment, they will either need to be stepped up or down in treatment, according to the guidelines.
· Step 1 is mainly for patients with infrequent asthma symptoms, typically presenting less than twice a month. The preferred reliever is an as-needed low dose inhaled corticosteroid (ICS)/short-acting Beta-2-agonist (SABA), such as budesonide- formoterol. Alternatively, a controller low dose ICS may be taken whenever the patient takes their reliever as-needed SABA.
· Step 2 is for patients who present with asthma symptoms or need to use their reliever twice a month or more. The preferred controller is a daily low dose ICS with an as-needed low dose budesonide-formoterol as a reliever. An alternative would be a leukotriene receptor antagonist (LTRA) or a low dose ICS whenever a SABA is taken.
· Step 3 is for patients who have troublesome asthma symptoms most days or who are waking from sleep due to asthma once a week or more. The preferred controller is a daily low dose ICS and a long-acting beta agonist (LABA). An alternative would be a medium dose ICS, or a low dose ICS-LTRA combination. The preferred reliever is an as-needed low dose ICS-formoterol combo for patients who are prescribed both maintenance and reliever therapy. This reliever option continues for steps 4 and 5.
· Step 4 is for patients whose initial asthma presentation is consistent with severely uncontrolled asthma or with an acute exacerbation. The preferred controller is a daily medium dose ICS and a long-acting beta agonist (LABA). An alternative would be a high dose ICS, add-on tiotropium, or add-on LTRA.
· Step 5 is for patients who continue to have uncontrolled symptoms and/or exacerbations despite Step 4 treatment. The preferred controller is a daily high dose ICS and a long-acting beta agonist (LABA). Furthermore, patients should be assessed for contributory factors, optimized treatment, and referred to a specialist to assess severe asthma phenotype, and potential add-on treatment. An alternative controller is an oral corticosteroid (OCS), but long-term systemic side effects are common and are burdensome to patients.
At each step, the patient’s response to the medication regimen should be reviewed and optimized if needed. If the asthma is not well-controlled with the current medications, treatment will need to be stepped up to the next level. If the asthma is well-controlled and maintained for 3 months, practitioners may consider stepping down treatment.3
Once the patient’s asthma is well-managed, it is important to keep them up to date on important patient education points. This is an opportunity for the pharmacist to play an active role in the patient care process. It is important to ensure that the patient understands what asthma is and how to recognize their symptoms in the event of an asthma attack. This empowers the patient to better understand the role that medication plays in management and allows them to better take care of themselves. Another critical counseling point is understanding when and how to use their medications. Given that asthma medications are administered in different ways, it’s important that the patient understands the differences; for example, the difference between a rescue inhaler and a maintenance inhaler. Since usage techniques can also vary from device to device, the pharmacist should demonstrate how to use each device properly. The pharmacist should also help the patient understand what triggers their asthma to avoid and limit their exposure to irritants that make their asthma worse.4
As our understanding of asthma improves, pharmacists will continue to play a larger role in educating patients on their evolving conditions, and ultimately find better ways to keep our patients’ airways happy and healthy.
- Morris M. Asthma. Medscape. https://emedicine.medscape.com/article/296301-overview#a1. Published 12/20/2019.
- Morris M. Asthma Clinical Presentation. Medscape. https://emedicine.medscape.com/article/296301-clinical#b1. Published 12/20/2019.
- Reddel H. Global Initiative For Asthma- Asthma Management and Prevention. https://ginasthma.org/wp-content/uploads/2019/04/GINA-2019-main-Pocket-Guide-wms.pdf. Published 01/01/1995. Last Updated 01/01/2019.
- American Lung Association. What Causes Asthma?. Lung. https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/asthma-symptoms-causes-risk-factors/what-causes-asthma. Published 04/10/2020.
- Fanta C. Patient education: Asthma treatment in adolescents and adults (Beyond the Basics). UpToDate. https://www.uptodate.com/contents/asthma-treatment-in-adolescents-and-adults-beyond-the-basics#H2194797247. Published 04/23/2020.