A Textbook of Clinical Pharmacology and Therapeutics

STEP 5: CONTINUOUS OR FREQUENT USE OF ORAL STEROIDS
Use daily steroid tablet in lowest dose providing adequate control
Maintain high dose inhaled steroid at 2000 μg/day*
Consider other treatments to minimize the use of steroid tablets
STEP 2: REGULAR PREVENTER THERAPY
STEP 1: MILD INTERMITTENT ASTHMA
Refer patient for specialist care
Add inhaled steroid 200–800 μg/day*
400 μg is an appropriate starting dose for many patients
Start at dose of inhaled steroid appropriate to severity of disease.
* BDP or equivalent
STEP 4: PERSISTENT POOR CONTROL
• Increasing inhaled steroid up to 2000 μg/day*
• Addition of a fourth drug e.g. leukotriene receptor
antagonist, SR theophylline, � 2 agonist tablet
STEP 3: ADD-ON THERAPY
1. Add inhaled long-acting � 2 agonist (LABA)
2. Assess control of asthma:
• good response to LABA – continue LABA
• benefit from LABA but control still inadequate – continue LABA and
increase inhaled steroid dose to 800 μg/day* (if not already on this dose)
• no response to LABA – stop LABA and increase inhaled steroid to
800 mcg/day.* If control still inadequate, institute trial of other therapies,
e.g. leukotriene receptor antagonist or SR theophylline
Inhaled short-acting � 2 agonist as required
4. Leukotriene receptor antagonists (e.g. montelukast) are
used in adults and children for long-term maintenance
therapy and can reduce glucocorticosteroid requirements.
5. In moderate to severe steroid-dependent chronic asthma,
the anti-IgE monoclonal antibody omalizumab can
improve asthmatic control and reduce the need for
glucocorticosteroids.
6. Hypnotics and sedatives should be avoided, as for acute
asthma.
7. Patients can perform home peak flow monitoring first
thing in the morning and last thing at night, as soon as
asthmatic symptoms develop or worsen. This allows
adjustment of inhaled medication, or appropriate urgent
medical assessment if the peak flow rate falls to less than
50% of normal, or diurnal variation (morning ‘dipping’)
exceeds 20%.
CHRONIC BRONCHITIS AND EMPHYSEMA 235
ACUTE BRONCHITIS
Figure 33.2: Stepwise approach to asthma
therapy in a non-acute situation. BDP,
beclometasone dipropionate. (Redrawn
with permission from the British Thoracic
Society, British guideline on the
management of asthma, p 26.)
Acute bronchitis is common. There is little convincing evidence
that antibiotics confer benefit in otherwise fit patients
presenting with cough and purulent sputum, and usually the
most important step is to stop smoking. In the absence of fever
or evidence of pneumonia, it seems appropriate to avoid
antibiotics for this self-limiting condition.
CHRONIC BRONCHITIS AND EMPHYSEMA
Chronic bronchitis is associated with a chronic or recurrent
increase in the volume of mucoid bronchial secretions