Asthma: The Pharmacist's Role in Improving Patient Outcomes

A Professional Program of the MWC Office of Continuing Professional Education

Behavioral Objectives

After completing this continuing education article, the pharmacist should be able to:

• Identify the goals of asthma management.
• Compare and contrast the 4 stages of asthma severity relative to symptoms and treatment options.
• List the common environmental triggers of asthma.
• Describe how to perform peak flow monitoring.
• Compare and contrast the controller and reliever medications used in the management of asthma relative to their role in treatment, their mechanism of action, and their side-effect profile.
• Apply the stepwise medication approach to asthma management to a patient case.
• Implement the steps for peak flow monitoring in developing an action plan for a patient.

Asthma is a chronic disease that is estimated to affect 1 of every 15 Americans or approximately 20 million Americans.¹ In the year 1999, 2 million emergency room visits and 478,000 hospitalizations were attributed to asthma attacks, and, in the year 2000, 11 million Americans reported asthma attacks.²

In addition, there are more than 5000 annual deaths directly caused by asthma and another 7000 deaths in which asthma is identified as a "contributing factor."¹

It is clear then that the cost burden asthma places on the United States' health care system is considerable. Recently, the annual cost of asthma was estimated to be almost $18 billion.¹ Hospitalizations (average length of stay is 3 days for a diagnosis of asthma) account for nearly $10 billion of this total cost. The indirect costs associated with lost earnings account for approximately $3 billion.¹ It is imperative, therefore, that action is taken to reduce the cost of this disease in human lives and dollars.

Asthma Pathophysiology

Asthma is a disease of inflammation. This inflammation is the basis for the definitive functional disturbance of airflow limitation.³ Airflow limitation, due to airways obstruction, results in the hallmark symptoms of cough, chest tightness, and wheezing.³ In patients who have asthma, this inflammatory process occurs all too easily and is referred to as airways hyperresponsiveness.³ The mechanisms of hyperresponsiveness are multifactorial and include, but are not limited to, hyperplastic and altered smooth muscle function; the presence of increased amounts of more viscous secretions and inflammation; and swelling of the submucosal lining of the airways.³ On a cellular level, it is the function of inflammatory mediators such as histamine, prostaglandins, interleukins, and other enzymes that facilitate this inflammatory process.

Asthma Guidelines?Classification of Severity and Treatment Goals

An understanding of the pathophysiology of asthma, knowing that patients may experience worsening of, as well as improvement in, their symptoms, and that it can be controlled have all contributed to the development of disease-specific guidelines. These guidelines include the basic tenet of the variable need for therapy as the symptoms of the disease improve or worsen.

Depending on the severity of symptoms, the disease can be characterized as mild intermittent (step 1), mild persistent (step 2), moderate persistent (step 3), or severe persistent (step 4).^2,4 The clinical features associated with each of these steps are identified in Table 1. Common causes or triggers of worsening symptoms are listed in Table 2. By identifying the "triggers"of asthma symptoms, appropriate education about environmental control as a means of controlling asthma can be provided. It also is important to understand the fluid nature of asthma as a disease?with the potential to worsen as well as improve?as the medical interventions to control the symptoms of this disease also are fluid and changing. This means that the aggressiveness of medication therapy is directly related to the severity of the disease. Whether discussing environmental control or control via medications, however, the goals of asthma care are the same. The characteristics that define asthma control?the goals of therapy?are identified in Table 3.

The following patient cases will be used to illustrate the application of the asthma guidelines to evaluate the severity of asthma symptoms as well as to identify treatment goals specific to each patient.

Evaluating the Severity of Asthma Symptoms? Two Patient Cases

Patient Case TR

TR is a 14-year-old white girl who presents to her provider with the following symptoms: shortness of breath in gym class (she attends 3 times a week) and waking from sleep due to coughing and tightness in her chest 1 to 2 times a month (usually during her menses). She was diagnosed with asthma 3 years ago but has not had any problems with it until recently.

What is the severity of TR's asthma? TR is presenting with symptoms consistent with mild persistent (step 2) asthma.

What are the goals of therapy for TR? Specific goals of therapy for TR include an absence of symptoms (both day and nighttime) and the ability to participate more fully in her gym class with the absence of symptoms.

Patient Case JW

JW is a 35-year-old African American man with a 25-year history of asthma who presents to his provider with worsening asthma symptoms. In particular, he is now waking up at least 4 nights a week with shortness of breath, and he has been requiring more asthma medication. He is also experiencing shortness of breath at rest on an almost daily basis. JW has recently married and moved into his wife's apartment. She has 2 cats.

What is the severity of JW's asthma? JW is presenting with asthma symptoms consistent with moderate persistent (step 3) asthma. His symptoms may have been exacerbated by the presence of his wife's 2 cats.

What are the goals of therapy for JW? Specific goals of therapy for JW include an absence of symptoms (both day and nighttime). In addition, the underlying cause of JW's worsening symptoms, the cats, should be addressed.

Asthma Guidelines?Limitations and Opportunities

Despite the presence of nationally recognized guidelines for the classification of asthma severity and the recommended treatment options for each, there exists a lack of adherence to such guidelines among the medical profession. In particular, although 86% of physicians recognize that patients with mild persistent (step 2) asthma should receive low-dose inhaled corticosteroids, only 19% of these patients reported taking them.⁵ It was also found that, whereas 83% of providers noted prescribing a peak flow meter for patients to evaluate their pulmonary functioning at home, only 62% of the patients knew of the device.⁵ In addition, although 28% of patients with asthma reported owning a peak flow meter, only 9% reported using it at least once per week.⁵

The lack of guideline adherence has been noted on both the part of the provider as well as the patient.⁶ Some have concluded that the disconnect between the existence of such guidelines and their actual application may, in large part, be due to insufficient education of both the provider and the patient.⁶ Provider education is key. In fact, there are specific actions providers can take to improve the control of asthma. Some of these actions include making the messages to patients consistent with the guidelines; using clinician communication techniques (oral and written) that have been demonstrated to enhance asthma management; and ensuring that all providers are trained relative to the content of the guidelines as well as how to communicate the guidelines to patients.⁷

Although the goals of incorporating the asthma guidelines into patient care have been discussed, the means by which these goals can be achieved includes good patient education that focuses on self-management. The elements of patient education that are thought to be essential are knowledge of the central role of airway inflammation, actions of the various medications, and strategies for environmental control.⁸ The performance of proper inhaler technique and exhibiting skills in monitoring and self-assessment and an understanding of an action plan for exacerbations are also necessary.⁸ Incorporating such elements into patient education have been proven to significantly improve adherence to inhaled therapy, patient perception of asthma control, and quality of life.⁸

Pharmacist's Role in Asthma Education

In response to the identified key areas of asthma education, several studies have been performed to illustrate the success of the community pharmacist as the primary provider of such education.^9-11 The outcomes evaluated in these studies include symptom scores, peak flow results, the need for medical and emergency room visits, days missed from work/school, and overall quality of life. McLean and colleagues illustrated that the provision of targeted asthma education by community pharmacists resulted in a 50% reduction in symptom scores, an 11% increase in peak flow readings, 0.6 fewer days missed from school/work annually, a 50% reduction in the use of rescue medications, an overall 19% improvement in quality of life, and a 75% reduction in both medical and emergency room visits.¹⁰

In the provision of asthma patient education, as noted above, the understanding of the disease is fundamental. Knowledge about the inflammatory nature of the disease is key to understanding the role of corticosteroids as the cornerstone of persistent asthma management. Understanding the fluid nature of asthma symptoms also is important because it allows the patient to comprehend the roles of reliever and controller medications. When asthma control is at its best, the use of a reliever medication on an as-needed basis is sufficient. As symptoms worsen and occur more often, becoming "persistent,"the need for adding scheduled controller medications or increasing the dose of such agents if already employed increases.

The preferred and alternative medications to be utilized on a daily basis in asthma management relative to the classification of persistent asthma symptoms are shown in Table 4. Of note, the table does not include the mild intermittent classification as it does not warrant the use of a daily medication. Regardless of severity, however, all patients with the diagnosis of asthma should have access to and use a bronchodilator such as an inhaled beta² agonist on an as-needed basis. In children >5 years of age and adults, such agents can be administered via a metered dose inhaler (MDI). In children <5 years of age, such agents should be administered by a nebulizer or face mask and space/holding chamber. Any patient requiring the use of such an agent >2 times a week should be evaluated for the use of a daily controller medication, or an increase in the dose of a daily controller medication if already taking one. Overall, all patients should be evaluated every 1 to 6 months for treatment efficacy and to see whether existing medications need to be increased, reduced, or deleted, or if additional agents need to be added. The agents used in asthma management as controller or reliever medications are classified in Table 5, as well as the recommended doses and common adverse effects. In addition to understanding the role(s) of the medications used in asthma management and utilizing them at the appropriate times, it is also suggested that the annual flu vaccine be administered to all patients with any level of persistent asthma.⁴

In order to obtain the maximum beneficial effects from the inhaled agents listed in Table 5, proper inhaler technique is necessary. The provision of education focusing on this skill is noted as one of the key elements of asthma education. Studies have demonstrated that when the community pharmacist incorporates inhaler technique as one of the components of asthma education, very positive outcomes occur, including a reduction in emergency room visits.¹¹ Now, with the addition of dry powder inhalers, patients also need to be educated about the technical steps in using such devices. Overall, patients should be instructed to sit or stand upright; actuate the MDI at the start of a long, slow breath inwards; or, if using a dry powder inhaler (DPI), actuate it and then follow with a long, slow breath inwards. Regardless of whether an MDI or a DPI is used, patients should be instructed to inhale 1 puff at a time. Once the inhalation has occurred, patients should try to hold their breath and count to 10 prior to exhaling and starting the next dose.

With proper inhaler technique, it is hoped that maximum efficacy can be achieved and that, over time, medications can be reduced or perhaps even discontinued in the presence of symptom improvement. In addition to monitoring the clinical aspects of the patient (number of times a month awakened with nocturnal symptoms; number of times a week experiencing daytime symptoms), the use of peak flow monitoring is also of importance. As a matter of fact, the guidelines recommend the use of such monitoring on a daily basis in the morning. The stability, decline in, or increase in the values obtained are useful in determining whether to continue the current asthma treatment regimen, step up the treatment regimen by increasing doses of controller agents or adding other agents, or step down the treatment regimen by decreasing medication doses or even discontinuing therapy, respectively. The proper way to use a peak flow meter is shown in Table 6.

Once the use of a peak flow meter becomes a routine part of asthma patients'day, they can then determine their personal best. This is the highest peak flow number that can be achieved over a 2-to 3-week period when their asthma is under good control. The personal best is used then to calculate the different ranges of peak expiratory flow values that help classify a patient's asthma severity. Peak flow readings should be obtained at the following times over a 2-to 3-week period to identify one's personal best: twice a day?upon awakening and between 12 noon and 2 PM; and before and after taking a quick reliever medication.

The asthma guidelines should be used to develop treatment goals for patients. Previously in this article, 2 patients were presented and evaluated for the severity of their asthma symptoms. Returning now to these patient cases, treatment goals using the guidelines will be identified.

Identifying Treatment Goals?Two Patient Cases

Patient Case TR

TR is currently not taking any medications?scheduled or on an as-needed basis?for her asthma. At her provider's office, her peak flow result is 258 L/min. The predicted value for her peak flow?given her height?is 293 L/min. The predicted value is used for TR because she does not do peak flow monitoring at home and her personal best value is unknown.

How should TR's peak flow be evaluated? TR's peak flow is 88% of her predicted value. This is consistent with her symptoms as noted earlier and helps to classify her asthma as mild persistent (step 2).

What would be the appropriate course of management for TR? The current persistent nature of TR's asthma makes her a candidate for a chronic controller medication. The guidelines recommend a low-dose inhaled corticosteroid. In addition, TR is a candidate for the use of a short-acting beta² agonist, 2 to 4 puffs as needed. For TR, the use of this agent 15 minutes prior to gym class would be warranted. It is also suggested that TR have her treatment regimen reevaluated in 1 to 6 months by assessing the presence or lack of clinical symptoms to determine the need for continued drug therapy, an increase in drug therapy needs, or the potential discontinuation of chronic drug therapy. An additional component of TR's therapy would include education on home peak flow monitoring to establish her personal best. The peak flow results can be used to help guide medication management, and the identification of her personal best value can be used to develop TR's asthma action plan.

How should an action plan be established for TR? Once TR's personal best is determined (Table 7), her "zones"can be calculated. Her green zone consists of peak flow readings that are ?80% of her personal best. The yellow zone exists when the peak flow readings are within 60% to 79% of her personal best. The red zone exists when the peak flow readings are <60% of her personal best. These zones are important in that the green zone exemplifies good asthma control when TR should continue her asthma medications as usual. When her values fall into the yellow zone, a short-acting beta² -agonist should be taken immediately, and she should contact her provider with these results, as her dose of inhaled corticosteroid may need to be increased or a long-acting beta² agonist be added. If the values fall into the red zone, TR should take her short-acting beta² agonist and call her provider or the emergency room immediately. The overall purpose of routine peak flow monitoring is to identify a "drop"into the yellow zone early enough that mediating steps can be taken to avoid falling into the red zone. TR should have her treatment regimen reevaluated in 1 to 6 months, along with her home peak flow results and presence or lack of clinical symptoms to determine the need for continued drug therapy, an increase in drug therapy needs, or the potential discontinuation of chronic drug therapy.

Patient Case JW

JW is currently taking fluticasone MDI 44 mcg/puff, 2 puffs twice daily, for control of his asthma. In addition, he has an albuterol MDI that he has been using (2-3 puffs at least 3 times daily). At his provider's office, his peak flow result is 325 L/min. His personal best peak flow value is 435 L/min.

How should JW's peak flow be evaluated? JW's peak flow is ~75% of his predicted value. This is consistent with his symptoms as noted earlier and helps to classify his asthma as moderate persistent (step 3).

What would be the appropriate course of management for JW? The current status of JW's asthma makes him a candidate for an increase in the dose of his chronic controller medication. In particular, his fluticasone dose should be increased to fluticasone 88 mcg/puff MDI, 2 puffs twice daily as needed. The guidelines also recommend the addition of a long-acting inhaled beta² agonist and the continued use of a short-acting beta² agonist on an as-needed basis. JW should have his treatment regimen reevaluated in 1 to 6 months, along with his home peak flow results and presence or lack of clinical symptoms to determine the need for continued drug therapy, an increase in drug therapy needs, or the potential discontinuation of chronic drug therapy.

Conclusion

Educating patients about asthma and its management via proper medication use and adherence, utilization of peak flow monitoring, and the development of action plans based upon peak flow monitoring is of the utmost importance. Provision of this education by a pharmacist has been proven to positively affect patient outcomes. Pharmacists should use this evidence as a driving force behind taking a more active role in the education of patients with asthma.

Elena M. Umland, PharmD: Associate Professor of Clinical Pharmacy, Philadelphia College of Pharmacy, University of the Sciences in Philadelphia; Adjunct Clinical Assistant Professor of Family Medicine, Jefferson Medical College, Thomas Jefferson University Hospital

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: astahl@ascendmedia.com.

MWC Office of Continuing Professional Education is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This program is approved for 2 contact hours (0.2 CEU) under the ACPE universal program number of 290-000-05-008- H01. The program is available for CE credit through April 30, 2008. ?

TESTING AND GRADING PROCEDURES

• Each participant achieving a passing grade of 70% or higher on any examination will receive a statement of credit giving the number of CE credits earned. This form should be safeguarded and may be used as documentation of credits earned.
• Participants receiving a failing grade on any exam will be notified and permitted to take 1 reexamination at no extra cost.
• All answers should be recorded on the answer form attached. For each question, decide which choice is the best answer, and circle the letter of the response representing your choice.
• Mail your completed exam form to the following address: Pharmacy Times, 405 Glenn Drive, Suite 4, Sterling, VA 20164-4432.

NEW SCORING OPTIONS

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Please print clearly?certificate will be issued from information given.

Please mail completed forms to: Pharmacy Times CE Department, 405 Glenn Drive, Suite 4, Sterling, VA 20164-4432

This educational lesson will be available to pharmacists on-line at www.pharmacytimes.com. (Based on the article starting on page 105.) Choose the 1 most correct answer.

1. Which of the following is a goal of asthma therapy?

• Routine use of as-needed medications
• Only 1 to 2 emergency room visits per year
• Near normal peak expiratory flow (PEF) values
• Less than 30% variation in PEF values throughout the day

2. Mild persistent asthma is associated with which of the following clinical features?

• Daytime symptoms ?2 days a week
• Daytime symptoms >2 days a week but <1 time a day
• Daytime symptoms on a daily basis
• Daytime symptoms that are continuous

3. Severe persistent asthma is associated with which of the following clinical features?

• Daytime symptoms ?2 days a week
• Daytime symptoms >2 days a week but <1 time a day
• Daytime symptoms on a daily basis
• Daytime symptoms that are continuous

4. The flu vaccine should be administered to all patients with mild intermittent asthma.

• True
• False

5. All patients with asthma, regardless of level of asthma severity, should be prescribed which of the following agents?

• Long-acting beta² agonist
• Short-acting beta² agonist
• Low-dose inhaled corticosteroid
• Medium-dose inhaled corticosteroid

6. Which of the following treatment options is preferred for a patient with mild persistent asthma?

• . Long-acting beta² agonist
• Short-acting beta² agonist alone
• Low-dose inhaled corticosteroid
• Medium-dose inhaled corticosteroid and a long-acting beta² agonist

7. Common environmental triggers of asthma include:

• Excessive sun exposure.
• Animals with fur or feathers.
• The overuse of high-efficiency particulate air filters.
• Snakes.

8. Which of the following agents used in the management of asthma is associated with hepatotoxicity and requires that patients taking it should have their liver function monitored?

• Cromolyn
• Nedocromil
• Zileuton
• Zafirlukast

9. Long-acting beta² agonists are added to a patient's medication profile once asthma reaches the severity of:

• Step 1?mild intermittent.
• Step 2?mild persistent.
• Step 3?moderate persistent.
• Step 4?severe persistent.

10. A 44-year-old white man presents with asthma with recent peak flow results averaging 360 L/min; his personal best result is 465 L/min. In addition, he has been experiencing symptoms at night at least 1 to 2 times weekly. His current asthma medications include an albuterol metered dose inhaler (MDI) 2 to 3 puffs as needed, salmeterol MDI 2 puffs (21 mcg/puff) every 12 hours, and beclomethasone hydrofluoroalkane (HFA) 1 puff (120 mcg/puff) twice daily. What would be most appropriate for this patient at this time?

• Continue his current medication regimen because his asthma is controlled
• Increase the albuterol dose to 4 puffs as needed.
• Increase the dose/frequency of salmeterol to 2 puffs every 6 hours.
• Increase the dose of the beclomethasone HFA to 2 puffs (120 mcg/puff) twice daily.

11. If a new asthma patient's predicted personal best is 420 L/min and an actual value of 325 L/min is obtained, into which severity stage does this patient fall?

• Step 1?mild intermittent
• Step 2?mild persistent
• Step 3?moderate persistent
• Step 4?severe persistent

12. Which of the following side effects of inhaled corticosteroids can be diminished by rinsing the mouth (swish and spit) with water after taking a dose?

• Coughing from upper airway irritation
• Osteoporosis
• Oropharyngeal candidiasis
• Dysphonia

13. Which of the following describes patients in their "yellow zone"relative to their asthma action plan?

• PEF is >80% of their personal best or predicted. They do not need to contact their physician.
• PEF is 60% to 80% of their personal best or predicted. They should take a short-acting beta² agonist immediately and call their provider to relay their current peak flow results.
• PEF is <60% of their personal best or predicted. They should go to the emergency room immediately.
• PEF is <60% of their personal best or predicted. They should take a short-acting beta² agonist immediately, and call their provider to relay their current peak flow results.

14. A patient with usually mild persistent asthma calls the pharmacist with peak flow results that indicate that the patient is in the "red zone"?results only 50% of personal best. The patient also complains of being very short of breath. The pharmacist has difficulty understanding the patient on the phone because of the shortness of breath. The pharmacist's recommendation should be that:

• The patient take an extra dose of short-acting beta² agonist and wait to see what happens.
• The patient should take a short-acting beta² agonist immediately and call a provider to relay current peak flow results.
• The patient should go to the emergency room immediately.
• The patient should take a long-acting beta² agonist immediately and call a provider to relay current peak flow results.

15. Chronic oral corticosteroid use is most likely to be used in which of the following cases?

• Step 1?mild intermittent
• Step 2?mild persistent
• Step 3?moderate persistent
• Step 4?severe persistent

16. Which of the following is a step in performing peak flow monitoring?

• Move the indicator to the top of the numbered scale.
• Sit down.
• Place the mouthpiece in your mouth and close your lips around it, putting your tongue inside the hole.
• Blow out as hard and as fast as you can in a single blow, completely emptying your filled lungs.

17. Leukotriene modifiers would be most appropriate in which of the following patients?

• A patient with daytime symptoms ?2 days a week currently taking a short-acting beta² agonist on an as-needed basis
• A patient with nighttime symptoms ?2 nights a month currently taking a short-acting beta² agonist on an as-needed basis
• A patient with daytime symptoms >2 days a week but <1 time a day currently taking a low-dose inhaled corticosteroid
• A patient with nighttime symptoms ~3 nights a month currently taking a long-acting beta² agonist alone

18. Asthma patients should be reevaluated every ________ to identify whether their asthma management plan should be changed.

• 2-4 weeks
• 1-6 months
• 6-8 months
• 8-12 months

19. Knowledge of the central role of airway inflammation in the development of asthma and its corresponding symptoms is a key component of asthma patient education.

• True
• False

20. Studies have illustrated the positive impact that pharmacists can have on improving the clinical outcomes in patients with asthma.

• True
• False