Managing Asthma During Pregnancy and Lactation Mary McMahon, RNC, MS Guidelines for Asthma during Pregnancy National Asthma Education and Prevention Program (NAEPP) • Working Group Report on Managing Asthma during Pregnancy: Recommendations for Pharmacologic Treatment – Update 2004 American College of Obstetrician and Gynecologist (ACOG) • Asthma in Pregnancy Bulletin 90, 2008, Reaffirmed 2012 Let’s Discuss… • Asthma Control • Management of Asthma during Pregnancy and Lactation • Educational Resources for Patients and Professionals Respiratory Physiology in Pregnancy Respiratory Rate Vital Capacity Unchanged Unchanged Tidal Volume Increased Minute Ventilations Increased Minute Oxygen Uptake Increased Functional Residual Capacity Decreased Residual Volume of Air Decreased Airway Conductance Increased Total Pulmonary Resistance Reduced Changes in respiratory status occur more rapidly in pregnant patients than in nonpregnant patients Effects of Pregnancy on Asthma When women with asthma become pregnant: • One-third of the patients improve, • One-third worsen, • Last third remain unchanged Effects of Asthma on Pregnancy • One of the most common chronic medical problem that occurs during pregnancy – Approximately 8% of pregnancy women • Let’s take a deep look at this…….. Asthma is Characterized by • Inflammation of the airways, with an abnormal accumulation of eosinophils, lymphocytes, mast cells, macrophages, dendritic cells, and myofibroblasts. • Leads to a reduction in airway diameter caused by smooth muscle contraction, vascular congestion, bronchial wall edema and thick secretions. Airway Inflammation & Symptoms Risk Factors Inflammation Airway Hyperresonsiveness Precipitating Factors Clinical Symptoms Adapted from NAEPP Expert Panel Report 2 & 3 Airway Obstruction Clinical Symptoms • • • • Cough Wheeze Shortness of breath Chest tightness Asthma • Impairment – Frequency and intensity of symptoms – Functional limitations • Risk – Likelihood of asthma exacerbations – Progressive decline in lung functions – Risk of adverse effects from treatment Adapted from NAEPP, Expert Report 3 What Are Goals of Treatment? • Your patient should be able to – Participate in activities, including physical activity without asthma symptoms – Sleep through the night without asthma symptoms – Have normal or near normal lung function – Minimal use of short-acting inhaled beta2agonist – Have few, if any side effects from medication taken Goals of Therapy: Asthma Control • Reduce impairment – Prevent chronic and troublesome symptoms (e.g. coughing or breathlessness in the daytime, in the night or after exertion) – Require infrequent use (<2 days a week) of SABA for quick relief of symptoms – Maintain (near) normal pulmonary function – Maintain normal activity levels (including exercise and other physical activity and attendance at work or school) – Meet patients’ and families’ expectations of and satisfaction with asthma care NAEPP Expert Panel Report 3 Goals of Therapy: Asthma Control • Reduce risk – Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations – Prevent progressive loss of lung function; blood oxygenation that ensures oxygen supply to fetus – Provide optimal pharmacotherapy with minimal or no adverse effects NAEPP Expert Panel Report 3 Treatment Goal - Pregnant Asthma Patient To provide optimal therapy to maintain control of asthma for maternal health and quality of live as well as for normal fetal maturation. When Asthma is not Controlled Maternal health risks include: • High Blood Pressure • Preeclampsia, which can affect – Placenta – Kidneys – Liver – Brain When Asthma is not Controlled Risks to the Fetus include: • Perinatal Mortality • Intrauterine Growth Restriction • Preterm Birth • Low Birth Weight Differential Diagnosis Patients presenting with new respiratory symptoms during pregnancy; Is it......? • Dyspnea • GERD • Chronic cough from postnasal drip • Bronchitis Goals • What are the patient’s and family’s personal goals? Asthma Severity • Severe persistent asthma 4 • Moderate persistent asthma 3 • Mild persistent asthma 2 • Intermittent asthma 1 Classification of Asthma Severity and Control in Pregnant Patients Components of Severity Impairment Risk Intermittent Mild Persistent Moderate Persistent Severe Persistent Symptoms <2 days/wk or less >2 days/wk, not daily Daily Throughout the day Nighttime awakenings <2 Xs/mth or less >2 Xs per month More than once a week Four times per week or more SABA prn <2 days/wk >2 days/wk, not daily, not >1 X/day Daily Several xs/day Interference with normal activity None Minor limitation Some limitation Extremely limited Lung function Normal FEV1 between exacerbations FEV1>80% FEV1/FVC normal FEV1>80% FEV1/FVC normal FEV1>60%, but <80% FEV1/FVC reduced 5% FEV1 <60% FEV1/FVC reduced >5% Step 3 Step 4 or 5 Exacerbations requiring oral steroids Recommended Step for Initiating Treatment 0-1/yr >2/yr Step 1 Step 2 Asthma Severity Dictates only initial therapy in the untreated patients. • Intermittent asthma is appropriately treated with only shortacting beta-agonists for rescue and prevention of symptoms, such as those that occur with exercise. • Persistent asthma should be treated with inhaled corticosteroids (ICS). If symptoms or rescue inhaler use are daily, nighttime awakenings at least weekly, there is moderated interference with normal activities, or there is reduced pulmonary function when not having symptoms, then initial treatment should be medium doses of ICS or a combination of low-dose ICS and a long-acting inhaled beta-agonist. Once the patient with asthma is receiving controller medication, further adjustments to asthma therapy are based on the level of asthma control. Spirometry • Get Valid Spirometry Results EVERY Time • DHHS (NIOSH) Publication No. 2011-135 Stepwise Approach to Asthma Int. Asthma Step 1 Persistent Asthma Step 2 Step 3 Step 4 Step 5 Step 6 Long Term Control Medication Patient Education, Environmental Control, Comorbidities Quick Relief Medication for all patients Step Up Assess Control Step Down Level of Asthma Control • Well-Controlled • Not Well-Controlled • Very poorly controlled – Many patients experience poor control of asthma Adapted from NAEPP, Expert Report 3 Asthma Control Test • Simple self assessment questionnaire (takes few minutes) • Patient fills out while waiting • 70-75% accuracy in determining level of asthma control • Validated & Guidelines recommended • Educates the goals of ‘Well Controlled’ Asthma Control Test • 5 items completed by the patient reflecting on the past 4 weeks – Daytime and nighttime symptoms – Activity limitations – Rescue inhaler use • Add up: 0 - 25 – > 20: well controlled – 16 – 19: not well controlled – < 15: very poorly controlled • A 23 year old patient, G1P0 at 11 wks with history of asthma was seen by her provider with recurrent cough and wheeze. She admits to waking twice per month with a cough and requiring albuterol twice per week. The provider knows that according to the EPR-3 guidelines, this woman’s level of asthma control would be classified as: A. B. C. D. Very well controlled Well controlled Not well controlled Very poorly controlled Controlling Asthma Triggers • Smoking • Avoiding Allergens – Pollen – Dust mites – Pet dander Team Approach to Managing Asthma During Pregnancy • • • • Expectant Mother and her family Obstetrical Provider Primary Care Provider Asthma Specialist – Refer to a specialist if asthma is poorly controlled. Asthma Action Plan • Everyone with asthma should have an asthma action plan. – Developed with patient and provider – Shows daily treatment • What kind of medicines to take • When to take medicines – How to control asthma long term – How to handle worsening asthma – When to call the doctor or go to the ED U.S. FDA Pregnancy Categories Pregnancy Category Definition A Well-controlled studies have failed to demonstrate a risk to the fetus. B Animal reproduction studies demonstrate an adverse effect on the fetus, There are no wellcontrolled studies in pregnant women. The potential benefits of this drug may outweigh the potential risks. C There is positive evidence of human fetal risk based on adverse reaction data from research or clinical experience. The potential benefits of this drug may outweigh the potential risks. D Studies in humans and animals have demonstrated fetal abnormalities. There is positive evidence of human fetal risk. The risks of this drug outweigh any benefit to its use. How Medications Work? • Bronchodilator • Anti-Inflammatory Stepwise Approach to Manage Asthma Stepwise Approach to Asthma • Asthma Medications – Quick relief • Taken when asthma symptoms present – Long term control • Taken daily, even when asthma well controlled Stepwise Approach to Asthma • Medications – Preferred treatment – Alternative treatment – Consider variability in response based on the individual Stepwise Approach - 12 yrs-Adult (revised) Int. Asthma Persistent Asthma Step 6 Step 5 Step 1 SABA prn Step 2 Preferred •ICS (low dose) Step 3 Preferred ICS (low dose) Or ICS (med dose) & •LABA Step 4 Preferred •ICS (med dose) & •LABA Preferred •ICS (high dose) & •LABA + •Omalizumab •(if allergens) Preferred •ICS (high dose) + •LABA + Oral Corticosteroid And Consider Omalizumab (if allergens) Long Term Control Medication Patient Education, Environmental Control, Comorbidities Quick Relief Medication for all patients (SABA) Adapted from NAEPP, Expert Report 3 Step Up Assess Control Step Down Quick Relief Medication • All levels of asthma severity require short-acting beta2-agonist (SABA) • Anyone with asthma can have a severe exacerbation Short-Acting Beta2-Agonists • Used as a pretreatment before exercise • Used to treat asthma symptoms • Increased use >2 days per week indicates inadequate asthma control • Regular use not recommended Long Term Control Medication • Preferred treatment • Inhaled Steroids – Most effective long term control medication for mild, moderate and severe persistent asthma Inhaled Steroids • • • • • • • Improve asthma control Improve quality of life Improve spirometry Decrease airway hyper responsiveness Prevent exacerbations Reduce severity of symptoms Reduce systemic steroids, ED visits, hospitalizations and death Inhaled Steroids • Mometasone – Twisthaler® • Ciclesonide – MDI • Fluticasone – MDI • Budesonide – Flexhaler ®, Respules® • Beclomethasone – MDI (HFA propellant) Comparative Daily Dosage Inhaled Corticosteroids Medicine Low Daily Dose Med Daily Dose High Daily Dose Beclomethasone HFA 40 80 mcg per puff 2-6 puffs 1-3 puffs More than 6-12 puffs More than 3-6 puffs More than 12 puffs More than 6 puffs Budesonide DPI 200 mcg/inhalation 1-3 puffs More than 3-6 puffs More than 6 puffs Flunisolide 250 mcg per inhalation 2-4 puffs 4-8 puffs More than 8 puffs Fluticasone HFA 44 mcg 110 mcg per puff, 220 mcg per puff 2-6 puffs 2 puffs 2-4 puffs 1-2 puffs More than 4 puffs More than 2 puffs Fluticasone DPI 50 mcg 100 mcg per inhalation 250 mcg per inhalation 2-6 puffs 1-3 puffs 1 puff 3-5 puffs 2 puffs More than 5 puffs More than 2 puffs Triamcinolone 75 mcg/inh Mometasone DPI 200 mcg/inh 4-10 puffs 10-20 puffs More than 20 puffs 1 puff 2 puffs More than 2 puffs Adapted from NAEPP Expert Panel Report 3 & ACOG Bulletin No. 90 Inhaled Steroids • Increased effect in lungs with decreased systemic side effects • Side effects – Thrush (oral candidiasis) – Sore throat – Hoarseness – Dry mouth Combination Therapy • Preferred treatment – Varies with age • The combination of long-acting inhaled beta2agonists (LABA) added to low-to-medium doses of inhaled steroids leads to improvements in: – Lung function – Symptoms – Reduced use of short-acting beta2-agonists • Increase in inhaled steroid given equal weight Anti-IGE Treatment • Omalizumab • Approved for: – Poorly controlled moderate to severe persistent asthma – Year round allergies – Individuals taking routine inhaled steroids • Not recommended to initiate during pregnancy Oral Corticosteroids • Action - Reduces and prevents inflammation • Pills – Prednisone – Methylprednisolone • Short course to speed recovery with moderate to severe exacerbation Medication Technique Is Important • Check inhalation technique at every visit Medication Technique Is Important • Patients should know – How to use the device – How to tell when the device is empty – How to clean the device • www.NJHealth.org Maintaining Asthma Control • Once asthma control achieved – Gradual reduction of pharmacotherapy (Step Down) – Monitor asthma control with the goal of providing optimal pharmacotherapy with minimal or no adverse effects Managing Exacerbations – Home Treatment • Assess Severity • Initial Treatment • Response – Good – Incomplete – Poor • Follow-up Management of Exacerbations – Emergency Dept. and Hospital Care • Initial Assessment • Initial Treatment depending on severity – Mild to mod exacerbation – Severe – Impending or actual respiratory arrest • Repeat Assessment – Level of Response Transition of Care • Admit to Hospital Intensive Care • Admit to Inpatient Unit • Discharge Home Key Patient Education Messages Teach and reinforce at initial visit and follow up • Basic facts about asthma • Well controlled asthma and patient's current level of control – Asthma Control Test – Ask “How often are you using your SABA in a week?” Key Patient Education Messages cont • Role of medications • Patient skills – Take medication correctly – Environmental control measures – Self monitoring • Asthma Symptoms • Use of peak flow • Use of written asthma action plan Patient Education Links • Asthma, Allergies and Pregnancy Tip to Remember American Academy of Allergy, Asthma & Immunology (AAAI) (2013) Home>Conditions & Treatments> Library>Asthma Library>http://www.aaai.org/conditionsand-treatments/library/asthma-library/asthma,allergies-andpregnancy/TTR • Pregnancy is Complicated by Allergies and Asthma American College of Allergy, Asthma & Immunology (ACAAI), 2010. Retrieved 08/13/2013 http://www.acaai.org/allergist/liv_man/pregnancy. • Asthma during Pregnancy March of Dimes, 2011. Retrieved 08/13/2013 http://www.marchofdimes.com/pregnancy/asthma-duringpregnancy. Current Studies Related to Asthma • Interaction between obesity and asthma • Dietary fat intake, may be an important modifier of airway inflammation • Acetaminophen and folate may modify asthma risk, although more data are needed • The effects of vitamin D on asthma are (in theory) significant, more date to come • EXPECT Pregnancy Registry - XOLAIRR use prior to conception or during pregnancy Conclusions • The ultimate goal of asthma therapy in pregnancy is maintaining adequate oxygenation of the fetus be preventing hypoxic episodes in the mother. • It is safer for pregnant women with asthma to be treated with asthma medications than it is for them to have asthma symptoms and exacerbations. References • • • • • American College of Obstetricians and Gynecologists (ACOG). (2008). Asthma in pregnancy. ACOG Practice Bulletin No. 90. Obstet Gynecol 2008 111:457-64 American College of Obstetricians and Gynecologists (ACOG). (2008). ACOG releases new recommendations on the management of asthma during pregnancy. Retrieved from http://www.acog.org/about_acog/news_room/news_ releases/2008/acog_releases. Retrieved 06/18/2013. Chambers, C., Asthma medications (2013) Clinician Reviews http://www.clinicianreviews.com/index.php?id=31613&type=98&tx_ttnews[tt_ne ws]=216. Retrieved 09/20/2013. Enriquez, R., Griffin, M., Carroll, K., Wu, P., Cooper, W., Gebretsadik, T., … Hartert, T. (2007). Effect of maternal asthma and asthma control on pregnancy and perinatal outcomes. Journal of Allergy, Asthma & Immunology, 120(3), 625630. Murphy, A., Proeschal, A., Brightling, C., Wardlaw, A., Parvord, I., Bradding, P., et al. (2012). The relationship between clinical outcomes and medication adherence in difficult-to-control asthma. Thorax, 67, 751-753. 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Weinberger, S. & Schatz, M., (2012) In B.S. Bockner, X.J. Lockwood & H. Hollingswork (Eds), Management of asthma during pregnancy. UpToDate. Retrieved from http://www.uptodateonline.com Questions? Comments?