A Textbook of Clinical Pharmacology and Therapeutics

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 omalizumabcan
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%.

ACUTE BRONCHITIS

Acute bronchitis is common. There is little convincing evi-

dence 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

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

Refer patient for specialist care

STEP 1: MILD INTERMITTENT ASTHMA

Inhaled short-acting 2 agonist as required

STEP 2: REGULAR PREVENTER THERAPY

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.

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

* BDP or equivalent

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.)

CHRONICBRONCHITIS ANDEMPHYSEMA 235