However, its use requires caution due to its narrow therapeutic range and potential side effects, including diuresis, tremors, and headaches. Theophylline is a medication that may be an alternative medication in Steps 2 through 6. Omalizumab may be a consideration for appropriate patients with allergy. Step 6 for ages 0-4 years is a high dose ICS + either LABA or montelukast or oral corticosteroids for ages 5-11 years – high dose ICS + LABA + oral systemic corticosteroid and for ages 12 and up, high dose ICS + LABA + oral corticosteroid are preferred. Omalizumab is a monoclonal antibody indicated for moderate to severe persistent asthma with objective evidence of perennial aeroallergen sensitivity and inadequate control with ICS. Since the publication of these guidelines, Omalizumab has received FDA approval for ages 6 years and above. EPR-3 also recommends consideration of omalizumab for ages 12 and above. Step 5 for 0-4 years is high dose ICS + either LABA or montelukast in 5-11 years and 12 and above, a high dose ICS + LABA. In ages, 5 to 11 years and 12 and above, a medium dose ICS + LABA is the preferred option. Step 4 in the 0 to 4-year-old age range is a medium dose ICS + either a LABA or montelukast. LABA monotherapy is indeed associated with an increase in asthma-related mortality and serious adverse events. For those ages 12 years through adulthood, the preferred choice is a low dose of ICS + LABA or medium-dose ICS. There was a black-box warning on LABAs due to concerns about increasing deaths in patients taking LABAs however, according to more recent studies, LABAs demonstrated safety when combined with inhaled corticosteroids. In the 5 to 11 year age group, the preferred option is either a medium-dose ICS or a combination ICS + long-acting beta-agonist (LABA) or leukotriene receptor antagonist (LTRA). The preferred option for step 3 is a medium dose ICS in the 0 to 4-year-old children. Single evening dosing prescribing is by age and FDA approved for asthma control from 12 months of age. Montelukast is a leukotriene receptor antagonist available in 4 mg granules, or 4 mg and 5 mg chewable tablets, as well as in a 10 mg tablet formulation. The preferred treatment for step 2 is a low-dose inhaled corticosteroid (ICS). In each of these steps, inhaled corticosteroids are a component of the preferred treatment regimen. STEPS 2-6 refer to options for persistent asthma. Their administration is most often by nebulizer or inhaler. They have a quick onset of action, within 5 to 15 minutes, and a duration of action of 4 to 6 hours. Albuterol and levalbuterol are examples of short-acting bronchodilators. The preferred treatment option for intermittent asthma, as well as for quick relief of asthma symptoms and the prevention of exercise-induced bronchoconstriction is a short-acting beta-2 agonist. The following discussion will highlight the step therapy proposed by EPR-3. In patients who do not demonstrate a significant bronchodilator response and in whom you continue to have a clinical suspicion of asthma, a 2 to 3 week trial of an oral corticosteroid may be a consideration. According to the ATS/ERS guidelines, reversibility is significant when there is an over 12% improvement from baseline or an increase of greater than 200 ml in FEV1. Assessment of the bronchodilator response begins with the baseline spirometry followed by the administration of a short-acting bronchodilator (most commonly, albuterol 2 to 4 puffs in adults and older children). The baseline spirometry provides the following information FVC (forced vital capacity), FEV1 (forced expiratory volume at 1 sec.), FEV1/FVC, and F25 to 75 (the difference between the forced expiratory volume at 25% and 75%). Spirometry is a non-invasive, objective test that can be performed in the office setting and is recommended in the EPR 3 guideline as to the preferred lung function test to assign asthma severity. In children over five years of age and adults, pre and post-bronchodilator spirometry can help confirm the diagnosis. However, subgroups with increasing prevalence were identified, notably in 10-17-year-olds, those living in the southern U.S. children ages 0 to 17 years and noted a plateau after 2009 followed in 2013 by an overall decline in pediatric asthma prevalence. examined trends in asthma prevalence in U.S. In a more recent pediatric study, Akinbami et al. Geographic Location Northeastern US > South or Western US (children: boys > girls and in adults: women > men) Gender Overall Females> males but varied by age Table 1: Factors affecting Asthma Prevalence National surveillance data shows that prevalence varies by age, gender, race, ethnicity, geographic location, and socioeconomic status. Currently, asthma prevalence in the United States is 7.8 % (1) down from 8.4% in 2010.
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