Asthma Management: During Pregnancy and Lactation
ASTHMA MANAGEMENT: DURING PREGNANCY AND LACTATION | |||||
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Goals of Therapy: Asthma Control | |||||
• Minimal or no chronic symptoms • Minimal or no exacerbations • No limitations on activities: no school/work missed |
• Maintain (near) normal pulmonary • Minimal use of short-acting inhaled • Minimal or no adverse effects from medications |
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CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT | |||||
Components of Severity |
Classification of Asthma Severity During Pregnancy and Lactation |
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Mild Intermittent | Persistent | ||||
Mild | Moderate | Severe | |||
Symptoms/Day | ≤2 days/week | >2 days/week but < daily | Daily | Continual | |
Symptoms/Night | ≤2 nights/month | >2 nights/month | >1 night/week | Frequent | |
PEF or FEV1 | ≥80% | ≥80% | >60%−<80% | ≤60% | |
PEF Variability | <20% | 20%−30% | >30% | >30% | |
STEPWISE APPROACH FOR MANAGING ASTHMA | |||||
Intermittent Asthma |
Persistent Asthma | ↑ Step up If control is not maintained, consider step up. First, review patient medication technique, adherence, and environmental control. ———————— Assess control ———————— Step down Review treatment every 1−6 months; a gradual stepwise reduction in treatment may be possible. ↓ |
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Step 4 (Severe Persistent) Preferred treatment: High-dose inhaled corticosteroid AND Long-acting inhaled beta2‑agonist AND, if needed, Corticosteroid tablets or syrup long term (2mg/kg/day, generally not to exceed 60mg/day). (Make repeat attempts to reduce systemic corticosteroid and maintain control with high‑dose inhaled corticosteroid.¹) Alternative treatment: High-dose inhaled corticosteroid¹ AND theophylline4 AND, if needed, oral corticosteroids |
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Step 3 (Moderate Persistent) Preferred treatment: EITHER Low-dose inhaled corticosteroid¹ and long‑acting inhaled beta2‑agonist OR Medium-dose inhaled corticosteroid.¹ If needed (particularly in patients with recurring severe exacerbations): Medium‑dose inhaled corticosteroid¹ and long‑acting inhaled beta2‑agonist Alternative treatment: Low-dose inhaled corticosteroid¹ and either theophylline4 or leukotriene receptor antagonist.² If needed: Medium‑dose inhaled corticosteroid¹ and either theophylline4 or leukotriene receptor antagonist.² |
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Step 2 (Mild Persistent) Preferred treatment: Low-dose inhaled corticosteroid.¹ Alternative treatment (listed alphabetically): cromolyn, leukotriene receptor antagonist² OR theophylline4 |
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Step 1 (Mild Intermittent) No daily medications, albuterol as needed. |
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Quick-Relief Medication for All Patients • Short-acting bronchodilator: 2−4 puffs short-acting beta2‑agonist³ as needed for symptoms. • Intensity of treatment will depend on severity of exacerbation; up to 3 treatments at 20‑minute intervals or a single nebulizer treatment as needed. Course of systemic corticosteroid may be needed. • Use of short-acting inhaled beta2‑agonist³ >2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term-control therapy. |
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Additional Information | |||||
• The stepwise approach is meant to assist, not replace, the clinical decisionmaking required to meet individual patient needs. • Classify severity: assign patient to most severe step in which any feature occurs (PEF is percent of personal best; FEV1 is percent predicted). • Gain control as quickly as possible (consider a short course of systemic corticosteroid), then step down to the least medication necessary to maintain control. • Minimize use of short-acting inhaled beta2‑agonist³ (eg, use of approximately one canister a month even if not using it every day indicates inadequate control of asthma and the need to initiate or intensify long-term-control therapy). • Provide education on self-management and controlling environmental factors that make asthma worse (e.g., allergens, irritants). • Refer to an asthma specialist if there are difficulties controlling asthma or if Step 4 care is required. Referral may be considered if Step 3 care is required. |
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NOTES | |||||
¹Budesonide is the preferred inhaled corticosteroid for use during pregnancy. However, pregnant patients whose asthma was well controlled on other inhaled corticosteroids before pregnancy may continue their treatment. ²There are minimal data on using leukotriene receptor antagonists in humans during pregnancy, although there are reassuring animal data submitted to FDA. ³There are more data on using albuterol during pregnancy than on using other short-acting inhaled beta2‑agonists. 4Achieve theophylline serum concentration 5−12mcg/mL. |
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REFERENCES | |||||
American College of Obstetricians and Gynecologists. Asthma in Pregnancy. ACOG Practice Bulletin No. 90. Obstet Gynecol 2008; 111:457-64. National Asthma Education and Prevention Program. Working Group Report on Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment 2004. U.S. Department of Health and Human Services. http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg/astpreg_full.pdf. Accessed November 26, 2012. (Rev. 4/2018) |