Asthma Management: During Pregnancy and Lactation
|ASTHMA MANAGEMENT: DURING PREGNANCY AND LACTATION|
|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
|CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT|
|Classification of Asthma Severity
During Pregnancy and Lactation
|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%|
|STEPWISE APPROACH FOR MANAGING ASTHMA|
|Persistent Asthma|| ↑
If control is not maintained, consider step up. First, review patient medication technique, adherence, and environmental control.
Review treatment every 1−6 months; a gradual stepwise reduction in treatment may be possible.
| Step 4
High-dose inhaled corticosteroid
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)
High-dose inhaled corticosteroid¹
if needed, oral corticosteroids
| Step 3
Low-dose inhaled corticosteroid¹ and long‑acting inhaled beta2‑agonist
Medium-dose inhaled corticosteroid.¹
If needed (particularly in patients with recurring severe exacerbations): Medium‑dose inhaled corticosteroid¹ and long‑acting inhaled beta2‑agonist
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
| Step 2
Low-dose inhaled corticosteroid.¹
cromolyn, leukotriene receptor antagonist²
| Step 1
No daily medications, albuterol as needed.
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.
• 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.
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.
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.