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Asthma (1 of 26)

Asthma (1 of 26)

(1 of 26)

1 Patient presents w/ signs & symptoms suggestive of asthma

2 3 DIAGNOSIS No ALTERNATIVE Is asthma DIAGNOSIS confi rmed?

Yes

ASSESS THE LEVEL OF CONTROL OF ASTHMA FOR THE PAST 4 WEEKS Controlled Partly Controlled Uncontrolled (All of the (Presence of 1-2 of these) (Presence of 3-4 of these) following) Children Adolescents Children Adolescents & ≤5 years old & Children ≤5 years old Children 6-11 years old 6-11 years old Frequency of daytime None >Few >2x/week >Few >2x/week symptoms minutes, minutes, >once a week >once a week Limitation of activities None Any Any Any Any Nocturnal waking up or None Any Any Any Any coughing due to asthma Need for reliever None >once/week >2x/week >once/week >2x/week * *Reliever taken prior to exercise excluded. Modified from: Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2020.

TREATMENT A Patient/guardian/caregiver education B Initial treatment of asthma C Management plans for long-term asthma control D Primary prevention E © Periodic assessmentMIMS & monitoring

Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS.

B13 © MIMS Pediatrics 2020 ASTHMA • • • • • • Episodes) Symptoms (Recurrent • • • • • • • • Spirometry Function TestingPulmonary • • • • • • Exam Physical • • • • • • • • • ofAsthma aDiagnosis forConsidering Indicators Key • • • History • • Cough thatCough that at isrecurrent worse orpersistent may night non-productive be activity Reduced tightness Chest breathingHeavy Breathlessness Wheezing intheSymptoms absence occur w/exercise, ofanapparent laughing orcrying respiratory time&inintensity, over that vary airfl together expiratory w/variable limitationow ofbreath, tightness chest shortness &cough wheeze, eg symptoms ofrespiratory history by Characterized  that age signifi groups causes inpediatric common emost chronic disease cant morbidity w/chronic inflA heterogeneous disease disorder ofthe airways ammatory (FEV Volume volumein 1second forced expiratory the ofthis iscalled during 1stsecond maneuver ofairexhaled inhalation the from of maximal point volumeofairexhaled ofthe maximal isa measure Forced capacity (FVC) vital children Some until correctly maneuvers the execute cannot age required 7years - inchildren valuable Generally ofage ≥5years short-acting administration ofinhaled &after donebefore shouldbe Allmeasurements - airfl Measures reversibility limitationow &determines - method diagnostic Preferred diffi tachycardia, drowsiness, present may (eg Other signs be cyanosis, culty speaking) - ventilation airfl attacks reduced asthma duetomarkedly insevere Occasionally, seen may notbe wheezing &ow ofallergicSigns skincondition mucosal polyps ornasal swelling secretion, nasal Increased breathing normal forced orprolonged during exhalation Wheezing oftheHyperexpansion thorax offorced inspection expiration &nasal Perform onobservation athorough w/focus exam allergic (eg ) atopic dermatitis, ofallergic disease history Presence orfamily ofpatient history Symptoms improve medication w/asthma (URTI) tractinfection ratory Symptoms (eg breathing) longerdays cough, than heavy in thelasting 10 presence wheeze, respi- of an upper etc Symptoms orexacerbated triggered animalfur, by , temperature dustmites, aerosol, changes, agePersistence 3years beyond symptoms ofasthma ofasthma the likelihood recurrent increases ofbreath, ordiffi shortness breathing, Heavy cult breathing exercise during oractivity, that isnoticeably Nighttime cough inthe absence infection orwheeze ofviral &recurrent orpersistent non-productive, shouldbe Cough - cough, breathingActivity-induced usuallyaccompanied orheavy wheeze by - more than once occurring amonth occur ofwheezing >3episodes/year Episodes orsymptoms - ofasthma isessential inthe ofvariability diagnosis History Focus 2weeks that inthe onsymptoms past occurred - pattern 3-4months symptom forthe past Determine duetoasthma likely the symptoms tobe Identify FEV Increase inFEV Increase FEV - Wheezing occurring during sleep, activity, laughing, or crying, & with increasing recurrence islikely increasing &with duetoasthma activity, orcrying, sleep, during occurring laughing, Wheezing time (eg day today, month tomonth orseasonally) Variability of refers aperiod over toimprovement occurring &lungfunction ofsymptoms orworsening 1 1 /FVC appears to be a more sensitive measure of severity ofimpairment ofseverity amore measure sensitive tobe appears /FVC ) 1 indicates risk forexacerbations risk indicates 1 ≥12% after administration airfl ofabronchodilator ≥12%after reversible indicates limitationow © MIMS 2 Asthma (2of26) 1 DIAGNOSIS ASTHMA B14 © MIMS Pediatrics 2020 ASTHMA • • • • ≤5Years Children in Diagnosis Asthma • Test In vitro • Test In vivo • TestsAllergy • • TestsOther • • • Measurement (FENO) Oxide Nitric Concentration ofExhaled Fractional • Response Bronchodilator • Measurements (PEF) Flow Peak Expiratory Function TestingPulmonary (Cont'd) • • • • Causes Other • • • • Obstruction Small-airway • • • • • Obstruction Large-airway • Diseases Airway Upper Patients which asthma iscommon may inthis have age virus-induced group - months 6 the within last noted have bronchial been of reversible obstruction if >3 episodes Consider asthma useful may &physical exam, be history medical To inadditiontoa thorough medications, ofasthma trial adiagnostic help ofasthma, establish adiagnosis once develops asthma severity development inthis forsubsequent ofasthma predicts Atopy age &italso factor group isamajor risk diffi may be oflungfunction measurements Objective cult inthis age group - dermatitis) ofsevere (eg cases performed be cannot test doneifin May vivo be - IgE panel test/radioallergosorbent (RAST) test Skin test prick asthma ofdeveloping predictive may be Presence offood-specifi toinhaled theofsensitization & risk c IgE&/oratopic dermatitis increases outother torule abnormalities pathologies &structural radiographyChest used may be Eg impulse specifi oscillometry, resistance, volume ofresidual measurements c airway - centers studies &specialist inresearch used Commonly -  forasthma tests diagnostic as are notevaluated ese - inchildren valuable May ofage be 2-5years - maneuvers required  that donotrely tests onpatient’s lungfunction ere are several the cooperation orthe ability toperform foradjustingtreatment asthma aguide measurement as the ofFENO toprove Further use studiesare needed intranasal &inpredicting school-age by diagnosis use anURTI after children may >4weeks w/recurrent inpreschool symptoms help inthe inFENO An increase levels ineosinophilic w/increases Associated ofairfl reversibility Determines totreatment limitationow inresponse ofasthma &monitoring Important indiagnosis Aspiration due to dysfunction in swallowing mechanism or gastroesophageal refl or gastroesophageal mechanism inswallowing duetodysfunction Aspiration ux Immune deficiency Tuberculosis tract infection respiratory lower Recurrent viral disease Congenital heart dysplasia Bronchopulmonary Cystic fibrosis orobliterative)Bronchiolitis (viral orbronchostenosis stenosis tracheal Laryngotracheomalacia, ortumor Enlarged lymph nodes webs Vascular orlaryngeal rings Vocal cord dysfunction orbronchus oftrachea Foreign obstruction body &chronic rhinosinusitis © MIMS orinhalant of alife-threatening tofood reaction ifcurrent discontinued, therapy be performed orifthere possibility cannot May be isaknown 3 ALTERNATIVE DIAGNOSIS 2 DIAGNOSIS (CONT’D) Asthma (3of26) B15 © MIMS Pediatrics 2020 ASTHMA • • • Written Plan Action Asthma • • • • • • • • • • • Modifi management forasthma Global strategy 2020. andprevention: Global Updated from: (GINA). Initiative forAsthma ed Presenting Symptoms Presenting -  ofaninhaler containing euse long-actingbeta rapid-onset - corticosteroid- low-dose inhaled doses as-needed Increasing - may tomedications includeChanges the following: Should include specifi access care &medical medications about instructions individualized c, attack May help patients appropriately &patient's &respond toanasthma recognize parents/guardian/caregiver help when necessary medical Seek - &takeappropriate asthma ofworsening action signs Recognize - control Monitorasthma status - Train inhalation correct about technique - Understand the difference “controller” between medications &“reliever” - Take accurately medications &appropriately - Avoid triggers &aggravating factors -  able epatient, toapply objectives shouldbe parents the following &caregivers patients istogive the ability Objective tocontrol their w/guidance professionals health care asthma from - patient/doctor partnership Develop - visits several over provided Education shouldbe Aims toactively involve the asthma inmanaging children, &caregivers their families actionplan asthma personal &awritten monitoring, symptom skillstraining, Includes - Depends on patient's presenting symptoms, risk factors, comorbidities &treatment preference factors, risk onpatient's Depends presenting symptoms, outcomes forbetter possible as soon as corticosteroid dose) tostart low ismade,itrecommended ofasthma (inhaled, diagnosis After medications reliever Needs month but<1x/day ≥2x/ symptoms Presence ofasthma exacerbations for factors No risk frequent <2x/month ornot Symptoms occur Other inhaled corticosteroid-long-actingOther inhaled &inhaled beta exacerbations w/ careful verbalw/ careful explanation ofthe treatment regimen Studies that have control asthma shown management asthma ofwritten w/the isimproved use plantogether medications, rapid deterioration, PEF orFEV rapid PEF deterioration, medications, &controller ofreliever A short-course doses oralcorticosteroids toincreased forpatients unresponsive regimens

© MIMS A Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not PATIENT/GUARDIAN/CAREGIVER EDUCATION Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing • • • • B beta fi er orcorticosteroids whenever (inhaled) modi- Daily Other options: short-acting) or combination acting) istaken separately orin as-needed beta as-needed w/ low-dose) Corticosteroid (inhaled, whenever beta whenever Corticosteroid (inhaled) Other options: short-acting) taken separately orincombination As-needed beta As-needed Recommended Options for Initial Treatment forInitial Options Recommended INITIAL TREATMENT OF ASTHMA 2 -agonist (inhaled, short-acting)-agonist (inhaled, is Children 6-11years Children 2 Asthma (4of26) -agonist (inhaled, short--agonist (inhaled, 2 2 -agonist (inhaled, -agonist (inhaled, 1 <60% of personal best, or a history of sudden severe ofsudden severe orahistory best, <60%ofpersonal B16 2 -agonist w/ low-dose corticosteroid-agonist w/low-dose • • • • • separately orincombination short-acting)(inhaled, istaken (inhaled) whenever beta whenever (inhaled) CorticosteroidOther options: plus low-dose) corticosteroid (inhaled, As-needed combination short-acting) istaken separately orin whenever beta whenever modifi er orcorticosteroids (inhaled) Dailyleukotriene Other options: plus low-dose) corticosteroid (inhaled, As-needed short-acting) w/ as-needed beta w/ as-needed low-dose) Corticosteroid (inhaled, 2 -agonist maintenance controlled Adolescents or Formoterol Formoterol 2 © MIMS Pediatrics 2020 -agonist (inhaled, 2 -agonist (inhaled, -agonist (inhaled, 2 -agonist ASTHMA • • ofGoals erapy • • • • Modifi management forasthma Global strategy 2020. andprevention: Global Updated from: (GINA). Initiative forAsthma ed Presenting Symptoms Presenting - - -  of: through acycle are achieved ese eff Minimaladverse ofmedication ects - function pulmonary normal ornear Normal - treatment forreliever Minimalorno need - including exercise Nolimitations onactivities, - symptoms &nocturnal Minimalorno daytime - Eff control symptom ective w/minimalornoexacerbations - management oflong-term includes: ofasthma Goals exacerbation Presence ofacute presentation at initial uncontrolled asthma Presence ofseverely exacerbation for factors Presence ofrisk ≥1x/week symptoms dueto or waking days most symptoms asthma troublesome Presence of Review response Review treatment ofmodifi strategies, non-pharmacological (medications, treatment Adjust able factors) risk adherence, technique, control, symptom parent factors, risk (diagnosis, preference)Assess C MANAGEMENT FOR PLANS LONG-TERM ASTHMA CONTROL

© effincluding medication &sideeffectiveness ects MIMS B Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Recommended Options for Initial Treatment forInitial Options (Cont'd)Recommended INITIAL TREATMENT OF ASTHMA (CONT'D) ASTHMA OF TREATMENT INITIAL Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing • • • • • • (inhaled, short-acting)(inhaled, dose) plus dose) medium Corticosteroids (inhaled, beta w/as-needed long-acting) beta w/as-needed long-acting) beta modifileukotriene er &as-needed w/daily low-dose) (inhaled, Corticosteroid Other options: beta w/as-needed medium-dose) Corticosteroid (inhaled, or modifier, beta w/as-needed or add-onTiotropium orleukotriene beta plus high-dose) (inhaled, DailycorticosteroidsOther options: needed may be Corticosteroids (oral) course short plus low-dose) Corticosteroid (inhaled, beta 2 2 2 2 2 -agonist (inhaled, short-acting)-agonist (inhaled, short-acting)-agonist (inhaled, short-acting)-agonist (inhaled, -agonist (inhaled, long-acting) -agonist (inhaled, short-acting)-agonist (inhaled, Children 6-11years Children 2 -agonist (inhaled, -agonist (inhaled, beta Asthma (5of26) 2 -agonist (inhaled, -agonist (inhaled, B17 2 -agonist • • • • • • plus low-dose) Corticosteroid (inhaled, beta w/as-needed medium-dose) Corticosteroid (inhaled, short-acting)(inhaled, or plus low-dose) Corticosteroid (inhaled, (inhaled) therapyreliever w/corticosteroid long-acting) course needed may be Corticosteroids (oral) short long-acting) beta w/ as-needed maintenance as only long-acting) dose) plus dose) medium Corticosteroids (inhaled, or high-dose) Corticosteroids (inhaled, beta 2 beta -agonist (inhaled, short-acting)-agonist (inhaled, Adolescents 2 2 plus -agonist (inhaled, -agonist (inhaled, -agonist (inhaled, -agonist (inhaled, beta as maintenance as & Formoterol or 2 © MIMS Pediatrics 2020 -agonist (inhaled, -agonist (inhaled, 2 -agonist ASTHMA Step 3 Preferred Controller Preferred Step 3 Step 2 Preferred Controller Preferred Step 2 Step 4 Step 1 Treatment For patients previously given low-dose /Formoterol or low-dose Beclomethasone dipropionate/Formoterol Beclomethasone combi- Budesonide/FormoterolFor orlow-dose low-dose given patients previously patients ofage considered ≥12years w/allergicMay insensitized rhinitis be &FEV1 >70%predicted. 6 5 3 optionforpatientsRecommended ofage. ≥12years off as Used -label therapy. Modifi management forasthma Global strategy 2020. andprevention: Global Updated from: (GINA). Initiative forAsthma ed Recommended forpatientsRecommended ofage. 6-11years Short-acting beta inhaled referral forpatients isrecommended 6-11 Expert is notwell-controlled oldasthma years treatment despite w/moderate-dose corticosteroids separately orincombination inhaled used may w/short-acting be beta Low-dose inhaled nation as maintenancenation as regimen. &reliever inhaled corticosteroids. inhaled include beta (inhaled), Steps C MANAGEMENT FOR PLANS LONG-TERM ASTHMA CONTROL (CONT’D) • controller options: Other • Reliever • Reliever • • controller options: Other • • Reliever • controller options: Other • • • Reliever • • modifi er plus low-dose) Corticosteroid (inhaled, doublelow-dose) (inhaled, Corticosteroid As needed beta As needed (inhaled) Intermittent corticosteroid modifiDaily leukotriene er low-dose) (inhaled, Daily corticosteroid As needed beta As needed Any ofthe following: referral Specialist Continue controller therapy (short-acting) (inhaled, short-acting)(inhaled, short-acting)(inhaled, As needed beta As needed required No dailymedication As needed beta needed As Add intermittent - corticosteroid Increase - - (inhaled, short-acting)(inhaled, corticosteroid (inhaled) frequency (inhaled) modifiAdd leukotriene er © MIMS ≤5 years Children 2 -agonists should be used as required to relieve symptoms. Other options for reliever medications Other medications options forreliever symptoms. torelieve required as used shouldbe -agonists Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not 5 Recommended Medications Based on Level ofControl onLevel Based Medications Recommended Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing leukotriene leukotriene 2 2 2 -agonist -agonist -agonist 2 -agonist 2 -agonists (oral,-agonists short-acting), or old). eophylline (≥12 years 6 Asthma (6of26) Daily Controller Medications Daily Preferred reliever & other reliever option same as Step 1 Step as optionsame &other reliever reliever Preferred • • • Preferred reliever & other reliever option same as Step 1 Step as optionsame &other reliever reliever Preferred • • • • controller options Other • Controller Preferred 1 Step as optionsame &other reliever reliever Preferred • • controller options Other • option reliever Other • reliever Preferred • • controller options: Other • (any controller options ofthefollowing): Other • Controller Preferred • • Controller(any ofthefollowing): Preferred • Controller Preferred • • (inhaled, long-acting) (inhaled, (inhaled, long-acting) (inhaled, House dust mite sublingual immunotherapy dustmite sublingual House (SLIT) modifi er plus low-dose) Corticosteroid (inhaled, plus Daily corticosteroid low-dose) (inhaled, House dustmite SLIT House modifiAdd-on leukotriene er Add-on Corticosteroid (inhaled, medium-dose) Corticosteroid (inhaled, medium-dose) Corticosteroid (inhaled, iftakingbeta low-dose) Corticosteroid (inhaled, modifiLeukotriene er beta As needed plus corticosteroid low-dose) (inhaled, As-needed Daily corticosteroid low-dose) (inhaled, iftakingbeta low-dose) Corticosteroid (inhaled, Corticosteroid (inhaled, high-dose) Corticosteroid (inhaled, (inhaled, short-acting)(inhaled, (inhaled, short-acting)(inhaled, Corticosteroid (inhaled, medium-dose) Corticosteroid (inhaled,medium-dose) As-needed corticosteroid (inhaled, low-dose) plus corticosteroid low-dose) (inhaled, As-needed Daily corticosteroid low-dose) (inhaled, plus corticosteroid low-dose) (inhaled, As-needed required No dailymedication Corticosteroid (inhaled, low-dose) plus low-dose) Corticosteroid (inhaled, - (inhaled, long-acting) (inhaled, Plus B18 beta 2 -agonist (inhaled, long-acting) -agonist (inhaled, 2 -agonist (inhaled, short-acting)-agonist (inhaled, 4 Children ≥6 years Children 5 2 2 7 1,3 1,3 (any ofthefollowing): (any ofthefollowing): plus 2 4 beta © MIMS Pediatrics 2020 2 -agonists. beta 4 2 -agonist beta leukotriene 2 Formoterol Formoterol Formoterol -agonist 2 2 2 7 -agonist -agonist -agonist 8 8 1,2 1,2 2 ASTHMA • • referral &expert continued therapy controller&reliever Step 4-Daily • • • • • referral &expert reliever controller,Step 3-Use ofadditional as-needed plus • • • • • • • • reliever as-needed controller plus Step 2-Use ofinitial • • • reliever Step 1-Use ofas-needed Stepwise onControl Based erapy 3 1 Modifi management forasthma Global strategy 2020. andprevention: Global Updated from: (GINA). Initiative forAsthma ed For patients previously given low-dose Budesonide/Formoterol or low-dose Beclomethasone dipropionate/Formoterol Beclomethasone com- Budesonide/FormoterolFor orlow-dose low-dose given patients previously optionforpatientsRecommended ofage. ≥12years Treatment Contraindicated inpatientsContraindicated ofage. <12years Refer patients assessment forphenotypic bination as maintenancebination as regimen. &reliever improvement isseen control corticosteroid mayIf symptom ofinhaled consider the until dose isstillnotachieved, increasing adherence, inhaler medication technique, &reinvestigate trigger factors Reassess diagnosis mite w/allergic rhinitis &FEV1>70%predicted dust considered tohouse may inpatients be dustmiteSLIT ofageAddition also ofhouse ≥12years sensitized modifiAddition oforalleukotriene corticosteroids considered mayers tolow-dose be corticosteroid inhaled ispreferred Medium-dose therapy orifexacerbations persisted months ofinitial For corticosteroids inhaled 3 patients were after whomsymptoms notcontrolled low-dose by factors torisk inquire exposure about up,re-confi stepping Before inhaler check &compliance technique & tomedications diagnosis, asthma rm treatment isanoptionforpatients controller given ≥12years forthe fi medications rst time Use of daily low-dose inhaled corticosteroid inhaled w/long-actingUse of dailylow-dose beta modifiLeukotriene patientsers may &oralcorticosteroidw/persistent reduce asthma symptoms inpediatric use control asthma 3months good It forat given least toachieve shouldbe - corticosteroid dailyinhaled forchildren ispreferred old ≤5years Low-dose initial therapy as fortreatment-naive used May be patients oldtocontrol ≤5years symptoms asthma medication reliever For requiring patterns children symptom are inconsistent episodes whose butw/frequent wheezing w/ asthma or w/≥3exacerbations/year For pattern are inadequately children symptom symptoms isconsistent &asthma controlled whose w/asthma, For patients inorder whorequire tomaintain controller control everyday medications oftheir asthma Patient adherence corticosteroids considered when shouldbe prescribing tomedication Intermittent corticosteroids inhaled anoptionforchildren may be w/intermittent wheezing viral-induced short-acting beta ofinhaled use symptoms, interval For &noorfew episodes children whohave wheezing infrequent viral - Step 5 Steps secondary to viral after initialtreatment after corticosteroids infections w/dailyinhaled toviral secondary ofwheezing frequency corticosteroids inhaled w/increased considered may inpre-schoolers be needed As relief onaverage ofsymptoms amonth forover of>2x/week A need for a trial ofcontroller foratrial short-acting ifthe child isindicated uses A need medication beta C MANAGEMENT FOR PLANS LONG-TERM ASTHMA CONTROL (CONT’D) 1 2 -agonist forrelief isrecommended ofsymptoms

© MIMS ≤5 years Children Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Recommended Medications Based on Level ofControl onLevel Based Medications Recommended Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing - Asthma (7of26) Daily Controller Medications Daily • Controller Preferred Preferred reliever & other reliever option same as Step 1 Step as option same & other reliever reliever Preferred • controller options: Other (inhaled, long-acting) (inhaled, Corticosteroid (inhaled, high-dose) Corticosteroid (inhaled,high-dose) Add-on corticosteroid (oral, low-dose) Anti-IL5 (SCBenralizumab - Anti-IL5 (SCMepolizumab) - Anti-IgE (SCOmalizumab) - Tiotropium bromide - anyPlus ofthefollowing: Anti-IL4α (SCDupilumab receptor - B19 2 -agonist initialmaintenance as controller Children ≥6 years Children 2 plus 3 © MIMS Pediatrics 2020 ) beta 3 ) 2 -agonist forthe 2 -agonist 4 ASTHMA • • (Cont'd) referral &expert continued therapy controller&reliever Step 4-Daily Stepwise onControl (Cont'd) Based erapy • • • • Step Up • • • • • Step Down • • Control ofAsthma Maintaining • • • referral &expert Step 5-Add-on treatment • • inhaled beta inhaled Add-on therapy modifi until control Oralleukotriene w/the symptom following isachieved: long-acting ers, &/orflpoor persist are-ups corticosteroids control ofinhaled orifsymptom the fails referraldose ifincreasing remainsConsider expert nation for mild asthma, ormaintenance/reliever corticosteroid-Formoterol inhaled nation therapy formildasthma, usinglow-dose corticosteroid-Formoterol inhaled low-dose combi- as-needed forpatients prescribed Daily adjustment isneeded allergens situations orseasonal inthe such infections presence as special ofviral corticosteroid for ofinhaled the for1-2weeks dose involved increasing of1-2weeks Short-term step-up treatmenttreatment good adherence despite regimen ofmodifi &removal able factors risk of2-3months duration step-up considered maySustained inpatients be toinitial whoare notresponding control,macological comorbidities) compliance patient &non-phar- ifcontrol techniques, medication Consider step-up (review isnotmaintained corticosteroid-Formoterol low-dose regimen reliever as-needed toonce-daily &continuecorticosteroid-Formoterol dose orlow-dose tolow-dose therapy medium-dose from corticosteroid-FormoterolIn patients oninhaled ≥12years combination Reduce maintenance therapy: inhaled Discontinuation corticosteroid ofinhaled therapy inadolescents isnotadvised - modifi Addition ofleukotriene corticosteroids inhaled ers considered may dose down when be stepping - corticosteroid-Formoterol inhaled low-dose therapy toas-needed May shift - corticosteroids toonce-daily reduced may dosing low-dose be Inhaled - corticosteroidPatients inhaled modifi adequately oraleukotriene controlled low-dose by er: - If given w/ long-actingbeta Ifgiven - 25-50%at by 2-3months dose Consider reducing interval - Patients currently corticosteroids: oninhaled Not applicable forpatients at ofexacerbations risk orpersistent &fi airflxed limitationow attempted intreatment reduction may be step-wise Once gradual control for≥3months, &maintained isachieved patient individual system, healthcare circumstances &cost Treatment resources of onthe availability ofantiasthmatic based medications, individualized shouldbe w/the currentobtained treatment approach totherapyStep-wise isthe advancement tothe oftherapy nextstep ifcontrol or isnotreached - - - - Addition ofTiotropium considered may are stillnotcontrolled ifsymptoms be antibody oramonoclonal & additionaltreatment ofphenotype including assessment evaluation diagnostic for further Patient toaspecialist referred shouldbe For are patients notcontrolled ifsymptoms 4medications old,Step 5 isrecommended step ≥6years by forsideeff risk the increased assessment forexpert referred &shouldbe ects about given shouldbe For advise corticosteroids, patients inhaled considered old,being forhigh-dose ≥6years & FEV1>70%predicted patients ofage considered may ≥12years w/allergic dustmiteSLIT insensitized Addition rhinitis be ofhouse - Tiotropium ofexacerbations topatients given oldw/ahistory mistinhaler ≥6years isonlytobe by - May addintermittent corticosteroid inhaled todailycorticosteroid ifmainconcern dose isexacerbation - or those onmaintenanceor those oralcorticosteroid 2asthma type inpatients Dupilumab ofage ≥12years w/severe Add-on anti-IL4α subcutaneous receptor 4regimen step adherence despite asthma uncontrolled inpatients ofage ≥12years to Benralizumab eosinophilic w/severe considered may forpatients be ofage, Mepolizumab ≥6years &anti-IL5 Additional receptor anti-IL-5 when combination asthma control despite treatmentsmoderate-severe isnotachieved w/ Addition patients ofanti-IgE ofage considered ≥6years may diagnosed inpediatric be combinationdespite therapy inStep 3 Tiotropium mistinhaler considered may via foradolescent be patients ≥ therapy aspecialist until by control ifapproved asthma isachieved of Routine use a controller eophylline as & an is may add-on not consideredrecommended as only be C MANAGEMENT FOR PLANS LONG-TERM ASTHMA CONTROL (CONT’D) 2 © MIMS -agonist incombination corticosteroid, w/inhaled  oralcorticosteroid eophylline, orlow-dose Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 2 -agonists & add-on agents, specialist referral is advised referral isadvised specialist &add-onagents, -agonists Asthma (8of26) B20 6 years old w/ history ofexacerbations oldw/history years 6 © MIMS Pediatrics 2020 ASTHMA • • • • • • Preferred erapy Controller Medications •  orAdd-On Alternative erapy • Beta - Use of Reslizumab in patients <18 years of age w/ asthma has not been established established notbeen inpatients Use ofReslizumab ofage has <18years w/asthma - &atopic Add-on asthma considered may Dupilumab dermatitis in patients be oldw/severe ≥12years - - - medications forrescue &the &exacerbations, need symptoms asthma Reduces - Treatment optionforpatients ofage ≥12years - Omalizumab) Mepolizumab, Dupilumab, (eg Benralizumab, Antibodies Monoclonal - ModifiLeukotriene ers (Oral) Weak anti-infl effammatory - eff less ect, corticosteroids inhaled than low-dose ective forpatients w/mildpersistent &exercise-induced used asthma May be - treatment inlong-term ofasthma use Limited - (Inhaled) Cromones dose at possible the lowest used shouldbe use Long-term - uncontrolled forseverely asthma required may be (>2weeks) use Long-term - Corticosteroids (Oral) - Discontinuation ofcontrol deterioration by tomonth isfollowed aweek within patients insome - - Corticosteroids (Inhaled) - Addition of long-acting inhaled beta Addition oflong-actinginhaled - - - - Eg Tiotropium bromide, - Anticholinergic (Inhaled) Beta Ipratropium considered bromide forexacerbations shouldonlybe therapy ¬for long-term - exacerbation tonextasthma interval May help &decrease improve lungfunction - - - Less eff Less beta than inhaled ective - when more bronchodilation onrare isneeded occasions Onlyused - corticosteroids analternative w/inhaled considered given add-on therapy May as be be &shouldalways - effi Most - corticosteroids whentogether given cacious w/inhaled noeff Has infl onairway ect - amonotherapyammation, as hence notused - considered inpatients inpatients ofage ofage ≥6years ≥12years &Benralizumab may be Mepolizumab For corticosteroids, notcontrolled asthma inhaled by eosinophilic patients w/severe corticosteroidscontrolled inhaled by w/allergic asthma component forpatients oldw/moderate tosevere Omalizumab isindicated ≥6years not - symptoms to severe add-ontherapy, as When used corticosteroid may ofinhaled reduce forpatients dose the required w/moderate - eff tomaintain control dose ective To sideeff minimize achievement ofcontrol, upon tolowest corticosteroids carefully titrated shouldbe ects, forpatients ofseverity medications w/persistent ofalllevels asthma  are the eff most ese anti-inflective &are forasthma the controller preferred used medications ammatory due to issues w/treatmentdue toissues adherence Combination w/Formoterol initialtreatment corticosteroid as dailyinhaled over ispreferred monotherapy Have anadditiveeff together when nebulized w/ashort-actingect beta forsideeff&/or higher risk ects Considered alternative toshort-actingConsidered beta inhaled beta inpatientsConsidered whoexperience eff adverse tremor) short-acting from (eg arrhythmia, tachycardia, ects - - than glucocorticosteroids Rapid control clinical when inhaled are alone isachieved given ofasthma - C Improves lung function & symptoms, reduces exacerbations, decreases need of short-acting need beta reduces exacerbations, decreases Improves & symptoms, lung function inhaled corticosteroidsinhaled monotherapy modifi as forcontrolleukotriene When used ofasthma, ers eff are less than low-dose ective side effect oropharyngeal may an alternative be that w/ decreased only in a prodrug theCiclesonide, is activated lungs, achieves faster clinical control of asthma, & may also be used toprevent exercise-induced asthma used control &may clinical be also faster ofasthma, achieves decreased use ofshort-acting use beta decreased lungfunction, improved symptoms, asthma nocturnal decreased scores, symptom improved Causes corticosteroids asubstitute for as used when alone;shouldnotbe given risk mortality Studies increased have shown 2 2 -Agonist (Oral, Long-acting) -Agonist (Oral,Long-acting) Long-acting) (Inhaled, -Agonists 2 MANAGEMENT FOR PLANS LONG-TERM ASTHMA CONTROL (CONT’D) © MIMS-agonists Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 2 -agonists & poses increased risk ofsideeff risk increased &poses -agonists ects 2 2 -agonists, & reduced number ofexacerbations &reduced -agonists, -agonist is preferred when daily low-dose inhaled corticosteroid inhaled fails -agonist when ispreferred dailylow-dose Asthma (9of26) B21 2 -agonists because they may ofaction have they onset aslower because -agonists 2 -agonists forexacerbations-agonists ofasthma © MIMS Pediatrics 2020 2 -agonists, -agonists, ASTHMA • • • • Preferred erapy Medications Reliever •  orAdd-On Alternative (Cont'd) erapy • • • Diffi cult-to-treat Asthma • • • • • -Specific Immunotherapy - - forpatients reliever Preferred ofage ≥12years - w/FormoterolCorticosteroids (Inhaled) - Review patient response after 3-4months patient after response Review - patient's inflAssess & considered treatments add-onbiologic once phenotype identifiammatory ed - - patient's totreatment 3-6months after response changes to assess patient/caregiver tofollow-up Advise Beta Bronchodilator, anti-infl has which at dose, low effammatory - ects Treatment optionforpatients ofage >12years -  eophylline (Oral,Extended-Release) - modifi Consider lifestyle avoidance treatments oftriggerscations, &other non-pharmacological - Treat comorbidities &modifiable factors risk - - visit review, &demonstrate correct inhaler every technique Check, - management: tooptimize Steps of a long-acting inhaled beta of along-actinginhaled adherence, exacerbation over-use include: inhaler Incorrect poor technique, factors comorbidities, Risk triggers, acting inhaled beta acting inhaled corticosteroids inhaled w/along- (eg medium-dose Step 4-5ofthe management asthma, planforlong-term Defi w/persistent &/orexacerbations asthma symptoms as adherence despite ned regimens asthma tohigh-dose Effi putinto consideration shouldbe trials onclinical initiating before therapy based orregimens ofextracts cacy Benefi eff adverse against weighed mustts be &inconvenience cost, oflength oftherapyects, development prevent asthma inchildren w/allergic possibly rhinoconjunctivitis& can improve use, allergen-specifi medication May reduce symptoms, c &non-specifi hyperresponsiveness c airway w/mildoral&GIsymptoms associated been has SLIT - use w/SCIT anaphylactic Life-threatening reported have reactions been - orSLIT immunotherapy subcutaneous (SCIT) as given May be  avoidance strict intervention have optionafter erapeutic oftriggers failed &medical - Used only when necessary; increased use indicates that indicates use management re-assessed increased shouldbe onlywhen necessary; Used - - eff Most bronchodilator ective - - beta ofexacerbations risk w/short-acting lungfunction &lower inhaled ofincreased due toaccumulated reports Reliever-only initial treatment ie as-needed short-acting beta Reliever-only inhaled initialtreatment ieas-needed maintenanceBeclometasone-Formoterol therapy &reliever Combination ofsteroid w/Formoterol Budesonide-Formoterol given or forpatients ispreferred previously to a specialist or to a severe asthma clinic asthma ortoasevere to aspecialist If w/uncontrolled &refer regimen &/orexacerbations symptoms treatment previous return after step-down, w/ modifi oftreatmentcations &optimization isstill w/uncontrolled clinic ifasthma asthma isrecommended even ortoasevere Referral toaspecialist corticosteroidsinhaled long-acting beta therapies Nonbiologic given: (eg Tiotropium ifnotpreviously Consider the following bromide, Azithromycin, included Confi actionplan&ifthe asthma patient/caregiver awritten ifpatient/caregiverrm understands has what is - toexerciseprior w/eff for0.5to2hours lasting ects forpre-treatment &areAgents useful ofasthma ofchoice forrelief acuteepisodes ofbronchoconstriction during combination inpatients ofage ≥12years corticosteroid-Formoterol alternative toinhaled reliever forpatients reliever Preferred ofage; <12years C to prevent sideeff ofshort-acting beta ects inhaled Concomitant use w/ corticosteroid is recommended w/ every intake ofashort-actingConcomitant beta w/corticosteroid use inhaled w/every isrecommended 2 -Agonists (Inhaled, Short-Acting) (Inhaled, -Agonists 2 MANAGEMENT FOR PLANS LONG-TERM ASTHMA CONTROL (CONT’D) -agonist monotherapy 2 2 -agonist), biologic therapies (eg Mepolizumab, Dupilumab, Benralizumab, etc), high-dose etc),-agonist), therapies high-dose Benralizumab, biologic Dupilumab, (eg Mepolizumab,

© MIMS-agonist modifi orleukotriene er, continuous/frequent therapy w/oralcorticosteroids) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 2 -agonist, psychosocial factors, adverse eff adverse factors, psychosocial -agonist, ofmedications ects Asthma (10of26) B22 2 -agonist monotherapy 2 -agonist isnolonger recommended © MIMS Pediatrics 2020 2 -agonist ASTHMA • Factors Psychosocial • Factors &Other Medications • • • EffMicrobial ects • Vaccinations • • • Pollutants • • Allergens • Vitamin D • • Breastfeeding Nutrition • • Modifi from: ed to early school age school to early  development ofasthma ifthere risk through birth ismaternal from that distress ere persists isanincreased discouraged Paracetamol/Acetaminophen, in the use 1st-2nd analgesic & broad-spectrum of life is year  w/ the diff associated may be ofdelivery emode - microfl gut infants’ erences between ora C-section by than born forasthma those risk at may lesser be delivery vaginal via born Infants development forasthma compared risk lower toother children milk)present w/ unprocessed topotential allergens stables &animals, Children inlife(eg early exposed farm tomicrobiota ofbenefi may be Exposure t inthe prevention ofasthma Annual infl vaccinationuenza may help reduce acuteexacerbations asthma inpatients w/moderate-severe road  residence eg amain near pollutants tooutdoor exposure with associated ofasthma risk ere isanincreased Avoid toenvironmental exposure &the fi tobacco pregnancy smokeduring oflife rst year eff development onlytoasthma inolder childrenect astrong eff has pregnancy Smoking during onyoungchildrenect while post-natal an maternal smokinghas asthma allergens the ofdeveloping risk increase home that tothese studiessuggested exposure eliminated as shouldbe mold&odor visible Dampness,  ere are confl onthe efficting evidences allergens ofpet onpatientsect w/asthma inchildren that illnesses studies show Some maternal intake the ofwheezing D&Elowers risk ofvitamin It benefi isstillencouraged positive forallofits ts lifebutmay inearly asthma notprevent developing episodes wheezing It may decrease prevention primary iscalled ofdisease Preventing the onset infl agreat inlifehas &early interactions pregnancy during uence that development asthma It &persistence gene-environment are by driven isbelieved interactions thus 4-5 years 0-3 years Age © MIMS 2020.p154. Updated management forasthma and prevention: Global strategy Global Initiative forAsthma (GINA). Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing nebulizer w/mouthpiece orfacemask or spacer w/face mask dedicated inhalerplus metered-dose Alternate: Pressurized inhalerplus metered-dose Pressurized Preferred: Alternate: Nebulizer w/face mask inhalerplus metered-dose Pressurized Preferred: PREFERRED INHALATION DEVICES D PRIMARY PREVENTION PRIMARY Asthma (11of26) B23 Device dedicated spacer w/mouthpiece dedicated spacer w/face mask dedicated © MIMS Pediatrics 2020 ASTHMA • • • &Symptoms Signs Monitoring • • • • • Function Pulmonary • • Patient-ProviderMonitoring &Patient Communication Satisfaction • • • Adherence toMonitoring erapy • • • • Exacerbations ofAsthma History • • • • ofLife Quality • Frequency of use ofbeta ofuse Frequency symptoms ofasthma aresult awakening as Nocturnal cough, ofbreath) tightness chest or shortness (wheezing, symptoms asthma Daytime 1-3months initiation oftherapy, after 3-12months thereafter then every - adjustments dose minimum todetermine isrecommended controlling &necessary dose follow-up Regular benefi days within whilemax Improvement observed may ofsymptoms be months 3-4 after achieved t may be - including exercise) levels activity &achievement ofnormal therapy ofcurrent (iereduction are impairment met risk, &future whether the todetermine goals of control ofasthma &monitoring performed Periodic assessment shouldbe - Low FEV Low - Spirometry inchildren ofage 5years Results &younger are unreliable reproducible ormay notbe Inability ordiffi symptoms ofasthma because activities normal culty inperforming severe exacerbationssevere Patient’s attitude &/orreluctance negative medication self-management for toward towards factors are risk Adverse eff regimen w/the experienced ects Patient concerns regimen drug about Adherence regimen todrug Cause Severity Rate ofonset Frequency Any change inthe caregiver’s duetoasthma activities disturbanceAny sleep duetoasthma exercise) recreation, (egAny home,school, inusualactivities reduction ofasthma because dayAny missed school - Refer tothe patient’s actionplanforthe asthma patient’s written fl peak best personal ow - Peak fl notdiagnosis forongoing monitoring, tools as best function meters ow - Peak Monitoring Flow test (ACT), childhood ACT, childhood diaries] (ACT), test forkids, quiz asthma that patient are allow used [eg the tools control symptoms asthma &parents torecordSeveral &describe frequent reviews are recommended frequent reviews isdependent on eff measurement ofPEF Because demonstrations & patient & technique, ort instructions, 1 © MIMS exacerbations ofsevere risk w/increased isassociated Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not E 2 Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing -agonist (inhaled, rapid-acting)-agonist forrelief (inhaled, ofsymptoms PERIODIC ASSESSMENT & MONITORING Asthma (12of26) B24 © MIMS Pediatrics 2020 ASTHMA Modifi from: ed 2 1 F In children ≤5 years old, short-acting beta inhaled Target O the fi relief for>24 hours. symptom persist orsymptoms rst 2 hourstoachieve consult at medical physician; the sameday shouldseek if>6puff supervising by advised within bronchodilator isneeded s ofinhaled Treatment • • • PRIMARY CARE MANAGEMENT OF MANAGEMENT CARE PRIMARY • • • Advise for follow up within 2-7days upwithin forfollow Advise Add orcontinue oralPrednisolone x 24-48 hours 3-4 hours Continue Salbutamolevery Administer O Consider 20minutes for1hour every 2-10puff onage s depending 2 saturation for patients old:93-95%;forpatients ≥6 years old:94-98%. ≤5years ASTHMA EXACERBATION ASTHMA PEF >50%predicted/best PEF &monitoring D PEF >60-80% predicted >60-80%predicted PEF Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2020. Updated management forasthma and prevention: Global strategy Global Initiative forAsthma (GINA). Periodic assessment assessment Periodic or personal best or personal Mild/Moderate TREATMENT Good response response Good TREATMENT to treatment to treatment Response Response after 1-2 after hours? 2 © MIMS2 Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Patient exacerbation asthma experiences 1 2 -agonist (eg Salbutamol) & oral corticosteroids previously at homeas started may be Asthma (13of26) ASSESS SEVERITY ASSESS Poor response Poor response personal best personal predicted or predicted PEF <60% PEF B25 4 F Treatment • • • - as needed Salbutamol 6-10puff 20minutes s every administer: While waiting, Transport toemergency department - - O Ipratropium bromide Prednisolone Oral/IV 2 PEF ≤50%predicted/best PEF Severe/Life-threatening therapy MANAGEMENT See next page See HOSPITAL 2 © MIMS Pediatrics 2020 ASTHMA ## # *Target O Modified from:GlobalInitiativeforAsthma (GINA).Globalstrategyforasthmamanagement andprevention:Updated2020. additional2-3puff**May give orrecur. persist s/hour ifsymptoms Initial treatment w/Ipratropium bromide forpatients isrecommended w/life-threatening asthma. <6 hours. IV doses may be administered in children who fail to respond toinitialtreatment inchildren administered may torespond &w/persistent be whofail hypoxemia doses orw/FEV IV <6 hours. ≤60% predicted after 1hour. after ≤60% predicted • • • • May consider nebulized sulfate as adjuvant tostandard for treatment as May sulfate consider lasting asthma Magnesium inchildren nebulized w/acutesevere ≥2year OF ASTHMA EXACERBATION OF ASTHMA - Achieve O Achieve - Administer O Beta - May be considered if no immediate response, w/ considered May response, if noimmediate be - Oral corticosteroids 20minutes x1 hour** every Consider Ipratropium bromide HOSPITAL MANAGEMENT MANAGEMENT HOSPITAL corticosteroid intake oforal orw/recent history episode, severe 2 2 -agonist (inhaled, short-acting)-agonist (inhaled, nebulizer via saturation forpatients old:93-95%. ≥6years 2 saturation 94-98%* 2 by face mask by © MIMSTREATMENT predicted/ PEF >50% PEF Moderate Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Mild - Mild best Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Patient fails to respond to primary care treatment treatment care toprimary torespond Patient fails or continues todeteriorate or continues Does patient respond to patient respond Does Asthma (14of26) ASSESS SEVERITY ASSESS treatment after after treatment See next page See RESPONSE RESPONSE CLINICAL CLINICAL Moderate Moderate or severe or severe episode? ASSESS ASSESS 1 hour? B26 Yes 4 • • • • • - Achieve O Achieve - Consider high-dose inhaled corticosteroid inhaled Consider high-dose (nebulized/IV) Consider Magnesium Corticosteroids (oral/IV) Administer O Beta bromide via nebulizer every 20minutes x1 hour nebulizerbromide via every 2 -agonist (inhaled, short-acting)-agonist (inhaled, +Ipratropium 2 saturation 94-98%* 2 by face mask by TREATMENT No predicted/best threatening PEF ≤50% PEF Severe/ Severe/ Life- • • DETERIORATION © MIMS Pediatrics 2020 admission forICU Re-assess Treat severe as CONTINUING CONTINUING ADMISSION See next page See ICU ICU ## # 1 ASTHMA **Target O consult frequently foracute seeks forrecently patients, considered, hospitalized especially shouldbe specialist *Referral toanasthma Modifi 2020. Updated management forasthma and prevention: Global strategy Global Initiative forAsthma (GINA). from: ed asthma attacks, & those onStep 4-5management &those >1-2exacerbations/year. attacks, planbut stillexperiences asthma • • • • • ASTHMA EXACERBATION CONT’D EXACERBATION ASTHMA Follow-up after 1-2days 1-2months &within Follow-up after care patientCheck &availability factors offollow-up risk patient'sCheck treatment adherence & inhaler techniques corticosteroids fororalorinhaled Instructions - basis toas-needed medication Reliever - formedications: instructions Provide actionplan written anindividualized Provide personal best & symptoms improved &symptoms best personal FEV HOSPITAL MANAGEMENT OF OF MANAGEMENT HOSPITAL 1 2 or PEF 60-80% of predicted or 60-80%ofpredicted orPEF saturation for patients old:93-95%. ≥6 years MODERATE DISCHARGE*

© MIMS 40-60% PEF • • • • • • predicted Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Beta Continue O Monitor PEF, O (IV) Consider Magnesium Corticosteroid (IV/oral) Consider high-dose inhaled corticosteroid inhaled Consider high-dose Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Yes 2 -agonist (inhaled) w/ or without Ipratropium w/orwithout -agonist (inhaled) bromide CLINICAL RESPONSE TO TREATMENT RESPONSE CLINICAL 2 2 HOSPITAL ADMISSION saturation,  pulse, ifindicated eophylline level Does patient respond patient respond Does Asthma (15of26) to treatment? RESPONSE ASSESS ASSESS B27 • • • • • Continue O ventilation intubation Prepare forpossible &mechanical Consider (IV) Corticosteroid (IV) Beta Yes 2 -agonist (inhaled) +anticholinergic-agonist (inhaled) (inhaled) personal best & symptoms improved &symptoms best personal FEV 2 (maintain at O₂sat 94-98%**) ICU ADMISSION ICU 1 or PEF <60% of predicted or <60%ofpredicted orPEF Does patient respond patient respond Does INTENSIVE CARE INTENSIVE to treatment? CONTINUE RESPONSE SEVERE ASSESS ASSESS No No © MIMS Pediatrics 2020 ASTHMA • • • • • • • Mild-Moderate Exacerbation Asthma ofAcute Assessment Initial • • Life-threatening • • • • • • • • • Severe • • • • • Treatment shouldcontinue until orFEV PEF - lifethreatening itmay be as attack asthma supervision close requires Severe - Progressively shorter period of relief after doses ofrapid actingbeta ofrelief doses after period Progressively shorter - promptly bronchodilator didnotrelieved the Inhaled child’s symptoms -  ere isapresence inthe ofacutedistress child - when: attention medical Immediate isneeded - - PEF orFEV PEF - Evaluate patient’s onthe following: ofdeath forrisk based severity - - Asthma phenotyping is recommended for patients diagnosed w/ severe asthma asthma w/severe forpatients isrecommended phenotyping diagnosed Asthma - function whileinitiating treatmentfunction w/short-acting beta immediately oflung through history, measures physical examination, &objective assessed must be Severity - consult treatment orrequires corticosteroid specialist w/systemic tohealth &wouldneed orrisk distress exacerbationAsthma control insymptom isanacuteorsub-acutedeterioration that issuffi cient tocause SaO - retractions subcostal Cyanosis, - ordrink Inability tospeak - inchildren transfer oldw/any isindicated hospital Immediate ≤5years ofthe following: SaO consciousness No altered - - Silent auscultation upon sounds chest - Drowsy, orsilent chest confused Unable tospeak or>180bpm(4-5years) rate >200bpm(0-3years) Pulse >120bpm(>5years); present may notbe Wheeze rate >30/minute Respiratory mayCyanosis present likely be whilesitting Hunched forward Subcostal &/orsubglottic present retractions Talks inwords SaO drowsy confused, Agitated, rate pulse bpm (4-5years) ≤200bpm(0-3years)/≤180 (bpm); ratePulse <100beats/minute Variable intensity wheeze rate respiratory Increased No central cyanosis Talks inphrases/sentences  rapid actingbeta inhaled tohave forachild <1year repeated ere isaneed reliever medication lethargy orreducedexercisetolerance,impairmentofdailyactivities(includingfeeding)&poorresponseto Episode of progressive increase in wheeze & shortness of breath, cough especially when the child is asleep, several hours several asthma atasthma home Availability ofacutetreatment isaff patient's by environmentected ability orcaretaker's tomanage acute ofimprovement signs ifw/clinical even beta No improvement to6puff Unresponsive initialbronchodilator treatment: after seen short-actings ofinhaled Diffi- cult toperceive airfl orseverity obstruction ow compliance actionplan orasthma ofpoor medication w/asthma History - problems orpsychosocial disease ofpsychiatric History - - Overdependent on rapid-acting inhaled beta onrapid-acting inhaled Overdependent - Currently glucocorticosteroids notoninhaled - Currently usingorrecently oralglucocorticosteroids stopped - exacerbation duetoasthma oremergency visit care hospitalization 1year) (within Prior - ofnear-fatal intubation requiring intubation asthma &mechanical history Past - - - therapy (eg Omalizumab, Mepolizumab, Benralizumab, Dupilumab) therapy Benralizumab, (eg Omalizumab, Mepolizumab, infl 2 airway Patients type w/ residual 2-targeted ammation type are to add-on biologic likely to respond PEF orFEV PEF patients w/post-treatment FEV who require hospitalization (iepatientswho require hospitalization w/pre-treatment FEV 2 2 at <92% at >90-95%( ≥92% forchildren ≤5years) 2 2 at <92%when breathing without support -agonist within 1-2 hours or persistent tachypnea after 3 doses of inhaled short-acting ofinhaled beta -agonist 3doses 1-2hoursorpersistent within tachypnea after 1 4 & arterial oxygen saturation should be measured to determine the degree ofhypoxemia the oxygen degree todetermine &arterial saturation measured shouldbe 1 are more reliable indicators ofairfl &may patients help also determine limitationow severity © MIMS ASSESSMENT OF SEVERITY ASTHMA EXACERBATION Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 1 or PEF <40% predicted or personal best) best) orpersonal <40%predicted orPEF Asthma (16of26) 1 has returned to their previous ideal value orplateau value ideal totheir previous returned has 2 -agonists (ie use of >1 canister per month) per of>1canister (ieuse -agonists B28 2 -agonist &O 1 or PEF <25% predicted or personal best or best orpersonal <25%predicted orPEF 2 2 -agonist 2 -agonist administration over © MIMS Pediatrics 2020 2 -agonist ASTHMA 1 Bronchodilator the combinations forspecifi latest MIMS see are available. Please c formulations. • • • Short-Acting bromide Tiotropium Long-Acting bromide Ipratropium of 20 mg/day for 0-2 years old & 30 mg/day for 3-5 years old or 0.6mg/kg/day for2days of 20mg/day old&30mg/day oldorDexamethasone for0-2years for3-5years of1-2mg/kg/day considered may dose for1-5days w/dose be uptomaximum Oral /Prednisolone admission hospital condition 1st-line orworsening after response treatment, continueIn patients w/poor therapy whilearranging - old:4-10puff ≥6years pMDIw/spacers by ormouthpiece &mask - onpatient's age: based ofSalbutamolshouldbe Dose Drug - nebulizer oroxygen-driven nebulizer SaO ifw/low old:2puff≤5 years s (100mcg/puff pMDIw/spacer) by ormouthpiece, &mask air-driven or2.5mgby repeat at 20-minute intervals for1hour at 20-minuterepeat intervals 1 hour, after toinitialdose If unresponsive may 2-6more puff give &may thes 20minutes 1stdose after All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All F 1.25 mcg/puff inhalation soln 0.025% unit dose inhalation soln 500 mcg/2mL 250 mcg/2mL, MDI 20 mcg/puff TREATMENT OF ACUTE EXACERBATIONS IN PRIMARY CARE PRIMARY IN EXACERBATIONS ACUTE OF TREATMENT Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products Available Strength placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 2puff≥6 yr: s 24 hrly required nebulizer via 6-8hrly as 1mL(250mcg) 6-12 yr: required 6-8 hrly as nebulizermcg) via 0.4-1mL(100-250 <6 yr: required 6-8 hrly as nebulizer500 mcg)via (250- 1 unitdose 12puff dose: Max s/day 2 puffs 6hrly (INHALED) ANTICHOLINERGICS Dosage Guidelines Dosage Asthma (17of26) B29 2 • • • • Instructions Special • Reactions Adverse - Should be added tobeta added Should be - 1st-line as Not used treatment ofdrug optimum delivery patient’sCheck inhaler for technique Avoid w/inhalation contact soln ofeyes myasthenia gravis obstruction, bladderglaucoma, neck Use w/caution inpatients w/narrow-angle ) rash, angioedema, (urticaria, reactions Hypersensitivity nausea); dyspepsia, bad taste, GIeff dizziness); (headache, mouth, (dry ects eff(chest pain,palpitation); CNS ects eff(URTI), sinusitis]; CV bronchitis, ects effResp tractinfection resp [upper ects 1 Remarks © MIMS Pediatrics 2020 2 -agonist therapy ASTHMA 1 foracuteexacerbations higher than be the here. maintenance can recommended note:Doses listed *Please doses Inhaled bronchodilator the combinations forspecifiInhaled latest MIMS see are available. Please c formulations. ebtln 5 c/u MI1-2puff required s 6-8hrly as 250mcg/puff MDI (Albuterol) Salbutamol ( 100&200mcg/puff Short-Acting Metaproterenol) Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed BETA inhalation soln 5mg/2mL 2.5 mg/2mL, turbuhaler DPI DPI, 500 mcg/dose inhalation soln 5 mg/mL(0.5%soln) unitdose soln 5 mg/2.5mLinhalation 2.5mg/2.5mL, 1 mg/mL, 200 mcg/cap DPI DPI diskhaler 200 mcg/dose DPI accuhaler200 mcg/dose DPI 100 &200mcg/dose MDI 100 mcg/dose easyhaler 100 &200mcg/dose evohaler) (autohaler/100 mcg/dose 1-2puff required s 8hrly as 10 mcg/puff MDI 750 mcg/puff MDI inhalation for 1.25 mg/2mLsoln MDI

© MIMS Available Strength Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not 2 Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing -AGONISTS () (INHALED) Dosage Guidelines Asthma (18of26) to 6 hrly as required to 6hrly as nebulizer 5mgvia up >20 kg: required to 6hrly as nebulizer 2.5mgvia up <20 kg: 8doses/day dose: Max 2 doses For exacerbations: severe required as 6hrly inhaled 1dose 3-12 yr: 8puff dose: Max s/day required 10minas over nebulizervolume of2-3mLvia tofiw/ normal nal amount Dilute required ofsoln 0.5-1mL(2.5-5mg) >12 yr: 0.5mL(2.5mg) >15 kg: 0.25mL(1.25mg) 10-15 kg: required as nebulizer2.5-5 mgvia 6-8hrly 1.2mg/day dose: Max 6-8 hrly ifnecessary to200mcg May increase 100 mcg6-8hrly treatment: For chronicorpreventive singledose 100 mcgas exertion: to relief/prior Immediate 1 puff required 6-12 hrly as for childn: countries some Approved in 12puff dose: Max s/day 8hrly 10drops 6-14 yr: 8hrly 5-10drops 1-6 yr: 8hrly 3-7drops <1 yr: required to 6hrly as nebulizer via 10-20 drops up required 8 hrly as 1-2puff >6yr: for childn s countries some Approved in B30 Dosage* • • • Instructions Special • • Reactions Adverse delivery ofdrug delivery foroptimumtechnique patient’sCheck inhaler asthma acute severe in Monitor Klevels arrhythmias insuffi ciency or myocardial hyperthyroidism, DM, patients w/ Use w/caution in asthma severe inacute especially mayhypokalemia result Potentially severe muscle tremor) eff (fiect ne skeletal Other bronchospasm); paradoxical irritation, eff (mouth &throatects Resp hyperactivity); effCNS (headache, ects patients);in susceptible especially arrhythmias cardiac palpitations, effCV (tachycardia, ects 1 © MIMS Pediatrics 2020 Remarks ASTHMA 3 2 1 *Please note: Doses foracuteexacerbations higher than be the here. maintenance can recommended note:Doses listed *Please doses Oral bronchodilator the combinations forspecifi latest MIMS see are available. Please c formulations. Should be used as an adjunct to inhaled corticosteroids in the management of asthma. Please see the forspecifi corticosteroids latest MIMS anadjunct toinhaled see as inthe management Please used Should be ofasthma. c formu- bronchodilator the combinations forspecifiInhaled latest MIMS see are available. Please c formulations. Long-Acting 1.2 mcg/kg/day PO divided 12hrly divided 1.2mcg/kg/day PO Clenbuterol Short-Acting Formoterol 4.5 mcg/dose 4.5mcg/dose Formoterol Procaterol ( Orciprenaline Fenoterol amtrl25mcg/puff MDI lations ofdifferent combination products. Metaproterenol) Drug Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All 2 BETA 12 mcg/cap DPI turbuhaler DPI 9 mcg/dose turbuhaler DPI diskhaler DPI accuhaler DPI, 50 mcg/dose Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed Available Strength 25 mcg PO 12-24 hrly 25mcgPO >6 yr: 12hrly PO 1.25mcg/kg/dose <6 yr: 6hrly 10mgPO 3-10 yr: 8-24hrly 0.5mgPO 6-10 yr: 8-24hrly 0.25mgPO 3-6 yr: 8-24hrly 0.125-0.25mgPO 1-3 yr: 8-24hrly 6-12 mth:0.125mgPO 12-24hrly 3-6 mth:0.125mgPO childn: for countries some in Approved foruse 8hrly 2.5mgPO 6-14 yr: 8hrly 1.25-2.5mgPO 1-6 yr: 8-12hrly 1.25mgPO <1 yr: childn: for countries some in Approved foruse 2 -AGONISTS (BRONCHODILATORS) (INHALED)

© MIMSBETA Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 2 -AGONISTS (BRONCHODILATORS) (ORAL) 1 cap inhaled 12hrly 1 cap inhaled ≥5yr: for childn countries some in Approved 2doses/day dose: Max 12-24hrly inhaled 1 dose ≥6yr: forchildn countries some Approved in 4doses/day dose: Max 12-24hrly inhaled 1-2 doses ≥6yr: forchildn countries some Approved in ≥4 yr: 2puff≥4 yr: s 12hrly 1 dose inhaled 12hrly inhaled 1dose ≥4 yr: Dosage Dosage Guidelines Asthma (19of26) Dosage* B31 • • Instructions Special • • • Reactions Adverse • • • Instructions Special • • Reactions Adverse Monitor K levels in acute severe asthma inacutesevere Monitor Klevels insuffi orarrhythmias ciency myocardial hyperthyroidism, DM, Use w/ caution inpatients w/ more common &thereforereceptors sideeff may be ects Orciprenaline is less selective forbeta Orciprenaline selective isless asthma inacute severe especially result Potentially may hypokalemia severe skeletal muscle tremor) patients);susceptible Other eff (fiect ne in especially arrhythmias cardiac eff CV restlessness); (palpitations, ects & agitation, hyperactivity disturbances, effCNS sleep (headache, ects optimum delivery ofdrug optimum delivery patient’sCheck inhaler for technique asthma inacutesevere Monitor Klevels insuffi orarrhythmias ciency myocardial hyperthyroidism, DM, Use w/caution inpatients w/ asthma inacutesevere especially result Potentially may hypokalemia severe eff (fiect ne skeletal muscle tremor) Other bronchospasm); paradoxical (mouth &throat irritation, eff Resp hyperactivity); (headache, ects eff patients);susceptible CNS ects in especially arrhythmias cardiac effCV palpitations, (tachycardia, ects 1 (CONT’D) Remarks Remarks 3 © MIMS Pediatrics 2020 2 ASTHMA 2 1 Combination w/other the forspecifi cough latest MIMS see preparation isavailable. Please c formulations. Oral bronchodilator the combinations forspecifi latest MIMS see are available. Please c formulations. Salbutamol (Cont'd)Short-Acting (Albuterol) Beta () Epinephrine Nonspecific Sympathomimetic Terbutaline Salbutamol in24hr inj x3-4doses IV 5-10mcg slow Hexoprenaline Formoterol 4 mcg/kg/day PO divided 8-12hrly divided 4mcg/kg/day PO (Albuterol) Salbutamol Formoterol Long-Acting Terbutaline Drug 2 -Agonists -Agonists Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All 2 Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products BETA every 20minx3doses every 10 mcg/kgupto300-500mcgSC/IM continuous infusion a as 25mcg/kg/day IV IV infusion: 300mcg/dose dose: Max required to 6hrly as up IV SC/slow 10mcg/kg/dose 2-15 yr: infusion 3-20mcg/minIV IV infusion: required 4hrly may as repeat 500 mcgIM/SC, required inj, as may repeat IV 250 mcgslow placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed Max dose: 32mg/day dose: Max 6-8hrly 2-4mgPO >12 yr: 24mg/day dose: Max 6-8hrly 2mgPO 6-12 yr: 12mg/day dose: Max 6-8hrly 1-2mgPO 2-6 yr: © MIMS 12hrly 4mgPO >12 yr: 12 hrly divided 0.3-0.6mg/kg/day PO <12 yr: Extended-release: childn 2-12yr) inAsian recommended are >10mg/day not PO (Doses 10mg/day 2-5yr: forchildn dose Max 2-12yr: childn for countries some in foruse Approved 15mg/day dose: Max 8hrly 2.5-5mgPO ≥12 yr: 5mg/day dose: Max 8hrly PO 0.05mg/kg/dose <12 yr: 2 -AGONISTS (BRONCHODILATORS) (ORAL) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing BRONCHODILATORS (PARENTERAL) Dosage 5-10 mg PO 24hrly 5-10 mgPO Dosage Dosage Guidelines Asthma (20of26) B32 • • Instructions Special • • • Reactions Adverse Monitor K levels in acute severe asthma inacutesevere Monitor Klevels insuffi orarrhythmias ciency myocardial hyperthyroidism, DM, Use w/caution inpatients w/ flhypertension, hypotension ushing, coldness headache, ofextremities, dizziness, weakness, hypersalivation, sweating, tremors, tachycardia, palpitations, restlessness, hyperglycemia, Epinephrine: Dyspnea, asthma inacutesevere especially Potentially may hypokalemia result severe &restlessness agitation, hyperactivity disturbances, sleep headache, patients, especially arrhythmias cardiac insusceptible Fine skeletal muscle tremor, palpitations, • • Instructions Special • • Reactions Adverse Monitor K levels in acute severe asthma inacutesevere Monitor Klevels insuffi orarrhythmias ciency myocardial hyperthyroidism, DM, Use w/caution inpatients w/ asthma inacutesevere especially result Potentially may hypokalemia severe skeletal muscle tremor) patients);susceptible Other eff (fiect ne in especially arrhythmias cardiac eff CV restlessness); (palpitations, ects & agitation, hyperactivity disturbances, effCNS sleep (headache, ects 1 (CONT'D) Remarks Remarks © MIMS Pediatrics 2020 ASTHMA 3 2 1 Modifi from: ed British British Jul Updated oracic 2019.p73 Society Modifi from: ed Ages ≥4years Ages ≥1year Ages ≥5years Ages propionate (DPI) Fluticasone dipropionate (HFA) Beclomethasone dipropionate (CFC) Beclomethasone (HFA)Fluticasone (DPI) furoate Fluticasone (DPI) Budesonide furoate (HFA) furoate Mometasone (DPI) furoate Mometasone neb Budesonide Budesonide neb Budesonide Mometasone furoate Mometasone Fluticasone propionate (HFA)Fluticasone Ciclesonide Beclomethasone dipropionate (HFA) Beclomethasone APPROXIMATE EQUIPOTENTDAILY DOSESOFCORTICOSTEROIDS(INHALED) APPROXIMATE EQUIPOTENTDAILY DOSESOFCORTICOSTEROIDS(INHALED) All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2020.p56. Updated management forasthma GlobalGlobal and strategy prevention: Initiative forAsthma (GINA). Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2020.p153. Updated management forasthma GlobalGlobal and strategy prevention: Initiative forAsthma (GINA). Drug Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed

© MIMS Drug Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 0-0 2040>0 0-0 5010 >1000 >500-1000 200-500 >400 >200-400 100-200 0-0 2040>0 0-0 4080>800 >400-800 200-400 >400 >200-400 100-200 5-0 5010 10 - >1000 >500-1000 250-500 (mcg) 010>0-0 201020>5-0 >500 >250-500 100-250 >200 >400 >100-200 >200-400 50-100 100-200 >200 >100-200 50-100 010>0-0 201020>5-0 >500 >250-500 100-250 >200 >100-200 50-100 Dosage Guidelines Dose Low ≥6-12 YEARSOFAGE 0 0 0 0-0 0-0 >400 200-400 200-400 200 100 100 05 0 0 200 100 100 - 50 50 0>010>6 010>6-2 >320 >160-320 80-160 >160 >80-160 80 - ≤5 YEARSOFAGE Asthma (21of26) 6-11 yearsofage Medium (mcg) Dose B33 o oe(c)MediumDose(mcg) Low Dose(mcg) 0 0 400 200 200 - - 500 100 100 50 - 3 1 2 1 (mcg) Dose High (mcg) Dose Low ≥12 yearsofage Medium >500-1000 © MIMS Pediatrics 2020 >200-400 >200-500 >160-320 (mcg) Dose -  (mcg) Dose High - ASTHMA 1 Corticosteroids combined w/ bronchodilators are available. Please see the forspecifi latest MIMS Corticosteroids combined w/bronchodilators see are available. Please c formulations. Prednisone Prednisolone, Methylprednisolone, Dexamethasone dipropionate Beclomethasone acetonide furoate Mometasone propionate Fluticasone 500mcg/puff MDI furoate 80,160mcg/actuation MDI Fluticasone Ciclesonide 100,200mcg/puff MDI Budesonide Drug Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © MIMS forinhalation unitdose 75, 200mcg/dose dose forinhalation unit 50, 100,200mcg/dose unit dose forinhalation 2mg/2mLsoln 0.5 mg/2mL, evohaler 250 mcg/dose diskhaler DPI;50,125, 250 mcgdose accuhaler50, 100,250mcg/dose DPI;50, 50, 125,250mcg/puff MDI evohaler 250 mcg/dose diskhaler DPI;50,125, 250 mcgdose accuhaler50, 100,250mcg/dose DPI;50, forinhalation1 mg/2mLsoln unitdose 500mcg/mL, 500mcg/2mL, 250 mcg/2mL, 100,200,400mcg/cap DPI easyhaler; 200mcg/dose swinghaler; 200 mcg/dose turbuhaler100, 200,400mcg/dose DPI; DPI easyhaler diskhaler DPI;200mcg/dose 100, 200mcg/cap DPI;100,200mcg/dose 50, 100,250mcg/puff MDI Max dose: 60mg/day dose: Max 6-8 hrly x3-10days divided 1-2 mg/kg/day PO tolerated when 4-5 days tooraldose &reduce over response accordingAdjust dose to 6hrly x24hr infusion IV IV/ slow 2-4 mg/kg/dose dept: emergency in exacerbations Asthma 6-12 hrly divided day IV/IM, 0.08-0.3mg/kg/ Childn: Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Available Strength Dosage CORTICOSTEROIDS (SYSTEMIC) CORTICOSTEROIDS (INHALED) Dosage Guidelines Asthma (22of26) B34 • • Special Instructions • Adverse Reactions • Reactions Adverse preventive treatmentforosteoporosis Patients onlong-termcorticosteroidsshould receive Should betakenw/food glaucoma cataracts, bruising, &easy striae weight skinthinning to DM, leading gain, imbalances, electrolyte impaired woundhealing, infection, to susceptibility increased painorweakness, wasting, Adrenocortical insuffi muscle ciency, osteoporosis, GI eff long-term: Ifadministered (gastritis). ect weakness) Other eff weight appetite, muscle gain, (increased ects eff disturbances);& psychic CV (tachycardia);ect effCNS (excessiveects mental stimulation, insomnia page page previous See Dosage 1 Remarks • Special Instructions • • Adverse Reactions 1:50 dilutionof out w/water,orgargling spacer, gargling&spitting minimized byusinga Local effects maybe Riskofsystemiceffects - osteoporotic fractures increased boneloss& adrenal suppression, thinning, easybruising, cataracts, glaucoma,skin steroids mayresultin Long-term useofhigh-dose bronchospasm (rare) dysphonia); paradoxical upper airwayirritation, candidiasis, coughfrom Local effects (oropharyngeal & thedrug’s system, theuseofspacers from thegut,delivery corticosteroid, absorption potency ofthe will dependondose, Remarks © MIMS Pediatrics 2020 ASTHMA Na cromoglycate) Na cromoglicate, Na, (Cromolyn negundo) (Vitex Lagundi Guaifenesin extract leaf ivy Dried ( Carbocisteine Bromhexine Ambroxol Carbocysteine) Drug Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed 15 mg/kg PO 8hrly 15 mg/kgPO 600 mg/day 600mg/day ≥6yr: dose Max 4-6hrly 20-100mgPO ≥7 yr: 4-6hrly 10-50mgPO 2-6 yr: 6hrly 25mgPO Infant: 32.5 mg PO 12hrly 32.5mgPO 6-12 yr: Eff Tabervescent 8hrly 5mLPO 6-10 yr: 8hrly 2.5mLPO 1-5 yr: Syr 375 mg PO 8hrly 375mgPO 6-12 yr: Tab 8 hrly Up to250mgPO 5-12 yr: 12-24 hrly 100-250mgPO 2-5 yr: 12-24hrly 50mgPO <2 yr: Syr 8 mg PO 8hrly 8mgPO >10 yr: 8hrly 4mgPO yr: 5-10 8hrly 2mgPO <5 yr: 5 mL PO 8-12hrly 5mLPO 7-12 yr: 8hrly 2.5mLPO 2-6 yr: 12hrly 2.5mLPO 7 mth-2yr: 12hrly ≤6 mth:1.25mLPO

© 2puffs 6hrly 5 mg/puff MDI MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Available Strength Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage COUGH &COLDPREPARATIONS Dosage Guidelines CROMONE (INHALED) been stabilized been once has asthma to 1puff 6hrly &reduce cases in more severe 2 puffs 6-8x/day to May increase Asthma (23of26) Dosage • Instruction Special • Adverse Reactions • Instruction Special • Reactions Adverse • Instructions Special • Reactions Adverse • Instruction Special • Reactions Adverse • Instruction Special • Reactions Adverse • • Instruction Special • Reactions Adverse B35 Use w/ caution in patients w/ hypersensitivity toLagundi Use w/ caution inpatients w/hypersensitivity GI eff (N/V,ects eff Dermatologic diarrhea); (rash) ect persistent orchronic cough Use old&inpatients w/ caution inchildn <2yr w/ headache) (drowsiness, GI eff eff CNS N/V); (GIdiscomfort, ects ects intolerance Use w/caution inpatients w/fructose/sorbitol Rarely, eff laxative duetosorbitol contentect Use w/ caution in patients w/ gastric or duodenal ulcer orduodenal Use w/caution inpatients w/gastric (hypotension) rashes);Othereff(bronchospasm, ect reactions GI eff Hypersensitivity N/V); (GIdisturbances, ects Use w/cautioninpatientsgastriculcer transaminases) ofserum increase GI eff eff Metabolic (GIirritation); ect (transientect Use w/cautioninpatientsgastriculcer taken inanemptyShould not be stomach fatigue) polyuria, GI eff (N/V,ects Other eff diarrhea); (headache, ects • Instructions Special • Reactions Adverse Should not be used for acute asthma attacks for acute asthma used Should notbe headache) nausea, taste, Other& anaphylaxis); eff (unpleasant ects edema laryngeal angioedema, bronchospasm, of throat, rarely,& irritation severe effResp (transient cough bronchospasm, ects Remarks Remarks © MIMS Pediatrics 2020 ASTHMA cflie500mg-2g/day Zafi 12hrly 3.5mg/kgPO rlukast Antagonists Receptor Leukotriene 5-Lipoxygenase (Dyphylline) theophyllinate Choline should Dosage Ketotifen Drug Drug Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products 20 mg PO 12hrly 20mgPO ≥12 yr: 12hrly 10mgPO 5-11 yr: 10mg/kg/day dose: Max bedtime before hrly 24 mg PO 10 ≥15 yr: bedtime before 24hrly 5mgPO 6-14 yr: 24 hrly bedtime before 4mgPO 6 mth-5yr: 12hrly PO 1.2g Extended-release: hrly 6 mg PO 600 ≥12 yr: 2 mg PO at bedtime 2mgPO >3 yr: Extended-release: 12hrly 1mgPO >3 yr: 12 hrly 0.5mgPO 6 mth-3yr: placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed doses individed PO PO 8-24hrly PO 200mg >12 yr: 12 hrly © PO kg/dose 6-9mg/ <12 yr: 6hrly PO 15 mg/kg/dose 6-8 hrly 100 mgPO individualized be MIMS Dosage MAST CELLSTABILIZER/ANTIHISTAMINE (ORAL) Dosage Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Dosage Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing LEUKOTRIENE MODIFIERS(ORAL) METHYLXANTHINES (ORAL) • • • Instructions Special • • Reactions Adverse Dosage Guidelines Optimal therapeutic concentration:Optimal 5-15mcg/mL(28-85μmol/L) ifapatient concentration Serum ischanged measured tobe needs - concentration are therapeutic within range concentration toensureSerum that isnecessary monitoring inneonates acutefebrile illness, hepatic dysfunction, failure, epilepsy, heart disease, orother arrhythmias cardiac CV hypertension, ulcer,Use w/ caution inpatients w/peptic hyperthyroidism, eff ofadverse risk w/ increased including reactions lethal adverse ects concentration Serum >15-20mcg/mL(85-110μmol/L)isassociated tremor); Other effdizziness, (palpitations) ect refl eff CNS ux); stimulation, anxiety, headache, (CNS restlessness, ects GI eff N/V, (irritation, ects gastroesophageal pain,diarrhea, abdominal Asthma (24of26) from one extended-release product toanother product one extended-release from • • Instructions Special • • • • Reactions Adverse • • • Instructions Special • Reactions Adverse Zafi Avoid inpatientsrlukast: w/hepatic impairment orcirrhosis attacks foracuteasthma used Should not be consistent eosinophilia systemic w/Churg-Strauss disease &edema, bruising bleeding, Very Agranulocytosis, rarely: hyperbilirubinemia hepatitis, Zafi rarely symptomatic liver , Raised rlukast: reactions hypersensitivity dizziness; fever, myalgia, pain,arthralgia, Generalized commonly: Less GIupset Headache, well-tolerated: Generally attacks foracuteasthma used Should not be therapy during &periodically before Monitor liver enzymes Avoid inpatients w/hepatic impairment/disease Other eff patients) inafew occurred has leukopenia (rashes, ects effCNS GIeff (headache); ect liver enzymes); raised (GIupset, ects • Instructions Special • Reactions Adverse Should not be used for acute asthma attacks foracuteasthma used Should notbe eff weight appetite, gain) mouth, increased (dry ects effCNS stimulation); GI CNS dizziness, (drowsiness, ects B36 Remarks Remarks Remarks © MIMS Pediatrics 2020 ASTHMA 1 Different formulations for the forspecifi latest MIMS see eophylline are available. Please c formulations. acefyllinate Heptaminol cflie1.5-2g/day IM Acefylline Omalizumab E(Anti-IgE) Antibody Anti-Immunoglobulin  eophylline rxpyln 400-800mgIM Aminophylline rgDosage Drug Drug Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All 1 weight &body level IgE pretreatment on depends Dose 2 or4wk 1-4 SCinj every 150-375 mgin ≥12 yr: 4 wk 2or SC inj every mg in1-3 75-375 6-11 yr: Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed or 0.5-1g/day IV or slow IV 8hrly IV or slow 0.8 mg/kg/hrIV 10-16 yr: 1 mg/kg/hrIV 6 mth-9 yr: dose: Maintenance 20-30 min over infusion 5 mg/kgIV dose: Loading 500 mg-1 g PO 8hrly 500mg-1gPO >15 yr: © MIMS 13mg/kg/day (nonsmokers): PO 12-16 yr 16 mg/kg/day PO smokers): adolescent (including 9-<12 yr 20-24mg/kg/day PO 1-<9 yr: : 12-18mg/kg/day6 mth-<1yr PO dose: Maintenance 5mg/kgPO methylxanthine: nottaking patients in dose Loading bronchospasm Acute Dosage Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing METHYLXANTHINES (ORAL)(CONT'D) METHYLXANTHINES (PARENTERAL) • • • • • Instructions Special • Reactions Adverse MONOCLONAL ANTIBODIES Use w/caution inpatients infections at ofparasitic risk gradually tapered Corticosteroids shouldbe children old <6 years &in tothe drug hypersensitivity inpatientsContraindicated w/severe asthmaticus forthe treatment used orstatusShould ofacutebronchospasm notbe inj delivered per site of150mgshouldbe Max Other effects (localsitereaction,viralinfection,anaphylaxis,malignancies) CNS effect (headache);Respeff ects (respinfections,sinusitis,pharyngitis); Dosage • • • • Instructions Special • • Reactions Adverse Dosage Guidelines Optimal therapeutic concentration:Optimal 5-15mcg/mL(28-85µmol/L) concentration are therapeutic within range concentration toensureSerum isnecessary monitoring inneonates acutefebrile illness, hepatic dysfunction, failure, epilepsy, heart disease, orother arrhythmias cardiac CV hypertension, s ulcer,Use w/caution inpatients w/peptic hyperthyroidism, porphyria, t c ff e e side &CV toprevent dangerous slowly CNS injAdminister very IV eff ofadverse risk w/ increased including reactions lethal adverse ects concentration Serum >15-20mcg/mL (85-110µmol/L)isassociated tremor); Other eff dizziness, anxiety, restlessness, (palpitations) ect reflgastroesophageal eff CNS ux); stimulation, headache, (CNS ects GI eff N/V, (irritation, ects pain,diarrhea, abdominal Asthma (25of26) B37 Remarks Remarks • • Instructions Special • Reactions Adverse - Increases  Increases eophylline clearance -  eophylline including smoking interactionsMany drug occur w/ page previous See page previous See Remarks © MIMS Pediatrics 2020 ASTHMA catarrhali N. S.viridans, pyogenes, S. S.aureus, ozaenae, K. pneumoniae, K. pneumoniae, infl D. uenzae, (Lyophilized H. lysate Bacterial Benralizumab Inhibitors Interleukin Dupilumab Mepolizumab Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Drug s) Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products wk 8 then every doses, 4wkx3 every 30mgSC ≥12 yr: every other week every 300mgSCgiven by SCfollowed doses) 600 mg(300x2 other or week 200mgSCevery by SCfollowed doses) mg (200x2 400 dose: Initial ≥12 yr: 24 hrly every 4wk 24 hrly every 100mgSC ≥12 yr: 4wk 24 hrly every 40mgSC 6-11 yr: OTHER DRUGSACTINGONTHERESPIRATORY SYSTEM placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed

© MIMS Dosage Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing x 10days 24hrly 50 mgPO treatment: Long-term 24hrly 50 mgPO treatment: Acute Please see the end of this section for the reference list. reference the for section this of end the see Please MONOCLONAL (CONT'D) ANTIBODIES Dosage • • • Instructions Special • Reactions Adverse • • • • Instructions Special • Reactions Adverse • • Instructions Special • Reactions Adverse Dosage Guidelines Monitor for hypersensitivity reaction Monitor forhypersensitivity old, abruptsteroid withdrawal Use w/caution inpatients w/helminth children infection, <12yr treatmentNot foracuteasthma papule) pruritus, effDermatologic inj erythema, sitereaction, rash, (urticaria, ects effCNS eff Resp (headache); ect (cough,ects pharyngitis); Administer each of the 2 doses intoAdminister diff ofthe each 2doses erent inj sites reaction Monitor forhypersensitivity old, abruptsteroid withdrawal Use w/caution inpatients w/helminth children infection, <12yr treatmentNot foracuteasthma pain oropharyngeal Inj eosinophilia, sitereaction, helminth abrupt steroid withdrawal infection, Use w/ caution inpatients w/uncontrolled asthma, worsening treatmentNot foracuteasthma toothache, infection) Other eff bronchospasm); allergic rhinitis, headache, (UTI, ects eff back(muscle pain);Resp spasm, congestion, dyspnea, (nasal ects eff Musculoskeletal burning); itching, swelling, erythema, ects effDermatologic inj including sitereaction eczema, (pruritus, ects Asthma (26of26) • Instructions Special • Reactions Adverse compromised immunity, activeTB,rheumatic disease insufficardiopulmonary ciency, conditions w/ inpatientsContraindicated w/autoimmune disease, problems) urological reactions, Other eff upset); gastric cutaneous (skinitching, ects GI eff pain, abdominal upper diarrhea, (nausea, ects B38 Remarks Remarks © MIMS Pediatrics 2020

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