Long-term control

Take These Long-Term-Control Medicines Each Day (Include an anti-inflammatory)... 

Patients must understand the role of long-term control and quick relief medications in their asthma treatment plan. The importance of understanding asthma as a chronic disease and the need for daily treatment with long-term control medications should be stressed. Additionally, the importance of proper use of medication delivery devices should be continually reinforced. Basic education should be provided over several visits with the health care provider. 

Severity Classification (Prior to Treatment) Clinical Features Before Treatment or Adequate Control3 /C Medication Required to Maintain Long-Term Control Adults and Children Older Than 5 Years of Age Medication Required to Maintain Long-Term Control Children 5 Years of Age and Younger... 

Use of short-acting 32-agonist greater than 2 times a week in intermittent asthma (daily or increasing use in persistent asthma) may indicate the need to initiate or increase long-term-control therapy... 

If it is necessary to use systemic corticosteroids for long-term control therapy, once-daily or every-other-day therapy should be used and repeated attempts should be made to decrease the dose or discontinue the drug. Withdrawal of chronic therapy may precipitate adrenal failure or unmask underlying inflammatory disorders such as Churg-Strauss syndrome. 

TABLE 11-4. Usual Doses for Long-Term Control Medications... 

In patients with mild intermittent asthma, long-term control medications are not necessary, and patients should use a short-acting inhaled P2-agonist t° prevent or treat symptoms.2 This classification includes patients with exercise-induced asthma, seasonal asthma, or asthma symptoms associated with infrequent trigger exposure. Patients can pre-treat with two puffs of cromolyn or nedocromil prior to exposure to a known trigger. The treatment of choice for exercise-induced asthma is two inhalations of albuterol 5 minutes prior to exercise.1 Cromolyn and nedocromil are less effective than albuterol for prophylaxis of exercise-induced asthma. 

The optimal treatment of acute severe asthma depends on the severity of the exacerbation (Figs. 11-2 and 11-3). The patient s condition usually deteriorates over several hours, days, or weeks however, rapid deterioration can occur in some patients.3 Gradual deterioration may indicate failure of long-term controller therapy. Patients with rapid deterioration usually respond well to bronchodilator therapy.40 Severity at the time of the evaluation can be estimated by signs and symptoms, but patient response 30 minutes after inhalation of a bronchodilator is the best predictor of outcome.12... 

Monitor and maintain PEF above 80% of personal best PEF variability should be less than 20%. Patients with PEF rates consistently greater than 80% over several months should be evaluated for a step down in long-term control therapy. Patients with a PEF less than 80% of personal best should begin to monitor PEF twice daily and consult their asthma action plan. Patients with a PEF less than 50% of personal best should immediately use their short-acting inhaled 32-agonist and consult their asthma action plan. 

Monitor patient activity levels. Inability of a patient to perform routine physical activities indicates inappropriate therapy, and long-term control medications should be increased according to the next step of therapy. 

Monitor frequency of patient exacerbations. Frequent exacerbations, unscheduled clinic visits, emergency department visits, and hospitalizations due to asthma may indicate a non-adherent patient or the need to step up long-term control medications. 

Monitor patient use of long-term control medications to ensure adherence to the medication plan. Patients not adhering to the long-term control medication regimen should be re-educated on the importance of these medications for asthma control. 

Monitor use of short-acting inhaled P2-agonists. Use of these agents more than twice a week in intermittent asthma may indicate the need to initiate long-term control therapy. Use of more than one canister per a month indicates the need to step up long-term control therapy. 

Assess the patient s adherence to long-term control therapy. If the patient is non-adherent, stress the importance of adherence to this therapy. Evaluate the complexity of the patient s treatment plan and simplify it as much as possible. Determine whether the patient would benefit from an inhaled corticosteroid/inhaled long-acting p2-agonist combination product. 

Evaluate therapy on a regular basis. Assess the patient s control of asthma by evaluating symptoms, PEF diary entries, and rescue medication use. Step long-term control therapy up or down based on these parameters. Before stepping up therapy, reassess the patient s inhaler technique to assure appropriate drug delivery. 

Some of the remedial measures tested in this study were not regarded as likely to form part of a long-term control stategy. For example, the installation of a mechanical ventilation system, with a heat recovery unit, would not be used in a dwelling of this type, because of the very high installation cost. Nevertheless, the availability of the dwelling enabled devices to be tested under real housing conditions, rather than in the laboratory. 

The answer is c. (Hardman, p 15230 Administration of intravenous CaG would immediately correct the tetany that might occur in a patient in whom a thyroidectomy was recently performed. Parathyroid hormone would act more slowly but could be given for its future stabilizing effect. Long-term control of a patient after a thyroidectomy can be obtained with vitamin D and dietary therapy Calcitonin is a hypocalcemic antagonist of parathyroid hormone. Plicamycin (mithramycin) is used to treat Paget s disease and hypercalcemia. The dose employed is about one-tenth the amount used for plicamycin s cytotoxic action. 

Inhaled corticosteroids are the preferred long-term control therapy for persistent asthma in all patients because of their potency and consistent effectiveness they are also the only therapy shown to reduce the risk of death from asthma. Comparative doses are included in Table 80-3. Most patients with moderate disease can be controlled with twice-daily dosing some products have once-daily dosing indications. Patients with more severe disease require multiple daily dosing. Because the inflammatory response of asthma inhibits steroid receptor binding, patients should be started on higher and more frequent doses and then tapered down once control has been achieved. The response to inhaled corticosteroids is delayed symptoms improve in most patients within the first 1 to 2 weeks and reach maximum improvement in 4 to 8 weeks. Maximum improvement in FEVj and PEF rates may require 3 to 6 weeks. 

Systemic corticosteroids (Table 80-4) are indicated in all patients with acute severe asthma not responding completely to initial inhaled /J2-agonist administration (every 20 minutes for three to four doses). Prednisone, 1 to 2 mg/kg/day (up to 40 to 60 mg/day), is administered orally in two divided doses for 3 to 10 days. Because short-term (1 to 2 weeks), high-dose systemic steroids do not produce serious toxicities, the ideal method is to use a short burst and then maintain the patient on appropriate long-term control therapy with inhaled corticosteroids. 

The addition of a second long-term control medication to inhaled corticosteroid therapy is one recommended treatment option in moderate to severe persistent asthma. 

Residual hydrocarbons will continue to serve as a source of groundwater contamination thus, remediation strategies for DNAPLs should emphasize long-term control and management (i.e., source containment, pool control, and recovery) vs. short-term fixes. Regardless of an increased level of effort (i.e., additional wells, increased pumping rates, etc.), the overall time for remediation is not expected to shorten by more than a factor of five. 

Clay minerals are important to the crustal-ocean-atmosphere fectory, not just for their abundance, but because they participate in several biogeochemical processes. For example, the chemical weathering reactions responsible for their formation are accompanied by the uptake and release of cations and, thus, have a large impact on the chemical composition of river and seawater. This includes acid/base buffering reactions, making clay minerals responsible for the long-term control of the pH of seawater and, hence, of importance in regulating atmospheric CO2 levels. 

Eifects of Long-Term Controlled Ozone Exposures on Growth, Yield, and Foliar Injury to Selected... 

Equally effective in reducing BP however, these have not been tested in long-term controlled trials to demonstrate reduction of morbidity and mortality. Reserve for special indications or when preferred agents are unacceptable or ineffective. 

Kozin SV, Boucher Y, Hicklin DJ, et al. Vascular endothelial growth factor receptor-2-blocking antibody potentiates radiation-induced long-term control of human tumor xenografts. Cancer Res 2001 61 39 14. 

On the whole dependence is quite quickly induced, when these drugs are used socially. Experience in terminal care has shown that careful long term control of pain does not usually need escalation of dose. 

Montelukast long-term control and prevention of relation to Churg-Strauss... 

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