Help patients gain better asthma control

,

Applied Evidence

Help patients gain better asthma control

J Fam Pract. 2008 September;57(9):594-602

By

Stuart W. Stoloff, MD

The latest government guidelines—which have more steps and an additional breakout for kids—make it easier for you to initiate, individualize, and adjust treatment.

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References

1. National Center for Health Statistics. Fast stats A to Z. Available at: www.cdc.gov/nchs/fastats/asthma.htm. Accessed August 1, 2008.

2. National Heart, Lung, and Blood Institute (NHLBI). National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Full Report 2007. Bethesda, MD: NHLBI; August 2007. NIH publication no. 07-4051. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed July 17, 2008.

3. Stout JW, Visness CM, Enright P, et al. Classification of asthma severity in children: the contribution of pulmonary function testing. Arch Pediatr Adolesc Med. 2006;160:844-850.

4. Bacharier LB, Strunk RC, Mauger D, et al. Classifying asthma severity in children: mismatch between symptoms, medication use, and lung function. Am J Respir Crit Care Med. 2004;170:426-432.

5. Eid N, Yandell B, Howell L, Eddy M, Sheikh S. Can children with asthma? Pediatrics. 2000;105:354-358.

6. Llewellin P, Sawyer G, Lewis S, et al. The relationship between FEV1 and PEF in the assessment of the severity of airways obstruction. Respirology. 2002;7:333-337.

7. Yawn BP, Enright PL, Lemanske RF, Jr, et al. Spirometry can be done in family physicians’ offices and alters clinical decisions in management of asthma and COPD. Chest. 2007;132:1162-1168.

8. Fuhlbrigge AL, Kitch BT, Paltiel AD, et al. FEV1 is associated with risk of asthma attacks in a pediatric population. J Allergy Clin Immunol. 2001;107:61-67.

9. Roorda RJ, Mezei G, Bisgaard H, Maden C. Response of preschool children with asthma symptoms to fluticasone propionate. J Allergy Clin Immunol. 2001;108:540-546.

10. Baker JW, Mellon M, Wald J, Welch M, Cruz-Rivera M, Walton-Bowen K. A multiple-dosing, placebo-controlled study of budesonide inhalation suspension given once or twice daily for treatment of persistent asthma in young children and infants. Pediatrics. 1999;103:414-421.

11. Kemp JP, Skoner DP, Szefler SJ, Walton-Bowen K, Cruz-Rivera M, Smith JA. Once-daily budesonide inhalation suspension for the treatment of persistent asthma in infants and young children. Ann Allergy Asthma Immunol. 1999;83:231-239.

12. Shapiro G, Mendelson L, Kraemer MJ, Cruz-Rivera M, Walton-Bowen K, Smith JA. Efficacy and safety of budesonide inhalation suspension (Pulmicort Respules) in young children with inhaled steroid-dependent, persistent asthma. J Allergy Clin Immunol. 1998;102:789-796.

13. Bisgaard H, Gillies J, Groenewald M, Maden C. The effect of inhaled fluticasone propionate in the treatment of young asthmatic children: a dose comparison study. Am J Respir Crit Care Med. 1999;160:126-131.

14. Szefler SJ, Eigen H. Budesonide inhalation suspension: a nebulized corticosteroid for persistent asthma. J Allergy Clin Immunol. 2002;109:730-742.

15. Guilbert TW, Morgan WJ, Zeiger RS, et al. Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med. 2006;354:1985-1997.

16. Bisgaard H, Allen D, Milanowski J, Kalev I, Willits L, Davies P. Twelve-month safety and efficacy of inhaled fluticasone propionate in children aged 1 to 3 years with recurrent wheezing. Pediatrics. 2004;113:e87-e94.

17. Knorr B, Franchi LM, Bisgaard H, et al. Montelukast, a leukotriene receptor antagonist, for the treatment of persistent asthma in children aged 2 to 5 years. Pediatrics 2001;108:e48.-

18. Russell G, Williams DA, Weller P, Price JF. Salmeterol xinafoate in children on high dose inhaled steroids. Ann Allergy Asthma Immunol. 1995;75:423-428.

19. Zimmerman B, D’Urzo A, Bérubé D. Efficacy and safety of formoterol Turbuhaler when added to inhaled corticosteroid treatment in children with asthma. Pediatr Pulmonol. 2004;37:122-127.

20. Simons FE, Villa JR, Lee BW, et al. Montelukast added to budesonide in children with persistent asthma: a randomized, double-blind, crossover study. J Pediatr. 2001;138:694-698.

21. Shapiro G, Bronsky EA, LaForce CF, et al. Dose-related efficacy of budesonide administered via a dry powder inhaler in the treatment of children with moderate to severe persistent asthma. J Pediatr. 1998;132:976-982.

22. Pauwels RA, Lofdahl C-G, Postma DS, et al. for the Formoterol and Corticosteroids Establishing Therapy (FACET) International Study Group. Effect of inhaled formoterol and budesonide on exacerbations of asthma. N Engl J Med. 1997;337:1405-1411.

23. Tattersfield AE, Harrison TW, Hubbard RB, Mortimer K. Safety of inhaled corticosteroids. Proc Am Thorac Soc. 2004;1:171-175.

24. Bateman ED, Boushey HA, Bousquet J, et al. For the GOAL Investigators Group. Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study. Am J Respir Crit Care Med. 2004;170:836-844.

25. O’Byrne PM, Barnes PJ, Rodriguez-Roisin R, et al. Low dose inhaled budesonide and formoterol in mild persistent asthma: the OPTIMA randomized trial. Am J Respir Crit Care Med. 2001;164:1392-1397.

26. Masoli M, Weatherall M, Holt S, Beasley R. Moderate dose inhaled corticosteroids plus salmeterol versus higher doses of inhaled corticosteroids in symptomatic asthma. Thorax. 2005;60:730-734.

27. Bousquet J, Wenzel S, Holgate S, Lumry W, Freeman P, Fox H. Predicting response to omalizumab, an anti-IgE antibody, in patients with allergic asthma. Chest. 2004;125:1378-1386.

28. Nelson HS, Weiss ST, Bleecker ER, Yancey SW, Dorinsky PM. For the SMART Study Group. The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest. 2006;129:15-26.

29. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004;113:59-65.

Practice recommendations

Assess asthma severity before initiating treatment; monitor asthma control to guide adjustments in therapy using measures of impairment (B) and risk (C) (National Heart, Lung, and Blood Institute [NHLBI] and National Asthma Education and Prevention Program [NAEPP] third expert panel report [EPR-3]).
Base treatment decisions on recommendations specific to each age group (0-4 years, 5-11 years, and ≥12 years) (A).
Use spirometry in patients ≥5 years of age to diagnose asthma, classify severity, and assess control (C).
Provide each patient with a written asthma action plan with instructions for daily disease management, as well as identification of, and response to, worsening symptoms (B).

EPR-3 evidence categories:

Randomized, controlled trials (RCTs), rich body of data
RCTs, limited body of data
Nonrandomized trials and observational studies
Panel consensus judgment

JJ, a 4-year-old boy, was taken to an urgent care clinic 3 times last winter for “recurrent bronchitis” and given a 7-day course of prednisone and antibiotics at each visit. His mother reports that “his colds always seem to go to his chest” and his skin is always dry. She was given a nebulizer and albuterol for use when JJ begins wheezing, which often happens when he has a cold, plays vigorously, or visits a friend who has cats.

JJ is one of approximately 6.7 million children—and 22.9 million US residents—who have asthma.¹ To help guide the care of patients like JJ, the National Heart, Lung, and Blood Institute (NHLBI) and National Asthma Education and Prevention Program (NAEPP) released the third expert panel report (EPR-3) in 2007. Available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm, the EPR-3 provides the most comprehensive evidence-based guidance for the diagnosis and management of asthma to date.²

The guidelines were an invaluable resource for JJ’s family physician, who referred to them to categorize the severity of JJ’s asthma as “mild persistent.” In initiating treatment, JJ’s physician relied on specific recommendations for children 0 to 4 years of age to prescribe low-dose inhaled corticosteroids (ICS). Without the new guidelines, which underscore the safety of controller medication for young children, JJ’s physician would likely have been reluctant to place a 4-year-old on ICS.

This review highlights the EPR-3’s key recommendations to encourage widespread implementation by family physicians.

The EPR-3: What’s changed

The 2007 guidelines:
Recommend assessing asthma severity before starting treatment and assessing asthma control to guide adjustments in treatment.
Address both severity and control in terms of impairment and risk.
Feature 3 age breakdowns (0-4 years, 5-11 years, and ≥12 years) and a 6-step approach to asthma management.
Make it easier to individualize and adjust treatment.

What’s changed?

There’s a new paradigm

The 2007 update to guidelines released in 1997 and 2002 reflects a paradigm shift in the overall approach to asthma management. The change in focus addresses the highly variable nature of asthma² and the recognition that asthma severity and asthma control are distinct concepts serving different functions in clinical practice.

Severity and control in 2 domains. Asthma severity—a measure of the intrinsic intensity of the disease process—is ideally assessed before initiating treatment. In contrast, asthma control is monitored over time to guide adjustments to therapy. The guidelines call for assessing severity and control within the domains of:

impairment, based on asthma symptoms (identified by patient or caregiver recall of the past 2-4 weeks), quality of life, and functional limitations; and
risk, of asthma exacerbations, progressive decline in pulmonary function (or reduced lung growth in children), or adverse events. Predictors of increased risk for exacerbations or death include persistent and/or severe airflow obstruction; at least 2 visits to the emergency department or hospitalizations for asthma within the past year; and a history of intubation or admission to intensive care, especially within the past 5 years.

FAST TRACK

Peak expiratory flow testing is not a reliable measure of asthma severity

The specific criteria for determining asthma severity and assessing asthma control are detailed in FIGURES 1 AND 2, respectively. Because treatment affects impairment and risk differently, this dual assessment helps ensure that therapeutic interventions minimize all manifestations of asthma as much as possible.

More steps and age-specific interventions. The EPR-3’s stepwise approach to asthma therapy has gone from 4 steps to 6, and the recommended treatments, as well as the levels of severity and criteria for assessing control that guide them, are now divided into 3 age groups: 0 to 4 years, 5 to 11 years, and ≥12 years (FIGURE 3). The previous guidelines, issued in 2002, divided treatment recommendations into 2 age groups: ≤5 years and >5 years. The EPR-3’s expansion makes it easier for physicians to initiate, individualize, and adjust treatment.

FIGURE 1
Classifying asthma severity and initiating therapy in children, adolescents, and adults

EIB, exercise-induced bronchospasm; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroids; NA, not applicable; OCS, oral corticosteroids; SABA, short-acting β₂-adrenergic agonist.
*Normal FEV₁/FVC values are defined according to age: 8–9 years (85%), 20–39 years (80%), 40–59 years (75%), 60–80 years (70%).
^†For treatment purposes, children with at least 2 exacerbations (eg, requiring urgent, unscheduled care; hospitalization; or intensive care unit admission) or adolescents/adults with at least 2 exacerbations requiring OCS in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.
Adapted from: National Heart, Lung, and Blood Institute (NHLBI).²

FIGURE 2
Assessing asthma control and adjusting therapy

ACQ, Asthma Control Questionnaire; ACT, Asthma Control Test; ATAQ, Asthma Therapy Assessment Questionnaire; EIB, exercise-induced bronchospasm; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; N/A, not applicable; OCS, oral corticosteroids; SABA, short-acting β₂-adrenergic agonist.
*ACQ values of 0.76 to 1.4 are indeterminate regarding well-controlled asthma.
^†For treatment purposes, children with at least 2 exacerbations (eg, requiring urgent, unscheduled care; hospitalization; or intensive care unit admission) or adolescents/adults with at least 2 exacerbations requiring OCS in the past year may be considered the same as patients who have asthma that is not well controlled, even in the absence of impairment levels consistent with that classification.
Adapted from: National Heart, Lung, and Blood Institute (NHLBI).²

FIGURE 3
Stepwise approach for managing asthma

EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting β₂-adrenergic agonist; LTRA, leukotriene receptor antagonist; OCS, oral corticosteroid; PRN, as needed; SABA, short-acting β₂-adrenergic agonist.
Adapted from: National Heart, Lung, and Blood Institute (NHLBI).²