SAN FRANCISCO The way physicians treat asthma lags behind current scientific knowledge and recommendations. This failing is reflected in one statistic: of the estimated $3.6 billion spent each year on asthma care, 43% is used for emergency treatment and hospitalization.
To bring physicians up to date, a panel of experts released new guidelines for the diagnosis and management of asthma. The new guidelines emphasize the need for anti-inflammatories and self-monitoring.
The "Report of the Second Expert Panel on the Guidelines for the Diagnosis and Management of Asthma" did not re-invent the wheel, rather it expanded and updated the existing guidelines, which were released in 1991, according to panelist Shirley Murphy, MD, professor and chair of the department of pediatrics at the University of New Mexico School of Medicine in Albuquerque.
"It has been six years since the first national asthma guidelines were released, and asthma still is a major health problem in the United States," said Murphy during a press conference at the joint meeting of the American Academy of Allergy, Asthma and Immunology. "Asthma is being underdiagnosed, and it is being undertreated. It is now time that medical professionals in the United States take asthma seriously and treat this disease aggressively."
Among the new features and recommendations are:
"The updated guidelines cover a number of issues that I think are important for the community at large. We re-emphasize the importance that this is a chronic disease of the airway in which airway inflammation is the principal factor in the cause of disease chronicity," said William Busse, MD, professor of medicine, medicine/allergy and immunology department at the University of Wisconsin, Madison.
"Furthermore, we use this scientific-based evidence to give us a rational and reasonable stepwise approach to the treatment of asthma and we have introduced discussion of some of the newer medications available and how they should be used most effectively," added Busse, who was a member of the panel that drafted the report.
The new guidelines reflect the increase in the scientific knowledge about diagnosing and treating asthma. For example, the new report continues to advocate a step-wise approach to pharmacological therapy, but based on the enhanced understanding of inflammation and its contribution to abnormalities in lung function, the report emphasizes that persistent asthma is a chronic disease that should be controlled with daily anti-inflammatory medications.
--- Taking control of asthma involves long-term treatment, quick relief options and patient education.
Medications are now categorized into two general classes: long-term control medications, used to achieve and maintain control of persistent asthma, and quick-relief medications, used to treat acute symptoms and attacks.
"These classifications really reflect how we use the medication, not necessarily what the mechanism of action is," Busse explained. "I think it is helpful for physicians to view the medications in this fashion, and I think it is also helpful for patients with asthma to have an idea of what to expect from the medications."
"Under long-term control, we are talking about inhaled corticosteroids and long-acting inhaled beta-agonist. For acute relief we are talking about short-acting inhaled beta-agonist. I think that this is an advance in the understanding of why and how we are using these medications" Busse said.
The pharmacotherapy portion of the report also considers the new class of medications called leukotriene modifiers, such as zafirlukast (Accolate, Zeneca Pharmaceuticals). These medications appear to provide long-term control in mild persistent asthma, improve lung function and prevent the need for short-acting beta-agonists. However, their optimal role in asthma management needs to be ascertained.
The report also establishes more relevant classifications for asthma severity and links its pharmacologic recommendations to the severity of each patient's asthma. The new classifications are mild intermittent, mild persistent, moderate persistent and severe persistent; the classifications are based on a patient's symptoms.
The new report confirms the close relationship between allergy and asthma in most asthma patients and the importance of reducing exposures to perennial indoor and outdoor allergens. The report recommends that allergy tests be used to identify relative sensitivity to indoor allergens for asthma patients with perennial symptoms. In addition, the report includes recommendations for controlling other factors that can increase asthma symptoms, such as rhinitis and gastroesophageal reflux.
The report also makes the point that asthma onset may be prevented by reducing exposure to allergens and tobacco smoke. "The data continue to accumulate that exposure of children to tobacco smoke increases the prevalence of asthma in children. In those that do have asthma, the severity is increased by exposure to passive smoke," said Harold S. Nelson, MD, senior staff physician, department of medicine at the National Jewish Medical and Research Center in Denver. Nelson was also a member of the expert panel.
Undertreatment of asthma in young children is a problem, the report says, and includes a new section on asthma in infants and young children, which incorporates recent studies of wheezing in early childhood and of asthma risk factors.
--- Once the severity of a patient's asthma is classified, treatment can be tailored for optimal effect.
The signs of asthma vary widely from patient to patient, as well as within each patient over time, which can complicate both diagnosis and management. The new report establishes clear criteria and mechanisms for an asthma diagnosis and strongly recommends that spirometry, which measures lung function, be used in an initial diagnostic work-up.
"Another important component of the guidelines is measuring lung function. Primary care physicians must have access to spirometry to measure lung function," said panel chair Murphy.
In addition, patients should be given peak flow meters and told how to measure their peak flows. Patients should have several treatment plans: a maintenance plan, as well as an emergency treatment plan. "Just as a diabetic checks glucose every day, an asthmatic with moderate or severe asthma should monitor their peak flows and know how their lungs are functioning at home," Murphy said.
"Patients must be taught to understand their asthma; they also need to know how to recognize symptom patterns indicating that their asthma is getting out of control. This is how we can prevent emergency room visits and hospitalizations by patients having action plans to use at home.
"Patients are being encouraged to learn their own symptom patterns so they know when their asthma deteriorates. They should have two plans at home: a daily medication plan that says what medication, how much and when they take every day and a rescue plan or a written action plan that tells them how to reverse their asthma or rescue themselves when their asthma worsens. And this is how we can prevent health care utilization of emergency rooms and hospitalizations," she said.
Murphy added that patient education is the cornerstone of the guidelines and that education has to be started when the condition is diagnosed. This education should include an explanation of the condition, demonstrations on how to use inhalers and peak flow meters, and written treatment plans. These issues should be re-visited every time a patient is seen.
"We believe that these new guidelines with their emphasis on guided self-management and on the clinician and the patient working in a partnership will be the bridge to future of better asthma control," Murphy said.
You can express your views on this article, or other relevant themes, in the Infectious Diseases in Children Specialty Forums.