Help patients gain better asthma control

,

Applied Evidence

Help patients gain better asthma control

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

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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.

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FAST TRACK

Spirometry testing, which is underused in family practice, often leads to adjustments in asthma therapy

Children 5 to 11 years of age

For Step 3 therapy, the guidelines recommend either low-dose ICS plus a LABA, leukotriene receptor antagonist (LTRA), or theophylline; or medium-dose ICS (Evidence: B). Treatment decisions at Step 3 depend on whether impairment or risk is the chief concern, as well as on safety considerations.
For Steps 4 and 5, ICS (medium dose for Step 5 and high dose for Step 6) plus a LABA is preferred, based on studies of patients ≥12 years of age (Evidence: B). Step 6 builds on Step 5, adding an OCS to the LABA/ICS combination (Evidence: D).
If theophylline is prescribed—a viable option if cost and adherence to inhaled medications are key concerns—serum levels must be closely monitored because of the risk of toxicity.
Closely monitor and be prepared to identify and respond to anaphylaxis in a child at Step 2, 3, or 4 who is receiving allergen immunotherapy.

Adolescents ≥12 years of age and adults

There are 2 preferred Step 3 treatments: Low-dose ICS plus a LABA, or medium-dose ICS. The combination therapy has shown greater improvement in impairment^24,25 and risk^24-26 compared with the higher dose of ICS.
Preferred treatments at Steps 4, 5, and 6 are the same as those for children ages 5 to 11 years, with one exception: Subcutaneous anti-IgE therapy (omalizumab) may be added to the regimen at Steps 5 and 6 for adolescents and adults with severe persistent allergic asthma to reduce the risk of exacerbations.²⁷

FAST TRACK

If a step down is in order, reduce ICS dosing gradually, at a rate of about 25% to 50% every 3 months

Weigh the benefits and risks of therapy

Safety is a key consideration for all asthma patients. Carefully weigh the benefits and risks of therapy, including the rare but potential risk of life-threatening or fatal exacerbations with daily LABA therapy²⁸ and systemic effects with higher doses of ICS.²³ Patients who begin receiving oral corticosteroids require close monitoring, regardless of age.

Regular reassessment and monitoring are critical

FAST TRACK

For a list of asthma education resources, see Table W1 online at www.jfponline.com

Schedule visits at 2- to 6-week intervals for those who are starting therapy or require a step up to achieve or regain asthma control. After control is achieved, reassess at least every 1 to 6 months. Measures of asthma control are the same as those used to assess severity, with the addition of validated multidimensional questionnaires (eg, Asthma Control Test [ACT])²⁹ to gauge impairment.

JJ’s physician scheduled a follow-up visit in 4 weeks, at which time he did a reassessment based on a physical exam and symptom recall. Finding JJ’s asthma to be well controlled, the physician asked the boy’s mother to bring him back to the office in 2 months, or earlier if symptoms recurred.

TABLE W1
Asthma education resources

Allergy & Asthma Network Mothers of Asthmatics 2751 Prosperity Avenue, Suite 150 Fairfax, VA 22030 www.breatherville.org (800) 878-4403 or (703) 641-9595	Asthma and Allergy Foundation of America 1233 20th Street, NW, Suite 402 Washington, DC 20036 www.aafa.org (800) 727-8462
American Academy of Allergy, Asthma, and Immunology 555 East Wells Street, Suite 1100 Milwaukee, WI 53202-3823 www.aaaai.org (414) 272-6071	Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 www.cdc.gov (800) 311-3435
American Association for Respiratory Care 9125 North macArthur boulevard, Suite 100 Irving, TX 75063 www.aarc.org (972) 243-2272	Food Allergy & Anaphylaxis Network 11781 lee Jackson Highway, Suite 160 Fairfax, VA 22033 www.foodallergy.org (800) 929-4040
American College of Allergy, Asthma, and Immunology 85 West Algonquin road, Suite 550 Arlington Heights, IL 60005 www.acaai.org (800) 842-7777 or (847) 427-1200	National Heart, Lung, and Blood Institute Information Center P.O. Box 30105 Bethesda, MD 20824-0105 www.nhlbi.nih.gov (301) 592-8573
American Lung Association 61 Broadway New York, NY 10006 www.lungusa.org (800) 586-4872	National Jewish Medical and Research Center (Lung Line) 1400 Jackson Street Denver, CO 80206 www.njc.org (800) 222-lUNG
Association of Asthma Educators 1215 Anthony Avenue Columbia, SC 29201 www.asthmaeducators.org (888) 988-7747	US Environmental Protection Agency National Center for Environmental Publications P.O. Box 42419 Cincinnati, OH 45242-0419 www.airnow.gov (800) 490-9198

Does your patient require a step down or step up?

A step down is recommended for patients whose asthma is well controlled for 3 months or more. Reduce the dose of ICS gradually, about 25% to 50% every 3 months, because deterioration in asthma control is highly variable. Review adherence and medication administration technique with patients whose asthma is not well controlled, and consider a step up in treatment. If an alternative treatment is used but does not result in an adequate response, it should be discontinued and the preferred treatment used before stepping up. Refer patients to an asthma specialist if their asthma does not respond to these adjustments.