Help patients control their asthma

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Applied Evidence

Help patients control their asthma

J Fam Pract. 2013 April;62(4):184-190

By

Jennie Broders, PharmD, BCPS

Krishna Desai, MD

Stephen A. Wilson, MD, MPH, FAA

For most asthma patients, long-term symptom control requires the frequent monitoring and aggressive medication management that family physicians are well positioned to provide.

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References

1. American Academy of Allergy, Asthma, and Immunology. Asthma statistics. Available at: http://www.aaaai.org/about-the-aaaai/newsroom/asthma-statistics.aspx. Accessed March 7, 2012.

2. National Asthma Education and Prevention Program. Expert Panel Report 3: guidelines for diagnosis and management of asthma. J Allergy Clin Immunol. 2007;120(5 suppl):S94-S138.

3. Centers for Disease Control and Prevention. National surveillance for asthma—United States, 1980-2004. MMWR Surveill Summ. 2007;56(8):1-54.

4. Stout JW, Visness CM, Enright P, et al. Classification of asthma severity in children. Arch Pediatr Adolesc Med. 2006;160:844-850.

5. Bacharier LB, Strunk RC, Mauger D, et al. Classifying asthma severity in children. Am J Respir Crit Care Med. 2004;170:426-432.

6. Juniper EF, Guyatt GH, Cox FM, et al. Development and validation of the Mini Asthma Quality of Life Questionnaire. Eur Respir J. 1999;14:32-38.

7. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med. 1999;159:179-187.

8. Miller MR, Hankinson J, Brusasco V, et al. ATS/ERS Task Force. Standardisation of spirometry. Eur Respir J. 2005;26:319-338.

9. Bateman ED, Hurd SS, Barnes PJ, et al. Global Strategy for Asthma Management and Prevention. Eur Respir J. 2008;31:143-178.

10. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD. February 2013. Available at: http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Accessed March 7, 2013.

11. AsthmaMD. Available at: http://www.asthmamd.org/#resources/iphone_chart.jpg. Accessed March 7, 2013.

12. Indiegogo. Huff & Puff. Available at: http://www.indiegogo.com/projects/the-best-asthma-education-app-in-the-world-period. Accessed March 7, 2013.

13. Vimukti Technologies Pvt Ltd. Peak flow calculator. Available at: http://appworld.blackberry.com/webstore/content/7615. Accessed March 7, 2013,

14. Morgan WJ, Crain EF, Gruchalla RS, et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med. 2004;35:1068-1080.

15. Phipatanakul W, Matsui E, Portnoy J, et al. Environmental assessment and exposure reduction of rodents: a practice parameter. Ann Allergy Asthma Immunol. 2012;109:375-387.

16. Nelson HS, Weiss ST, Bleeker ER, et al. The Salmeterol Multicenter Asthma Research Trial. Chest. 2006;129:15-26.

17. Ducharme FM, Ni Chroinin M, Greenstone I, et al. Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma. Cochrane Database Syst Rev. 2010;(4):CD005533.-

18. Papi A, Corradi M, Pigeon-Francisco C, et al. Beclometasone-formoterol as maintenance and reliever treatment in patients with asthma. Lancet Respir Med. 2013;1:23-31.

19. Patel M, Pilcher J, Pritchard A, et al. Efficacy and safety of maintenance and reliever combination budesonide-formoterol inhaler in patients with asthma at risk of severe exacerba-tions. Lancet Respir Med. 2013;1:32-42.

20. Chauhan BF, Ducharme FM. Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children. Cochrane Database Syst Rev. 2012;(5):CD002314.-

21. Ducharme FM. Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma. Cochrane Database Syst Rev. 2004;(1):CD003133.-

22. Ducharme FM, Lasserson TJ, Cates CJ. Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma. Cochrane Database Syst Rev. 2011;(5):CD003137.-

23. Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med. 2010;363:1715-1726.

24. Vandenplas O, Dramaix M, Joos G, et al. The impact of concomitant rhinitis on asthma-related quality of life and asthma control. Allergy. 2010;65:1290-1297.

25. Gibson PG, Henry RL, Coughlan JL. Gastroesophageal reflux treatment for asthma in adults and children. Cochrane Database Syst Rev. 2003;(2):CD001496.-

26. The American Lung Association Asthma Clinical Research Centers. Efficacy of esomeprazole for treatment of poorly controlled asthma. N Engl J Med. 2009;360:1487-1499.

27. Eneli IU, Skybo T, Camargo CA, Jr. Weight loss and asthma. Thorax. 2008;63:671-676.

28. Stenius-Aarniala B, Poussa T, Kvarnstrom J, et al. Immediate and long term effects of weight reduction in obese people with asthma. BMJ. 2000;320:827-832.

29. Sariman N, Levent E, Cubuk R, et al. Bronchial hyperreactivity and airway wall thickening in obstructive sleep apnea patients. Sleep Breath. 2011;15:341-50.

30. Di Marco F, Verga M, Santus P, et al. Close correlation between anxiety, depression, and asthma control. Respir Med. 2010;104:22-28.

PRACTICE RECOMMENDATIONS

• Classify and treat asthma based on the patient’s worst symptom, whether or not it is the symptom that occurs most frequently. C

• Treat patients with poorly controlled asthma aggressively to gain quick control, then scale back slowly to the fewest medications and lowest doses needed to maintain control. A

• Reserve long-acting beta-agonists for use as an adjunct to inhaled corticosteroids for adults with poor baseline pulmonary function tests. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE Angela D, a 34-year-old patient, has asthma with recurrent exacerbations. She uses a low-dose inhaled corticosteroid (ICS) daily and an albuterol inhaler, as needed, for shortness of breath or wheezing. She also has allergic rhinitis, for which she uses nasal fluticasone. Yet despite this regimen, Ms. D reports she still experiences wheezing, chest tightness, and shortness of breath 3 to 4 times a week and is awak-ened by coughing at least twice a week. In the past 6 months, she has had one emergency department (ED) visit and completed 2 courses of oral steroids.

Ms. D has gained weight since her last visit 3 months ago; her body mass index has gone from 27.5 to 29 kg/m². And, while she has always been somewhat anxious, Ms. D notes that her anxiety has gotten progressively worse, as well.

About 25 million Americans—approximately one in 12—suffer from asthma¹ and, despite improvements in asthma guidelines and treatment in the last 20 years,² many still struggle with uncontrolled symptoms.³ The consequences can be severe.

Suboptimal control of asthma is associated with a significant decrease in quality of life, a greater likelihood of absence from work or school, and an increased risk for life-threatening events, trips to the ED, hospital admissions, and death.¹ A multifaceted approach, including regular assessment, aggressive medication management, and attention to comorbidities, is needed to alleviate the suffering of patients with persistent asthma. This evidence-based review can help you provide such broad-based treatment.

Diagnosis and classification go hand in hand

The cornerstones of asthma management are accurate diagnosis and assessment of disease severity, based on both qualitative and quantitative measures. Start with a patient history, eliciting information about symptoms, triggers, risk factors, and most importantly, how often symptoms occur. Classic high-pitched wheezing sounds during exhalation, a cough that often worsens at night, shortness of breath, and chest tightness should raise suspicion for an asthma diagnosis.² But frequency (and timing) of symptoms and exacerbations, as well as changes in the patient’s ability to function normally, help to determine whether asthma is classified as mild intermittent, mild persistent, moderate persistent, or severe persistent (TABLE).²

TABLE
Classifying asthma severity²

Findings	Mild intermittent	Mild persistent	Moderate persistent	Severe persistent
Frequency	≤2/wk	>2/wk, but <1/d	Daily	Continuous
Exacerbations	Rare	<2/wk	≥2/wk	Frequent
Activity level	Normal	May decrease with exacerbation	Frequently limited	Significantly limited
Nighttime symptoms	≤2/mo	>2/mo	>1/wk	Frequent
FEV₁ (or PEF) predicted	>80%	>80%	>60% to <80%	≤60%
PEF variability	<20%	20%-30%	>30%	>30%
FEV₁, forced expiratory volume in one second; PEF, peak expiratory flow.

Because asthma treatment should be based on its classification, an accurate assessment of disease severity is especially important for patients like Ms. D, who have been treated for asthma but continue to have unresolved symptoms. Keep in mind that asthma classification should be based on the worst symptom a patient has, not necessarily the symptom that occurs most frequently. Thus, a patient who has daytime symptoms requiring use of a rescue inhaler 2 to 3 times a week but is awakened at night with shortness of breath 2 times a week would receive a diagnosis of moderate persistent asthma on the basis of the night-time symptoms.

FAST TRACK

When inquiring about compliance with asthma therapy, ask whether the patient can afford the medications that have been prescribed.

In assessing asthma severity, it is also important to ask specifically about recent events, including ED visits, hospitalizations, and intubations. This information, as well as answers to questions about smoking status, mental health problems, quality of life, and treatment compliance—and whether the patient can afford to purchase the asthma medications you’ve prescribed—can be used to assess the likelihood of poor outcomes.²

Factor in spirometry findings
History and physical examination alone cannot adequately diagnose and classify asthma severity.^4,5 Spirometry, a reimbursable office test that can be administered by trained staff members, can be beneficial for any patient older than 5 years for whom a diagnosis of asthma is being considered or disease severity being determined.² Other objective measures, such as the Mini Asthma Quality of Life questionnaire (http://erj.ersjournals.com/content/14/1/32.full.pdf+html) and peak expiratory flow measurement, may be helpful, as well.^2,6

FAST TRACK

Spirometry testing can be beneficial for any patient older than 5 years for whom an asthma diagnosis is being considered.