The main highlights of the 2007 asthma guidelines were presented during the Annual Meeting of the American College of Allergy, Asthma and Immunology (ACAAI) in an attempt not only to increase awareness of the new recommendations, but also to help make sure they get put into practice.
"Asthma is not an event, it is a chronic disease that can be managed so that symptoms are controlled and severe attacks are prevented. The guidelines underscore the fact that people who are diagnosed with asthma do not have to suffer breathing difficulties or cut back on their activities. We want to make this a reality for all asthma patients," said Michael B. Foggs, M.D chief of asthma, allergy and immunology, Advocate Health Care, Chicago.
According to the NAEPP report, under-diagnosis and inadequate treatment are significant contributors to poor asthma control and the worsening of asthma severity. The new guidelines are the first major update in a decade; include the latest information on the best way to manage the chronic disease. Highlights of the guidelines include emphasis on ongoing monitoring and management of asthma, routine use of inhaled corticosteroids as the standard of care for most patients with chronic persistent asthma, distinguishing between managing acute and chronic asthma, and the identification of new risk factors for the disease.
Dr. Foggs said that the guidelines put a new emphasis on the physician-patient partnership and ongoing monitoring and management. Specific recommendations include:
• All asthma patients should be monitored by a doctor every one to six months, regardless of how severe their condition is and whether they are experiencing symptoms.
• Each patient should have a written asthma action plan with instructions for daily treatment and what to do if symptoms become worse. The action plan should be developed by a doctor or nurse, with input from the patient, and shared with all those who interact with the patient such as family members, teachers and coaches.
• Education that takes into account cultural background and literacy should be part of asthma care, and patients should play an active role in managing their condition.
• Asthma treatment based on severity is classified in six steps, rather than four in previous guidelines. A stepwise approach to treatment is still recommended, with medication stepped up or increased when asthma symptoms increase and stepped down, if possible, when asthma is under control.
"When patients and physicians work together to follow these guidelines, asthma symptoms can be prevented and patients can participate in all activities, and not miss days of work or school because of asthma. No one should expect anything less," Dr. Foggs said. Anti-inflammatory medications should be routinely prescribed for long-term control of chronic persistent asthma. "Low to medium dose inhaled corticosteroids are very safe, and remain the first line of treatment for preventing asthma symptoms. Unfortunately, they are not prescribed as often as they should be," said H. William Kelly, PharmD, professor emeritus, department of pediatrics, University of New Mexico Health Sciences, Albuquerque.
"Some people confuse these safe medications with the risky anabolic steroids used by some athletes to improve performance. When used appropriately, corticosteroids are safe and effective in controlling asthma," Dr. Kelly said. Kids between the age group of 5 to 11 have been singled out as a separate category, based on research suggesting they may respond somewhat differently to medications than adults. For many kids in this age group, disease control usually can be maintained with a low daily dose of an inhaled corticosteroid, rather than combination treatments, such as long acting beta agonists, needed by many adults. Other age groups in the new guidelines are children up to 4 years old and ages 12 to adult.
The guidelines insist that patients must take their controller medications even when they do not have symptoms, and should be taught how to use inhalers properly so the medication reaches their lungs. According to Carlos Camargo, M.D., DrPH, Massachusetts General Hospital, Harvard Medical School, Boston, the guidelines also emphasize the distinction between acute and chronic asthma management.
"The new guidelines modify the spirometry cut points used to assign the severity of an asthma exacerbation, or flare-up," Dr. Camargo said. Spirometry is a test that measures lung function. "The guidelines also encourage increased use of 'quick relief' medications such as albuterol and oral corticosteroids in the pre-hospital setting, and consideration of adjunctive treatments in severe exacerbations. The guidelines also recommend that emergency physicians and other acute care providers consider prescribing inhaled corticosteroids before patients are discharged from the hospital," he said.
"According to one study, exposure to new surface materials such as linoleum flooring, synthetic carpeting, particle board, wall coverings and furniture, and recent painting significantly increased the risk of asthma in children," Dr. Nelson said. Other risk factors identified in the past include allergy to pollen, molds, animal danders and house dust mites, some occupational exposures, and exposure to tobacco smoke and to certain types of air pollution.
The guidelines insist the importance of specialty care when early treatment by primary care physicians is not sufficient to control asthma symptoms. For example, referral to a specialist is recommended for most patients who have tried the first three steps for asthma treatment, and have not improved. It also should be considered for those who have completed the first two treatment levels without improvement. Patients who have had a life-threatening asthma attack and those whose disease is not well-controlled after three to six months of therapy also should be referred to a specialist.
The guidelines also recommend that immunotherapy - or allergy vaccinations - be considered for patients with persistent allergic asthma. ACAAI is developing materials for patients and health care professionals about the new guidelines and asthma treatment.