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May 27, 2008

National Asthma Education and Prevention Program Updates Guidelines for Asthma Management




National Asthma Education and Prevention Program Updates Guidelines for Asthma Management
News Author: Laurie Barclay, MDCME Author: Désirée Lie, MD, MSEd
August 30, 2007 — The National Asthma Education and Prevention Program (NAEPP) has issued comprehensive updates to their clinical guidelines for the diagnosis and management of asthma. The Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma — Full Report, 2007, has been posted online by the National Heart, Lung, and Blood Institute (NHLBI).
The revised guidelines, which update the complete asthma guidelines published in 1991 and 1997, as well as the update of selected topics issued in 2002, highlight the importance of asthma control and introduce novel strategies to monitor asthma symptoms. They also feature an expanded section on childhood asthma, including an additional age group,
The US Centers for Disease Control and Prevention (CDC) estimate that US prevalence of asthma is 22 million, including 6.5 million children younger than 18 years, and mortality from asthma exacerbations is estimated at 4000 per year.
"Asthma is one of the most common health problems in the United States — and it can significantly affect patients' lives — at school, at work, at play, and at home," NHLBI Director Elizabeth G. Nabel, MD, said in a news release. "It is essential that asthma patients benefit from the best available scientific evidence, and these guidelines bring such evidence to clinical practice."
Under the aegis of NHLBI, an expert panel of 18 unpaid experts convened by NAEPP conducted a rigorous, systematic review of the published medical literature to incorporate the best available evidence into the updated asthma guidelines.
The new recommendations offer treatment options based on a patient's specific needs and level of asthma control. Because the degree of control can change with time and varies among individuals and by age groups, regular monitoring is essential to optimize treatment.
"The goal of asthma therapy is to control asthma so that patients can live active, full lives while minimizing their risk of asthma exacerbations and other problems," said Expert Panel Chair William W. Busse, MD, from the University of Wisconsin in Madison.
The new guidelines for asthma management focus on 4 main areas: measures to evaluate and monitor asthma control, patient education outside the healthcare provider's office, control of environmental exposures known to trigger or exacerbate asthma symptoms, and pharmacotherapy.
"Overall, these components have stood the test of time, and many of the earlier recommendations have been solidly confirmed by additional research throughout the years," said Busse. "For instance, inhaled corticosteroids are still the best long-term control treatment for asthma patients of all ages because we have even stronger evidence that they are generally safe and are the most effective medication at reducing inflammation, a key component of asthma. Our review of the recent scientific evidence helps us incorporate these four components even more effectively to provide quality asthma care."
Specific recommendations in these 4 areas of asthma management are as follows:
Assessment and Monitoring: Multiple measures of the current level of impairment include frequency and intensity of symptoms, markers of lung function, and limitations of daily activities. Determination of future risk should consider risk for exacerbations, progressive loss of lung function, or adverse effects associated with antiasthma medications. Some patients with good daily functioning when evaluated may still be at high risk for frequent exacerbations, according to the EPR-3.
Patient Education: It is essential to teach patients appropriate skills to self-monitor and manage their asthma. A written asthma action plan is needed for each patient, which should include instructions for daily treatment as well as strategies to detect and manage asthma exacerbations.Unlike previous guidelines, the EPR-3 emphasizes reaching beyond the medical office for educational opportunities, with new settings for teaching to include pharmacies, schools, community centers, and patients' homes. An additional section of the EPR mandates clinician education programs to improve patient communications and to implement system-wide approaches that will incorporate the guidelines into healthcare practice.
Control of Environmental Factors and Other Asthma Triggers: Isolated measures to limit exposure to allergens and other triggers are seldom sufficient, so the EPR-3 reviews recent evidence for using a combination of several strategies.A newly expanded section of the guidelines describes comorbid conditions commonly present in asthma patients. Asthma control is often improved by treating chronic diseases including rhinitis and sinusitis, gastroesophageal reflux, overweight or obesity, obstructive sleep apnea, stress, and/or depression.
Pharmacotherapy: As in previous asthma guidelines, the EPR-3 advocates a stepwise approach to control asthma, increasing medication dosages and types as needed, and decreasing them whenever possible, based on the level of asthma control. The EPR-3 includes revised stepwise asthma management charts that are expanded to guide treatment for 3 age groups: 0 to 4 years, 5 to 11 years, and 12 years or older.Although earlier guidelines combined the 5- to 11-year age group with adults, the EPR-3 added this group because of new data concerning pharmacotherapy in this age group, as well as emerging evidence supporting differences in response to anti-asthma drugs between children and adults.The EPR-3 has updated pharmacotherapy recommendations based on recent efficacy and safety data. As in previous guidelines, the EPR-3 reiterates that patients with persistent asthma, defined as daytime symptoms more than twice weekly or nighttime symptoms more than twice monthly, should have a 2-pronged approach to asthma control. This includes medications to control asthma and prevent exacerbations during the long-term, as well as fast-acting medications to control acute symptoms on an as-needed basis.
For all age groups, the EPR-3 recommends inhaled corticosteroids as the most effective medication for long-term control. New treatment options covered in EPR-3 include leukotriene receptor antagonists and cromolyn for long-term control, long-acting β-agonists as adjunct therapy with inhaled corticosteroids, and omalizumab for severe asthma.
For acute asthma exacerbations, albuterol, levalbuterol, and corticosteroids are recommended. Urgent medical care in the emergency department should include oxygen to relieve hypoxemia; a short-acting β2-agonist (SABA) to relieve airflow obstruction, with inhaled ipratropium bromide added for severe exacerbations; systemic corticosteroids to decrease airway inflammation in moderate or severe exacerbations, or for patients who do not respond promptly and completely to a SABA; and adjunct therapy in some cases, such as intravenous magnesium sulfate or heliox, for patients refractory to the aforementioned measures.
Additional strategies being tested to improve asthma management include new strategies to monitor asthma control by testing sputum and exhaled air and treatment options tailored to patient-specific clinical characteristics and genetic profile makeup.
"Research is beginning to help us identify genes that influence how well certain patients respond to certain asthma medications," said James Kiley, PhD, director of the NHLBI Division of Lung Diseases. "This information is helping us move toward providing personalized treatment for asthma based on a patient's individual characteristics."
To facilitate implementation of the guidelines, NAEPP will release a Summary Report of EPR-3 on October 17 and is developing other tools, partnerships, and an action plan.
The NHLBI funded development of the resource document and the guidelines report. Some Expert Panel members have disclosed various financial relationships with GlaxoSmithKline, Merck, Novartis, Pfizer, Altana, and others. A complete list of disclosures is available in the original document.
National Heart, Lung, and Blood Institute. Published online August 29, 2007.
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
Clinical Context
According to the authors of the current NAEPP guidelines, there are 22 million persons with asthma in the United States including 6.5 million children younger than 18 years, 4000 Americans die from asthma exacerbations each year, and guidelines for the diagnosis and management of asthma have not been updated recently. This is the first comprehensive update of clinical practice guidelines with an expanded section on childhood asthma and an additional age group. The guidelines were developed by an expert panel of the NAEPP using comprehensive searches of the literature, ranking of evidence, and consensus discussion among the panel. The guidelines focus on 4 essential components: assessment and monitoring, patient education, control of factors contributing to asthma severity, and pharmacologic treatment.
The panel defined asthma as a chronic inflammatory disorder of the airways with hyper-responsiveness, airflow limitation, and disease chronicity, with gene expression contributing to the pathophysiology, and viral infections a major cause of exacerbation and development of asthma. The key differences of these guidelines from the 1997 and 2002 panel reports are emphasis on variability of the chronic inflammation, gene-environment interaction, recognition of early childhood risk factors, and the role of anti-inflammatory agents in disease progression.
Study Highlights
Assessment and Monitoring
Multiple measures of current impairment are recommended to assess current and future risk.
Risk assessment includes risk for the disease and of treatment.
During initial presentation, asthma severity should guide clinical decision.
Once therapy is initiated, the assessment of asthma control should guide therapy.
Even patients whose asthma is well controlled must be monitored because responsiveness to therapy is variable.
Patient Education
Patients should be taught to self-monitor and manage asthma and use a written asthma plan.
All members of the healthcare team should be involved and goals of treatment and medications negotiated with key messages reinforced and expanded.
The clinician should develop an active partnership with the patient and family.
Clinicians should maintain knowledge of system-based interventions and information systems to enhance care.
Targeted education in the emergency department and hospital is associated with improved outcomes.
Community pharmacies are a potential resource for point-of-care self-management education.
Home programs for multifaceted allergen control are beneficial but cost-effectiveness should be evaluated.
Computer and Internet education may be incorporated.
Control of Environmental and Other Exacerbating Factors
Single steps to control environmental allergens are insufficient.
Patients with persistent asthma should have potential allergen exposure evaluated.
Formaldehyde and volatile organic compounds are potential allergens.
Patients with asthma of any severity should avoid allergens, cigarette smoke, fireplaces, and strong odors; reduce exertion outdoors when air pollution is high; avoid sulfite-containing foods; and consider allergen immunotherapy.
Allergen immunotherapy should only be offered in a physician's office where a life-threatening reaction can be managed.
Patients with persistent asthma, nasal polyps, or sensitivity to aspirin should avoid aspirin and nonsteroidal anti-inflammatory agents.
Treating comorbid conditions of gastroesophageal reflux, sleep apnea, rhinitis/sinusitis, obesity, and chronic stress/depression is likely to improve asthma symptoms.
Use of humidifiers and swamp coolers is not recommended in homes of patients with asthma sensitive to house-dust mites or mold.
There is insufficient evidence to recommend specific environmental strategies to prevent the onset of asthma.
Influenza vaccine does not reduce the frequency or severity of asthma exacerbations during the flu season.
Medications
The most effective medications are those with anti-inflammatory effects.
Classes for long-term control include corticosteroids, cromolyn sodium and nedocromil, immunomodulators, leukotriene modifiers, and long-acting bronchodilators (LABAs): salmeterol and formoterol.
LABAs should not be used as monotherapy for long-term control.
In adolescents older than 12 years, adults, and children older than 5 years with moderate persistent asthma, LABA is the preferred therapy in combination with inhaled corticosteroids.
LABAs are not recommended for acute exacerbations.
Sustained-release theophylline is an alternative, not a preferred adjunctive therapy with inhaled corticosteroids.
Short-acting bronchodilators (ie, SABAs) are the therapy of choice for acute symptoms and exercise-induced asthma; anticholinergics are an alternative.
Systemic corticosteroids are used as adjunct to SABAs to prevent recurrence and speed recovery.
Pearls for Practice
Risk assessment and asthma control are the cornerstones of management, and patients should self-monitor and manage asthma with support from all healthcare team members.
Treatment of comorbid conditions and allergen avoidance enhance outcomes, and anti-inflammatory agents remain the most effective medication.

Medscape Medical News 2007. ©2007 Medscape

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