Vol. 11 •Issue 7 • Page 48
Breathing New Air into Asthma Care
Updates Bolster 1997 NAEPP Guidelines
The National Asthma Education and Prevention Program issued an update on several topics covered in the “Guidelines for the Diagnosis and Management of Asthma,” first published in 1991 and revised in 1997.
The NAEPP, coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health, convened an expert panel of 11 members, including representatives from allergy and immunology, family practice, internal medicine, pediatrics, pharmacology, public health and pulmonary medicine. The NAEPP focused on reviewing selected topics, based on the level of activity in the scientific literature or concern in clinical practice. This approach to updating the guidelines is different from a wholesale revision of the entire guidelines.
Because the number of Americans suffering with asthma continues to rise, “it is essential that they are treated according to the best available scientific evidence, and this update brings such evidence into clinical practice,” stated NHLBI director Claude Lenfant, MD, in an NIH news release.
The updated guidelines covered several areas with regard to the management of asthma:
• listed long-acting beta2-agonists, in combination with inhaled corticosteroids, as the most effective therapy for people with moderate or severe asthma
• suggested considering initiation of long-term control therapy in a broader group of infants and young children
• positioned leukotriene modifiers as an alternative, but not preferred, treatment for mild asthma or as add-on treatment combined with low-to-medium doses of inhaled corticosteroids for moderate persistent asthma
• recommended adding long-acting beta2-agonists or leukotriene antagonists to doses of inhaled corticosteroids rather than increasing the dose of inhaled corticosteroid
• maintained that antibiotics are not recommended for treating acute asthma exacerbations, except when needed for comorbid conditions, such as sinusitis and pneumonia
• acknowledged that the evidence is insufficient to either refute or support the benefits of written action plans compared to medical management alone, and therefore continued the recommendation in favor of written action plans when given as part of a broader effort to educate patients in self-management
• upheld that clinicians should consider peak flow monitoring for patients with moderate or severe persistent asthma or patients who experience severe exacerbations
• stated that in terms of prevention, treatment provides control for asthmatic children ages 5 to 12, but does not appear to modify the .underlying disease in this group.
One of the most significant changes to the guidelines is the recommendation that physicians should add other agents to inhaled corticosteroids, such as long-acting beta2-agonists and leukotriene modifiers, rather than just increase the dose of inhaled steroid from medium-to-high dose, said expert panel member Gail G. Shapiro, MD, clinical professor at the University of Washington School of Medicine in Seattle.
“Leukotriene modifiers were so new back in 1997 that not much was said about them in the guidelines,” Dr. Shapiro said. “Now the guidelines mention leukotriene modifiers in a more positive light than they did in the past.” Information from research compiled after the 1997 guidelines were released shows leukotriene receptor antagonists can be clinically effective and safe.
Robert F. Lemanske Jr., MD, professor of pediatrics and medicine at the University of Wisconsin Medical School in Madison, added that the use of leukotriene receptor antagonists could be very helpful for patients with mild asthma. “They may be controlled very effectively with this form of therapy,” he said.
Other welcome news from the updated guidelines is the safety of inhaled corticosteroids for children.
“We have learned a lot about the effectiveness and safety of inhaled steroids in the past few years,” said William Busse, MD, professor of medicine in the allergy and immunology department of the University of Wisconsin Medical School and chair of the NAEPP expert panel.
Recent studies indicate low-to-medium doses of inhaled corticosteroids have no adverse effects on bone mineral density in children and no significant effects on the incidence of cataracts or glaucoma, according to the update report.
“As a pediatrician, the data we have been able to accumulate with regards to adverse effects, particularly with reference to growth effects, is very reassuring. This type of treatment used at recommended doses is very safe and also very effective,” Dr. Lemanske said.
While clinicians knew steroids were an effective asthma treatment, they couldn’t reach any type of closure about steroids’ effect on growth when the 1997 Guidelines were published because of a lack of sufficient evidence. Research now shows that children who have mild or moderate asthma and who take inhaled corticosteroids at recommended doses may experience slight decrease in growth rate within the first three to six months of use. Yet this appears to be temporary, and growth rates return to normal. By the time these children reach adolescence, they attain their predicted adult heights, Dr. Lemanske said.
Research for treating children under the age of 5 years is a high priority for the NHLBI because “the data in children under age 5 is almost nonexistent,” Dr. Kiley said.
Previous recommendations for starting long-term control therapy advised therapy begin in infants and young children who require symptomatic treatment more than twice a week or who experience severe exacerbations less than six weeks apart. The recent updates add that such therapy should be considered also in children who have had more than three wheezing episodes in the past year that last more than one day and affect sleep, and in those who have risk factors for developing asthma.
Pediatric patients were the focus of another revision, one that deals with the effects of early treatment on the progression of asthma. A recent large, randomized controlled clinical trial involving children ages 5 to 12 with mild or moderate persistent asthma showed that symptoms and airway hyperresponsiveness returned when treatment was discontinued. The results suggest that treatment for this age group provides control but doesn’t modify the underlying disease process.
However, evidence from epidemiologic studies demonstrates that children with asthma have declines in lung function before age 5. This suggests that treating children after age 5 may be too late to prevent lung function declines. Thus, clinical trials are under way, including the Childhood Asthma Research and Education (CARE) network, a research group supported by the NHLBI, to investigate early intervention with inhaled steroids in very young children. This study will hopefully answer some questions as to whether early treatment can prevent the progression of asthma in young children.
In addition to treatment, the updates focused on monitoring asthma. The panel reaffirmed the concept of having a written management plan for an asthma patient to spell out exactly what the treatment plan is. This will help them refer to pertinent written information rather than the memory of what their health care provider explained to them.
“Even though there is not a lot of hard .evidence-based material that shows a written plan vs. no written plan makes a difference, it was the consensus of the panel that it makes sense,” Dr. Shapiro said.
The panel also maintained that peak flow monitoring might be valuable to patients with moderate or severe asthma. The rationale is that patients who are aware of changes in their asthma symptoms might be able to head off exacerbations.
The evidence reviewed showed that although peak flow monitoring doesn’t appear to be superior to symptom monitoring, it showed the benefits are equivalent. Peak flow monitoring may be especially appropriate for people who have difficulty perceiving — or reporting — symptoms indicative of worsening asthma.
While all asthmatics can benefit from monitoring their symptoms, information in this area was insufficient to broaden the 1997 NAEPP guidelines’ recommendation to also consider peak flow monitoring for patients with mild asthma, Dr. Shapiro said.
A science-based committee of the NAEPP reviews and evaluates new research conducted continuously. As the committee identifies various areas that they feel need attention, they will recommend a systematic review of the literature on selected topics.
In the meantime, the NHLBI encourages applications for studies where asthma research is lacking, Dr. Kiley said.
Diehl is a free-lance writer in Gettysburg, Pa.