Physician's Weekly Article - Updating Current Comprehensive Asthma Guidelines

       A long-awaited update of new national asthma guidelines has been unveiled, providing important approaches for monitoring asthma control and treating the condition in all sufferers.

      The National Asthma Education and Prevention Program (NAEPP) has released a comprehensive update on the diagnosis and management of asthma. The Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma, developed under the leadership of William W. Busse, MD, and colleagues, assessed four essential components of asthma care, including assessment and monitoring, patient education, control of factors contributing to asthma severity, and pharmacologic treatment. “Asthma is a common disease with significant variability in treatment,” says Dr. Busse. “The purpose of the NAEPP update is to provide a more uniform guideline to manage patients with asthma. Although asthma can be controlled, the condition can change over time and differs among individuals and age groups. Our goal is to maintain asthma control and provide patients with treatments that allow them to lead a normal life.”

      Assess Severity & Establishing Asthma Control

      The EPR-3 guidelines build on the comprehensive asthma recommendations issued in 1991 and 1997. In the original report, a classification system was established to define asthma severity based on several factors, including symptom frequency, activity limitations, need for rescue therapy, and lung function values. The intensity of initial treatment relied on the severity of the patient’s asthma (Table 1). “Although this was a reasonable approach to guiding asthma treatment,” Dr. Busse explains, “our new update includes another variable to consider in that equation—the patient’s response to therapy. Patients who initially present with severe symptoms may respond quickly to a conservative treatment. As a result, they may not, in fact, have severe asthma and should not be classified as such. A new phase of these guidelines is to emphasize the importance of asthma control and evaluate both current impairment and future risk.”

      The updated NAEPP guidelines identify two domains for asthma severity and control that need to be assessed and monitored: 1) current impairment, and 2) future risk (Table 2). According to Dr. Busse, current impairments in asthma include components of the disease that present during a patient’s visit, such as lung function, rescue medication use, and activity limitations; treatment of these components aims to minimize the effect of each. “On the other hand,” Dr. Busse notes, “future risk factors may indicate the likelihood that an individual will ultimately have an attack of asthma. These may not be apparent by evaluating current impairment. Furthermore, there is new evidence to suggest that some patients with asthma may have a progressive loss of lung function over a period of time. The data we now have emphasize the need to assess future risk. Although effective therapies to prevent this occurrence are not yet available, the possibility should be recognized and documented.”

      Recognize That Asthma is a Heterogeneous Disease

      The EPR-3 guidelines also expanded the previous section on childhood asthma and included an additional age group in the stepwise management charts. “The heterogeneity of the disease is reflected in many aspects of management,” says Dr. Busse, “and is most dramatically seen when looking at the different age brackets. A child with asthma up to and including the age of 5 often exhibits complexities not necessarily seen among older children or adults. Symptoms and measurements of lung function may be more difficult to identify in this age group of patients because they’re unable to communicate their symptoms as well as adolescents or adults. In addition, we now have evidence to suggest that response to the medications that we’re using in the adult population may be somewhat different than that of children younger than 5 years of age.”

      According to Dr. Busse, combination therapy is an example of treatment to which children respond differently than adults. “In adults, the use of long-acting beta-agonists and inhaled corticosteroids is highly efficacious, and the combination of the long-acting beta-agonists with inhaled corticosteroids is associated with further added benefits,” he says. “But we’re not seeing this consistently in children under the age of 5. An important emphasis of the updated NAEPP guidelines in this area is that children in this age range are not young adults; they have a very different disease process.”

      Use Patient-Focused Asthma Strategies

      In order to achieve optimal asthma control, the updated guidelines recommend using a patient-driven approach. According to Dr. Busse, patients with asthma are primarily concerned about their quality of life and the prevention of exacerbations. “We can measure quality of life by obtaining and evaluating current impairments and making efforts to prevent them from having an asthma exacerbation,” he says. “We’re now placing a stronger emphasis on meeting the needs of patients. For the vast majority of people with asthma, the treatments available are highly efficacious and safe. By being appropriately aggressive when necessary, physicians can maintain disease control, improve lifestyles, and reduce limitations for asthma sufferers.”

      Dr. Busse has indicated to Physician’s Weekly that s/he has or has had no financial interests to report.