Aligning Patient Care and Asthma Treatment Guidelines

This article describes how the National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma can be used in the clinical setting to improve a patient’s everyday function and quality of life. Major ecommendations are detailed and case studies provide a practical approach for patient management.

(Am J Manag Care. 2005;11:S416-S421)In 2002, it was reported that 72 of 1000 Americans (20 million) had asthma. Children were most affected: 83 of 1000 children aged 17 years or younger (6 million) had asthma compared with 68 of 1000 adults aged 18 years or older (14 million).¹ Asthma attack prevalence (ie, the number of people who had at least 1 severe exacerbation within the past 12 months) is a simple indicator of how many people have uncontrolled asthma and are at risk for a negative clinical outcome, such as hospitalization or death. Data show that in 2002, 12 million people (60% of those with asthma at the time of the survey) suffered an asthma attack in the preceding year.

The guidelines include the following basic recommendations⁵:

- Diagnose asthma and draw up an action plan that actively involves the patient

- Reduce inflammation, symptoms, and exacerbations

- Monitor and manage asthma over time with pharmacotherapy

- Treat asthma episodes promptly

1. Measures of Assessment and Monitoring. Although there are no tests considered to be the “gold standard†for diagnosing asthma, one can be established if a history of airflow obstruction exists (eg, wheezing, chest tightness) and if the obstruction is at least partially reversible.⁵ The use of spirometry to perform pulmonary function tests is a valuable tool in evaluating a patient's degree of airway obstruction. However, other potential etiologies must be ruled out, such as the presence of foreign bodies and of other lung diseases, such as chronic obstructive pulmonary disease and gastroesophageal reflux disease. After a diagnosis, the first step of treatment is to set up a written action plan for managing asthma that specifies treatment goals. These goals must be determined and agreed on by both the clinician and the patient. For example, the patient's goal may be to play sports without experiencing lung problems or to sleep through the night without having difficulty breathing. The clinician will educate the patient about allergen avoidance and medication use to help the patient realize the goals. A written action plan can provide guidance on treating the patient's asthma and is a document to which patients can refer as they become more involved in their therapy.

2. Control of Factors Contributing to Asthma Severity. The NAEPP guidelines state that anti-inflammatory medications should be prescribed to all patients with mild, moderate, or severe persistent asthma.⁵ As mentioned earlier, the ICSs are the most potent inhaled anti-inflammatory medications currently available to manage persistent asthma.⁵ Identifying allergens and irritants that can trigger exacerbations and advising patients to avoid them can also help reduce asthma symptoms.⁵ Written and verbal instructions should be provided to the patient on how to avoid or reduce factors that can trigger or exacerbate breathing problems.

3. Pharmacologic Therapy. It is important that patients take an active role in managing their asthma. The clinician should teach the patient how to monitor symptoms (eg, to be aware if nighttime symptoms are increasing or if wheezing is on the rise). Patients with moderate-to-severe persistent asthma should learn to monitor their peak flow.⁵

Depending on the level of symptom control, patients should visit their physician at least every 1 to 6 months to assess treatment goals, address any concerns about medications or lifestyle modifications, review the action plan, and check inhaler and peak flow techniques.

4. Patient Education for a Partnership in Asthma Care. Effective control of an asthma exacerbation begins with an immediate response to the onset of episodic symptoms.

A short-acting, beta2-agonist should be immediately administered in most cases of asthma, whereas an oral steroid for 3 to 10 days is more appropriate in cases of severe asthma exacerbations. Equally important is prompt and consistent communicationbetween the patient and physician.⁵

The Stepwise Approach to Therapy The NAEPP guidelines stress the importance of stepwise therapy, which is increasing the dosage and number of medications as necessary to maintain control of asthma, and decreasing them when possible.⁶ The stepwise approach to therapy is summarized in Figure 1. The approach to stepwise therapy is as follows and includes a number of key objectives⁶:

- Asthma severity dictates the amount and frequency of medication - There are 2 acceptable approaches to treatment

1. Start medication at a level higher than the patient's onset severity level to establish prompt control; it should then be stepped down to the minimum medication necessary to control symptoms.

- Patients should be monitored continually to ensure adequate control

The next 2 case studies illustrate the stepwise approach to managing patients with asthma.

Case Study: Patient 1.⁷

- Presently at Step 2 (mild persistent asthma)

- Preferred treatment:

- Alternative treatments (listed alphabetically):

– Leukotriene modifier

This patient is currently experiencing worsening symptoms and has been classified as Step 3 (moderate persistent asthma). Symptoms are now daily, with more than 1 night per week. The preferred treatment is a low-dose ICS plus a long-acting inhaled beta2-agonist, or a medium-dose ICS alone. An alternative treatment would be a low-dose ICS plus either a leukotriene modifier or theophylline.

Case Study: Patient 2.7 - Female, aged 21 years

– Symptoms >2 times/week but <1 time/day; >2 nights/month; peak expiratory flow variability >30%

- Preferred treatment: – Low-dose ICS

– Cromolyn or nedocromil

– Sustained-release theophylline (serum concentration 5-15 µg/mL)

This patient is now experiencing a remission in her symptoms and is in Step 1 (mild intermittent asthma). Her symptoms now occur 2 days per week or less and 2 nights per month or less. The preferred treatment for this patient is no daily medication.⁶ Because severe exacerbations may occur periodically, it is recommended that the patient be supplied with a prescription for a course of oral corticosteroids. For quick relief, she should use an inhaled, short-acting beta2-agonist as needed for symptoms. The patient should be monitored for increased use of the inhaler (>2 times/week), because this is generally a sign of exacerbation.

The 2002 Guidelines Update The most recent (2002) update of the NAEPP guidelines focuses on medications (long-term management of asthma in children; combination therapy and antibiotic use), monitoring (written action plans compared with medical management alone; symptom-based vs peak flow—based action plans), and prevention (effects of early treatment on asthma progression).

The guidelines suggest that long-term management of asthma in children can be enhanced with use of ICSs.⁸ Clinical trials in children provide strong evidence that ICSs, when taken as needed, improve asthma control compared with beta2-agonists, as well as limited evidence when compared with cromolyn, nedocromil, theophylline, and leukotriene modifiers. Furthermore, therapy should be initiated in infants and young children if more than 3 episodes of wheezing have occurred in the past year lasting more than 1 day and affecting sleep, especially if risk factors exist (eg, family history of asthma, allergic rhinitis, atopic dermatitis). Long-term therapy should also be started if symptomatic treatment is needed more than twice per week or severe exacerbations are less than 6 weeks apart.⁸

The use of antibiotics in combination with standard care for asthma exacerbations has been questioned. Clinical trials show no benefit from routine antibiotic therapy for asthma exacerbations. According to the 2002 NAEPP guidelines update: “Antibiotics are not recommended for the treatment of acute asthma exacerbations, except as needed for comorbid conditions (eg, for those patients with fever and purulent sputum, evidence of pneumonia, or suspected bacterial sinusitis).”⁸

A written action plan can be an integral part of improving patient outcomes. A review of 25 studies showed that the selfmanagement interventions associated with written action plans reduced ED visits, decreased hospitalizations, and improved lung function (Figure 2).⁹ Only 42% of patients had written action plans for self-management of asthma exacerbations. According to the 2002 NAEPP guidelines update: “The use of written action plans as part of an overall effort to educate patients in self-management is recommended, especially for patients with moderate or severe persistent asthma and patients with a history of severe exacerbations.”⁷

Patient monitoring is also crucial for improving patient outcomes, whether it is peak flow—based or symptom-based.⁸ Evidence is not sufficiently strong to mandate either type of action plan for improving symptoms or lung function. Patient preferences and circumstances (eg, the inability to recognize or report signs and symptoms of worsening asthma) may warrant choosing peak flow monitoring. The 2002 NAEPP guidelines update states that peak flow monitoring in patients with moderate or severe persistent asthma can “enhance clinicianpatient communication and may increase patient and caregiver awareness of the disease status and control.”⁷

Asthma and PregnancyIn 2005, the NAEPP issued updated asthma treatment guidelines for use during pregnancy. ¹⁰ The report recognized that inadequate asthma control poses a risk to both mother and fetus. Because most asthma medications are safe to use during pregnancy, it is safer to use asthma medications than to suffer asthmatic symptoms and exacerbations. Also, obstetric care providers should be included in the patient's asthma management team so the patient's asthma care plan can be adjusted as needed to ensure a healthier pregnancy.

Summary The NAEPP guidelines suggest a systematic course of action to best manage asthma patients based on expert opinion while using the most current information available. The guidelines cover all aspects of asthma management from diagnosis and medication use, to environmental issues and monitoring. Using these guidelines in the practice setting can potentially make the difference between a patient who is functionally limited to one who is active and enjoying a good quality of life.

Address correspondence to: Eric Cannon, PharmD, Director, Pharmacy Services and Health and Wellness, IHC Health Plans, 4646 West Lake Park Blvd, Salt Lake City, UT 84120; e-mail: eric.cannon@ihc.com

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