Updated National Asthma Guidelines Focus on Long-Term Disease Control

Key Point

Guidelines issued by the National Asthma Education and Prevention Program focus on monitoring, patient education, control of environmental factors, and medication use.

Asthma control, approaches for monitoring asthma, and patient education are among the topics revisited by the National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute (NHLBI) in the Expert Panel Report 3 (EPR-3)—the first comprehensive update of their guidelines in 10 years.

James P. Kiley, PhD, MS, told Pulmonary Reviews, “The NAEPP’s Science Base Committee, which routinely monitors the scientific literature, decided that the volume of research over the last 10 years and the findings from several significant clinical trials warranted convening an Expert Panel to conduct a thorough review and update. Guidelines with specific recommendations for diagnosis and management are the best way to assure that the latest scientific evidence is translated into practice.” The 2007 EPR-3 is intended to assist patient and clinician decision making for asthma and be a source for the development of clinical practice tools and patient educational materials.

“With appropriate medical care and healthy environments, well-informed and empowered patients can control their asthma and live full, active lives,” noted Dr. Kiley, who is Director of the Division of Lung Diseases at the NHLBI at the National Institutes of Health in Bethesda, Maryland. “Our goal is to help clinicians use this information to reduce illness and death from asthma and to improve the quality of life of those who have this disease.”

LONG-TERM ASTHMA CONTROL

As defined by the EPR-3 guidelines, the goal of asthma therapy is to attain control by reducing impairment and reducing risk. “The distinction between the domains of impairment and risk for assessing asthma control and guiding decisions for therapy emphasizes the need to consider separately asthma’s effects on quality of life and functional capacity on an ongoing basis (ie, in the present) and the risks it presents for adverse events in the future, such as exacerbations and progressive reduction in lung growth or lung function,” the Expert Panel stated.

Reducing impairment entails prevention of chronic daytime, nighttime, or exercise-induced symptoms, such as coughing and breathlessness; reduction in use of medications for quick relief of acute symptoms; maintenance of normal or near normal pulmonary function and normal activity levels; and meeting patients’ and families’ expectations of satisfactory asthma care. Reducing risk includes the prevention of exacerbations, the prevention of progressive lung function loss, and the provision of optimal pharmacotherapy with minimal or no adverse effects.

MONITORING AND FOLLOW-UP

The guidelines recommend a stepwise approach to disease management. “The guidelines have expanded the stepwise approach from four to six treatment steps in order to simplify the actions recommended in each step,” Dr. Kiley explained. “The recommendations on specific medication options for each step have been updated to reflect the latest evidence on effectiveness and safety.”

According to the EPR-3, the severity of a patient’s asthma should dictate which treatment is initiated. Subsequently, the patient should be monitored at two- to six-week intervals until disease control is achieved. Through use of a stepwise approach, adjustment of therapy should be based on the patient’s asthma control, as assessed by follow-up visits every one to six months, the guideline authors stressed.

“The stepwise asthma management charts are revised and expanded to specify treatment for three age-groups: 0 to 4 years, 5 to 11 years, and 12 years and older,” Dr. Kiley remarked. “The 5-to-11 age-group was added (earlier guidelines combined this group with adults) as a result of new evidence on the use of medications in children that suggests that children may not respond in the same manner as adults to different asthma medications. The additional age-group also allows us to address developmental issues in school-aged children that differ from infants to preschool-aged children and from the adolescent and adult periods.”

MEDICATIONS

The EPR-3 guidelines—which categorize medications as those deemed for long-term use in maintaining control of persistent disease and those suited for quick relief of acute symptoms—include updated information based on research published since 1997. The Expert Panel maintains that medications with anti-inflammatory properties are the most effective for long-term use, citing inhaled corticosteroids as “the most potent and effective anti-inflammatory medication currently available.” As such, treatment with inhaled corticosteroids is preferred.

Among the new data included in the EPR-3 is the addition of the immunomodulator omalizumab to the list of medications available to consider for patients 12 or older who have allergies and severe persistent asthma. Omalizumab is indicated as adjunctive therapy, and its use should be monitored to prevent or treat possible anaphylaxis.

The guidelines also include an update of safety information on long-acting b2-agonists (LABAs). LABAs are not to be used as monotherapy for long-term control, according to the EPR-3, but can be used in combination with inhaled corticosteroids in moderate or severe persistent asthma.

One change is the recommendation that for patients 12 or older with moderate persistent asthma or asthma inadequately controlled on low-dose inhaled corticosteroids, there are two equally preferred step-up options: either adding a LABA to low-dose inhaled corticosteroids or increasing the dose of inhaled corticosteroids.

Among the other medications cited by the guidelines as potential medications for long-term therapy are:

Cromolyn sodium and nedocromil. An alternative, but not preferred, medication for mild persistent asthma, or a preventive treatment prior to exercise or unavoidable exposure to know allergens.

Leukotriene modifiers. An alternative, but not preferred, treatment for mild persistent asthma or as an adjunctive therapy with inhaled corticosteroids (although for patients 12 and older,
LABAs are preferred as adjunctive therapy with inhaled corticosteroids).

Methylxanthines. An alternative, but not preferred, therapy for mild persistent asthma, or an alternative adjunctive therapy with inhaled corticosteroids. Monitoring of serum concentrations is “essential.”

The preferred quick-relief medications are short-acting b2-agonists and, for severe exacerbations, the early use of systemic corticosteroids.

EDUCATING PATIENTS

“EPR-3 emphasizes the importance of teaching patients skills to self-monitor and manage asthma and to use a written asthma action plan, which should include instructions for daily treatment and ways to recognize and handle worsening asthma,” noted Dr. Kiley. Self-management education should begin at diagnosis and should be reinforced at each health visit encounter, including at clinics, medical offices, emergency departments, hospitals, and pharmacies and involving all members of the health care team, according to the EPR-3. The Expert Panel also pointed out the growing evidence that school-, computer-, and Internet-based education programs may be useful tools in asthma self-management.

“EPR-3 emphasizes the importance of teaching patients skills to self-monitor and manage asthma and to use a written asthma action plan, which should include instructions for daily treatment and ways to recognize and handle worsening asthma,” noted Dr. Kiley. Self-management education should begin at diagnosis and should be reinforced at each health visit encounter, including at clinics, medical offices, emergency departments, hospitals, and pharmacies and involving all members of the health care team, according to the EPR-3. The Expert Panel also pointed out the growing evidence that school-, computer-, and Internet-based education programs may be useful tools in asthma self-management.

Key topics for education programs should include:
· Basic facts about asthma.
· What defines well-controlled asthma and assessment of the patient’s current level of control.
· The roles of medications.
· Skills associated with use of medications, such as inhaler technique and use of a valved holding chamber or spacer.
· Knowing the signs and symptoms of worsening asthma and when and where to seek help.

The EPR-3 also encourages that self-management approaches be tailored to the patient’s needs and background. “In the guidelines, a new section addresses the need for clinician education programs to improve communications with patients and to use system-wide approaches to integrate the guidelines into health care practice,” Dr. Kiley added.

ENVIRONMENTAL TRIGGERS

As single steps are rarely sufficient, a comprehensive approach to eliminating allergens or irritants is recommended, Dr. Kiley pointed out. EPR-3 describes measures to reduce those factors to which a patient is exposed and sensitive (see “Recommendations for Control of Environmental Factors Regardless of Patients’ Asthma Severity”). For patients with persistent asthma, clinicians should use the medical history and allergen testing to identify those environmental factors that may worsen a patient’s symptoms.

New to the EPR-3 is the information that formaldehyde and volatile organic compounds may be risk factors for asthma and wheezing.

While recognizing the general benefits of influenza vaccinations, the Expert Panel notes that a review of the medical literature suggests that flu shots should not be given with the expectation that they will reduce the frequency or severity of asthma exacerbations. In addition, “the guidelines expand the section on other common conditions that patients with asthma can have and notes that treating chronic problems such as rhinitis and sinusitis, gastroesophageal reflux, overweight or obesity, obstructive sleep apnea, stress, and depression may help improve asthma control,” Dr. Kiley stated.           

—Adriene Marshall

Suggested Reading
Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Full Report 2007. www.nhlbi.nih.gov/guidelines/asthma/index.htm. Accessed September 5, 2007.

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