www.medscape.com/viewarticle/562258?src=mpAugust 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 â-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 â2-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.
www.nhlbi.nih.gov/guidelines/asthma/index.htm
