Updated National Asthma Guidelines
By Neil Gershman, M.D.
The National Institutes of Health's National Heart, Lung, and Blood Institute has been publishing guidelines on the management of asthma over the past several years. As part of the National Asthma Education and Prevention Program, the NAEPP Expert Panel recently updated their recommendations to address specific questions about medications, monitoring, and the prevention of asthma. The NAEPP was formed in 1989 for the purpose of lessening asthma-related illness and death and to improve the quality of life of those with asthma.
The Expert Panel is composed of the nation's top allergy, pulmonary, family practice, internal medicine, and pediatric specialists, as well as pharmacology and public health scientists. This update was needed in light of many important studies on asthma that had been completed in the past several years, with the last guidelines being published in 1997 (see NIH Publication No. 02-5075, June 2002 at http://www.nhlbi.nih.gov).
Previously published guidelines discussed several important aspects of the diagnosis and treatment of asthma. Most importantly, the Expert Panel had stressed the importance of assessing and treating inflammation of the airways in asthma. They discussed the need for performing lung function tests to gain insight into the amount of inflammation in a given patient. Previously, they also had divided asthma medications into two main categories: "controllers" and "relievers".
The controllers refer to medications that are used on a daily basis, regardless of symptoms. One could divide the controllers further into anti-inflammatory drugs (e.g. inhaled steroids like Flovent[TM] or Pulmicort[TM], cromolyn-type drugs like Intal[TM] or Tilade[TM], and leukotriene modifiers like Accolate[TM] and Singulair[TM]) and long-acting bronchodilators. Examples of long-acting bronchodilators would be Serevent[TM], Foradil[TM] and the theophylline drugs. Currently there is one brand name product that combines a steroid and long-acting bronchodilator in one inhaler - Advair diskus[TM]. Lastly, the relievers (i.e., fast-acting bronchodilators like Ventolin[TM] and Proventil[TM]) are used on an as-needed basis for symptoms of asthma. Mild intermittent asthmatics need only relievers, while persistent asthmatics require controller and reliever medications.
The previous NAEPP guidelines had also stated the need to treat patients with anti-inflammatory medications in patients with "persistent" asthma, defined as having symptoms more than twice a week on average. This anti-inflammatory treatment would be in addition to fast-acting bronchodilator medications used to treat acute symptoms. The guidelines also discussed the need for recognizing triggers of asthma, such as allergies, sinus infections, and stomach acid reflux disease. In addition, the guidelines had discussed the goals for every asthma patient: patients should achieve normal or near normal lung function, their symptoms should not interfere with school, work or play, and they should experience minimal if any side effects from medications.
In this latest update, the Expert Panel refined their recommendation regarding three important questions: What is the preferred anti-inflammatory medication in children and adults? How early in life, and at what level of severity, should anti-inflammatory medications be started in children? In moderately severe patients not controlled on inhaled steroids, does the addition of another controller agent have benefits? Other issues were discussed in the update, but did not involve major changes in the panel's opinions.
To the first question, they state that inhaled steroids are the "preferred" anti-inflammatory medication in children. Although they admit that there are few scientific studies directly comparing the different drugs, they report that inhaled steroids have shown to produce the greatest and most consistent benefits to children with asthma (e.g. improving lung function, decreasing hospitalization rates). They also cite the recently published studies on the safety of this therapy in children. For instance, ten years of treatment of children with low-to-medium doses of inhaled steroids did not affect final growth. They also mention that some studies of inhaled steroid in children show a brief growth slowing, but the effect is not sustained, as children appear to reach their expected height. In light of all this, the 2002 update also strongly states that inhaled steroids are the "preferred" controller drug in adults with persistent asthma.
Regarding how early anti-inflammatory drugs should be started in children, there were important changes made in the opinion of the Expert Panel. They believe that infants and children who have had just three episodes of significant wheezing (it affected sleep and lasted more than one day) over a one-year period and who have a certain number of risk factors for asthma should be on long-term controller therapy. These asthma risk factors include having a parent with asthma and the child being diagnosed with atopic dermatitis or allergic rhinitis. This is in addition to previous recommendations for controller drugs when asthma symptoms occur more than twice a week on average and when severe symptoms occur less than six weeks apart. It is felt that early treatment may prevent permanent scarring from inflammation, and may potentially cure the disease in some children.
The Expert Panel also discussed the benefit of adding another controller to those asthmatics not doing well on inhaled steroids alone (these would most likely be moderately severe asthmatics). They cite studies that show that an additional controller can be very beneficial. That is, it might be preferable to add another drug than to raise the inhaled steroid to medium or high levels. They specifically state that for adults and children over 5 years old the "preferred" treatment is adding a long-acting bronchodilator to low to medium dose inhaled steroid. Although there is no direct information in younger children, the "preferred" options for moderate asthma are low dose inhaled steroids plus a long acting bronchodilator or medium dose inhaled steroid.
First, I would like give a few comments on the leukotriene modifiers (LKM's). I believe that in the very mild persistent asthmatics (those with symptoms more than twice a week, but have been PROVEN to have perfect lung function testing on at least two occasions), drugs like Singulair(TM) might be a good choice. These pills are easy to take, and they may have added beneficial effects on allergic rhinitis. Again, I believe that lung function data must be obtained (via peak flow monitoring and/or spirometry) if an LKM is going to be the only controller drug used in a given patient. I also believe the LKM's should never be used as the only controller drug in patients who have needed to go to the emergency room for their asthma.
Since LKM's can help with allergic rhinitis, I also believe they can be a good additional agent for those already taking inhaled steroids, even though the effects on lung function and symptoms are not as good as those of the long-acting bronchodilators. That is, LKM's are so safe and easy to use, they should be considered, at least as an additional drug, in all asthmatics.
I will conclude with the following about inhaled steroids. These asthma drugs are nearly perfect - they are very safe and very effective. However, they are greatly underused, particularly in children. Since asthma is an inflammatory disease, why don't we use the best anti-inflammatory drug more often? Also, inhaled steroids are they only drug proven to lessen a patient's chance of dying from asthma, and they are likely the only drug that can decrease the permanent lung scarring that occurs in some asthmatics.
Perhaps many of the 4000 deaths per year in this country could be prevented and millions of asthmatics would have a better quality of life if inhaled steroids were prescribed more often. I believe this under use is partly due to "steroidphobia" on the part of patients and parents. This is compounded by the fact that today's doctors often don't have enough time to explain the benefits and safety of inhaled steroids. Lastly, many asthma sufferers never see a doctor about their asthma because of social and economic reasons. This can only be solved by public awareness campaigns, of which these NAEPP guidelines are a part.
Published in July-August 2002 Newsletter of the Florida Asthma, Allergy & Immuniology Society