Summary of NIH Guidelines On Asthma
NIH - sponsored Guidelines for the Diagnosis and Management of Asthma were recently updated (initial publication was in 1991), and a draft was presented at the 1997 Annual Meeting of the American Academy of Allergy Asthma and Immunology. Comprised of Allergy / Immunologists, Pulmonologists, Primary Care physicians, and various research scientists, the Expert Panel II reiterated important issues and presented new recommendations. Some of the major points are summarized below:
- Specific recommendations about the use of salmeterol (Serevent™) were offered.
- not to be used for acute symptoms or started during exacerbations.
- dosage not to exceed 4 puffs / day
- salmeterol should used in conjunction with low or mid dose inhaled steroids
- salmeterol can be added in a poorly controlled patient instead of increasing the dose of the inhaled steroid
- patients should be specifically instructed to not self D/C the inhaled steroid even though they may have improved symptomatically
- The "jury is still out" on whether inhaled steroids have a detrimental effect on growth in children. A few studies have shown grow delay, while others have not shown any significant effects on growth. The general feeling is that poorly controlled asthma likely has a greater deleterious effect on growth than inhaled steroids. They state that further study is needed in this regard.
- There is now a specific recommendation for Flu vaccination in persistent asthmatics. Pneumovax is not specifically recommended.
- They recommend awareness of coexisting and contributing factors to asthma such as chronic sinusitis, rhinitis, and gastroesophageal reflux disease.
- RAST or allergen skin testing to common allergens (e.g., dust mite, cockroach, animal danders, aspergillus) is now specifically recommended for those with persistent asthma.
- The classification scheme for asthma severity was changed. "Mild asthma" has been broken down into "mild intermittent" and "mild persistent asthma," with mild intermittent having symptoms < 2 times/week. This has therapeutic implications in that they recommend that mild persistent asthmatics receive some maintenance therapy with some type of anti-inflammatory medication (i.e., inhaled steroids, nedocromil, cromolyn, or one of the new Leukotriene modifiers [Accolate™, Zyflow™]).
- Although clearly effective in some patients, they state that the role of Leukotriene modifiers in the asthma armamentarium is yet to be clearly defined.
- The Expert Panel II summarized recent research concerning the sub-basement membrane fibrosis in the lung that accompanies even mild disease. These changes, left unaddressed over many years, may possibly contribute to irreversible airflow limitation. The implication is that future recommendations might include more aggressive anti-inflammatory therapy for even the mildest asthmatics.
We hope this summary will be helpful to you. Please do not hesitate to call us if you have any questions or need help in obtaining a copy of the guidelines. You can also find the guidelines at the National Heart, Lung, and Blood Institute section of the NIH (National Institutes of Health) web site.