Pharmacotherapy for Asthma Stepwise Approach

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Important Caveats

The NAEPP report emphasizes that the stepwise approach should be used to guide but not replace physician decisions regarding treatment of individual patients (2). In rating severity, a patient should be assigned to the most severe step if any one feature of the higher severity category is present. Physicians should follow the strategy of achieving control as quickly as possible (e.g., treating with a burst of oral prednisone, if indicated) and then stepping down to the least medication needed to maintain long-term asthma control. As already mentioned, it is essential to provide patient education in self-management and control of environmental triggers (e.g., allergens). Severely asthmatic patients with acute exacerbations or hospitalizations or poor perception of asthma symptoms should be trained in the use of serial PEFR measurements to aid in early recognition of asthma flare-ups. This should involve intensive education regarding self-management of acute exacerbations in which patients are provided with a written ''action plan.'' This important aspect of self-management is to facilitate intensification of asthma therapy early, which usually involves timely administration of a burst of systemic corticosteroids. How these strategies lead to favorable clinical outcomes is discussed later in this chapter. Finally, referral to an asthma specialist is recommended for adults and children greater than five years with severe persistent asthma that is difficult to control. Referral is recommended in children <5 years with moderate or severe asthma and should be considered in mild persistent asthma.

The authors introduce pharmacotherapy for chronic asthma with some thoughtful considerations and caveats. First, individual treatment responses to given regimens may differ significantly from the average response in the asthmatic population at large. Second, treatment decisions are the product of a compromise between physician and patient. Third, the advantages of delivering medications via the inhaled route are emphasized, thereby maximizing local drug delivery and minimizing potential adverse effects.

Physicians and allied health professionals are primarily concerned with relieving asthma symptoms, preventing exacerbations, and improving quality of life. Long-term asthma control is defined in GINA by achieving the following goals: (i) minimal chronic asthma symptoms, including

Table 4 Asthma Stepwise Categories of Disease Severity as Presented in Most Recent Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) Reports

Step 1: Mild intermittent

Symptoms less than once a weeka Brief exacerbations

Nocturnal symptoms not more than twice a month

• PEF or FEV1 variability < 20 % Step 2: Mild persistent

Symptoms more than once a week but less than once a dayb Exacerbations may affect activity and sleep Nocturnal symptoms more than twice a month

• PEF or FEV1 variability 20-30% Step 3: Moderate persistent

Symptoms daily

Exacerbations may affect activity and sleep Nocturnal symptoms more than once a week Daily use of inhaled short-acting 2-agonist

• PEF or FEV1 variability > 30 % Step 4: Severe persistent

Symptoms daily Frequent exacerbations Frequent nocturnal asthma symptoms Limitation of physical activities

"Symptoms are <2days/wk for mild intermittent in NAEPP 1997 report. bSymptoms are > 2days/wk for mild-persistent asthma in NAEPP 1997 report. Source: From Refs. 2 and 5.

nocturnal symptoms; (ii) infrequent or no acute exacerbations; (iii) no hospital visits; (iv) little if any requirement for rescue p-agonist; (v) reduction in activity or exercise limitations; (vi) normalization of PEF variability; and (vii) minimal adverse effects attributable to asthma medications (5).

Both the GINA and NAEPP reports recommend that pharmacotherapy should be customized to asthma severity using a stepwise approach. Asthma medications are increased as a function of disease severity. In the 1991 NAEPP report, three step-categories of asthma disease severity were introduced: mild, moderate, and severe (1). As shown in Table 4, these were expanded in the second report to include the following four graded or ''stepwise'' categories: mild intermittent, mild persistent, moderate persistent, and severe persistent. These severity classes are defined by frequency of daytime and nocturnal asthma symptoms, FEVj and PEFR variability. This classification scheme serves as a usefUl framework for making stepwise recommendations to achieve pharmacologic control of chronic asthma. The phar-macotherapeutic recommendations and relevant rationale for each category of asthma severity will be discussed below.

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