SELECTED ARTICLES FROM THE RECENT LITERATURE 2004
10/7/04
Changes in recommended treatments for mild and moderate asthma
Summary
Background - There has been a gradual evolution in the thinking by leaders in the field about the management of persistent asthma (PA). However, one has to continue to keep an open mind in view of alternative therapeutic approaches to asthma being investigated and promoted.
Findings - Redding and Stoloff of the Children's Hospital in Seattle , WA reviewed current concepts of treatment of mild-moderate PA. They concluded that all patients with PA, regardless of disease severity, should be treated with controller medications. Inhaled corticosteroids (ICS) should be considered first in this regard when choosing a controller medication in both adults and children with PA. Leukotriene antagonists (such as montelukast), cromolyn or nedocromil may be considered as alternative, but not preferred to ICS, controller medications for PA. Inhaled long-acting beta agonists can be considered as valuable additive therapy but not as monotherapy in PA. Long term use of ICS at recommended doses is generally safe for children with asthma in terms of growth, bone density, eye complications and adrenal function. However, patients treated with ICS should be monitored closely with the aim of maintaining asthma control with the lowest ICS dose feasible. It is possible that long-term cumulative ICS doses may slightly increase the risk for cataracts in older adults.
Reference
J Fam Pract 2004;53:692-700
Editor's Comments
These impressions and recommendations are quite similar to that written by many leading asthma investigators. I have reviewed it here because of this article's appearance in a journal directed to family practice physicians. Many of such family practitioners currently still prescribe inhaled beta agonists as first-line maintenance therapy of PA and have been shown to under-utilize ICS in this role. Hopefully, the rather strong, unequivocal recommendation in this report will stimulate family practitioners to utilize ICS first in such treatment approaches to PA. Because of possible “steroid phobia” and/or for patient convenience reasons, some patients or their parents may insist on a non-ICS controller approach to asthma. However, most studies have shown that the leukotriene antagonist medications are less effective than even modest daily doses of ICS in treating PA. Nedocromil therapy is even less potent in this regard and also requires multiple treatments each day.
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