SELECTED ARTICLES FROM THE RECENT LITERATURE 2004

11/29/04

The revised asthma guidelines

Summary
Background - In the year 2002, the National Asthma Education and Prevention Program (NAEPP) issued an update to its recommendations about the diagnosis and management of asthma based on reviews of more recent evidence and consensus decisions of the Expert Panel convened.

Findings - As reviewed recently by Stoloff, a member of the Expert Panel involved, the main addition/revisions to existent recommendations were: 1) inhaled corticosteroids (ICS) are the preferred initial therapy for persistent asthma (PA) of all degrees of severity; 2) for patients with moderate PA, addition of an inhaled long-acting beta agonist (LABA - such as salmeterol or formoterol) to low dose ICS therapy leads to better symptoms control, improved lung function and decreased need for rescue medication than the with ICS treatment alone. Indeed, adding an LABA is preferable to doubling the dose of ICS to improve asthma control; 3) addition of an LABA may permit reduction of the dose of ICS needed for asthma control. This is quite important since adverse systemic effects of ICS such as a decrease in growth velocity appear to be ICS dose-dependent. Such decreases in growth velocity appear to be non-progressive and may be reversible; 4) for severe asthma not adequately controlled on a combination of medium dose ICS plus LABA, increasing the daily ICS dose above 800-1000 mcg/day generally affords only a modest added benefit while definitely increasing the potential for adverse systemic effects.

Reference
J Respir Dis 2004;25:210-19

Editor's Comments
This nice succinct review of the updated NAEPP treatment recommendations make some important points. One of the most important, in my opinion, was shown in a graph that illustrates the impressive dose-dependent increase in ICS efficacy in asthma (usually up to daily doses of 400-800 mcg/day in adults for most ICS agents, perhaps a lower daily dose for fluticasone). Above those daily doses, there is relatively little added benefit but a significant increase potential for adverse systemic effects. Severe asthmatics may require additional therapy such as the lowest dose of oral steroids needed for asthma control.

Of note, this review commented that ICS is the preferred controller medication for asthma in children < 5 years without an initial trial of inhaled cromolyn/nedocromil (as formerly recommended). Leukotriene antagonist (LA) agents may e considered an alternative but not preferred to ICS therapy in young children because of the lack of good controlled comparisons of LA and ICS treatments in young children.

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