A new perspective on concepts of asthma severity and control.

Concepts of asthma severity and control are important in the evaluation of patients and their response to treatment but the terminology is not standardised and the terms are often used interchangeably. This review, arising from the work of an American Thoracic Society/European Respiratory Society Task Force, identifies the need for separate concepts of control and severity, describes their evolution in asthma guidelines and provides a framework for understanding the relationship between current concepts of asthma phenotype, severity and control. "Asthma control" refers to the extent to which the manifestations of asthma have been reduced or removed by treatment. Its assessment should incorporate the dual components of current clinical control (e.g. symptoms, reliever use and lung function) and future risk (e.g. exacerbations and lung function decline). The most clinically useful concept of asthma severity is based on the intensity of treatment required to achieve good asthma control, i.e. severity is assessed during treatment. Severe asthma is defined as the requirement for (not necessarily just prescription or use of) high-intensity treatment. Asthma severity may be influenced by the underlying disease activity and by the patient's phenotype, both of which may be further described using pathological and physiological markers. These markers can also act as surrogate measures for future risk.

Adherence to asthma controller medication regimens.

BACKGROUND: Improved adherence to inhaled corticosteroids (ICS) is recognized as an important factor in reduced morbidity, mortality and consumption of health care resources. The present study was designed to replicate previous reports of patient adherence with fluticasone/salmeterol in a single inhaler (FSC), fluticasone and salmeterol in separate inhalers (FP+SAL), fluticasone and montelukast (FP+MON), fluticasone alone (FP) and montelukast alone (MON). METHODS: A 24-month observational retrospective study was conducted using administrative claims data. Subjects were 12 years old with 24 months of continuous enrollment; had 1 asthma claim (ICD-9: 493), 1 short-acting beta(2)-agonist claim, and 1 FSC, FP, SAL, or MON claim. Outcomes included asthma medication refill rates and persistence measured by treatment days. This study was designed with a unique population of patients with asthma from different health plans to validate previous findings. RESULTS: A total of 3,503 subjects were identified based on their index medication: FSC (996), FP+SAL (259), FP+MON (101), FP (1254) and MON (893). Mean number of prescription refills for FSC (3.98) was significantly higher than FP (2.29) and the FP component of FP+SAL (2.36), and FP+MON (2.15), P<0.05. No significant differences were observed between FSC and MON fill rates (4.33). Mean number of treatment days was greater for FSC compared to FP, FP+SAL, and FP+MON (P<0.0001). CONCLUSION: This study confirms a previous report that adherence profiles of fluticasone and salmeterol in a single inhaler are significantly better when compared to the controller regimens of fluticasone and salmeterol in separate inhalers, fluticasone and montelukast, or fluticasone alone and similar to montelukast alone.

Is mild asthma really 'mild'?

Current evidence suggests that patients with mild asthma are often under-recognised, and those that are diagnosed can remain with this initial classification and be treated accordingly, despite worsening of their condition. There is considerable overlap between mild and more severe asthma in terms of the underlying pathophysiology and poorly reversible airway changes, such as subepithelial fibrosis and airway wall remodelling, which are present very early in the progression of asthma in patients with normal lung function. Life-threatening exacerbations can also occur in patients with mild asthma. In view of these factors and given that asthma is a two-component disease (airway inflammation and smooth muscle dysfunction), recent studies have examined the effects of both early intervention with steroids and combination therapy comprising an inhaled steroid and a long acting beta(2)-agonist. These studies suggest that early intervention is likely to provide better asthma control and possibly prevent or delay the worsening of disease and fatalities in patients considered to be mild asthmatics.

Improved asthma control after changing from low-to-medium doses of other inhaled corticosteroids to low-dose fluticasone propionate.

OBJECTIVE: To evaluate the efficacy and safety of changing from low-to-medium doses of other inhaled corticosteroids to low-dose fluticasone propionate. METHODS: Data from 11 randomized, double-blind, parallel-group trials in adults (>= 12 years; n = 1453; % predicted FEV1 = 42% to 89%) and 4 trials in children (4-11 years; n = 161; % predicted FEV1 = 50% to 112%) with chronic asthma were retrospectively analyzed. Symptomatic adults (n = 1181) treated with low-to-medium doses of beclomethasone dipropionate (168-672 mcg/day), triamcinolone acetonide (400-1200 mcg/day), or flunisolide (>=1000 mcg/day) were switched to low-dose fluticasone propionate (176 or 200 mcg daily) for 6-26 weeks. Patients (n = 272) remaining on low-dose beclomethasone dipropionate (336 mcg daily) served as controls. Pediatric patients previously treated with low doses of triamcinolone acetonide (4-8 puffs/day), or low-to-medium doses of beclomethasone dipropionate (4-8 puffs/day) or flunisolide (2-6 puffs/day), were changed to low-dose fluticasone propionate (100 mcg daily) for 12-52 weeks. RESULTS: Improvements in FEV1, morning and evening peak expiratory flow (PEF), rescue albuterol use, asthma symptom scores, and symptom-free days were significantly greater in adults who changed from low-to-medium doses of beclomethasone dipropionate or triamcinolone acetonide to low-dose fluticasone propionate (P <.001). Regardless of the degree of asthma severity, these improvements were 1.5- to 4-fold greater in adult patients changed to low-dose fluticasone propionate vs those remaining on low-dose beclomethasone dipropionate. Significant improvements in lung function, albuterol use, and asthma symptoms (P <=.002) were also seen in pediatric patients who changed from beclomethasone dipropionate, flunisolide, or triamcinolone acetonide to a much lower dose of an inhaled corticosteroid (100 mcg fluticasone propionate daily). Drug-related adverse events were low in adults and children, and were comparable among adults receiving low-dose fluticasone propionate or beclomethasone dipropionate. CONCLUSIONS: Results indicate that patients with persistent asthma can change from other inhaled corticosteroids to a lower dose of fluticasone propionate and still maintain or improve asthma control.

The role of LTRAs in the management of persistent asthma.

Two leukotriene receptor antagonists (LTRAs)--montelukast and zafirlukast--are currently available in the United States. Montelukast is approved for the treatment of asthma in patients as young as 2 years old and zafirlukast, in patients 7 years of age or older. In more than 15 clinical trials of LTRA therapy for mild to moderate persistent asthma, both of these oral agents produced rapid improvement in pulmonary function and daytime asthma symptoms. They also decreased the frequency of nocturnal awakening and the need for rescue therapy with beta2-adrenergic agonists and oral corticosteroids. These effects were maintained throughout the treatment period; tolerance did not develop. When used concomitantly with an inhaled corticosteroid (ICS), each LTRA further improved asthma control, thus permitting the partial or complete tapering off of the ICS dose needed to maintain clinical control. Although rare, previously undiagnosed cases of Churg-Strauss syndrome have been unmasked when ICS use is decreased or discontinued. The improved adherence gained with an oral agent administered as infrequently as once daily maximizes the effectiveness of these newest antiasthma medications.

Current asthma management: the performance gap and economic consequences.

Despite the availability of effective antiasthmatic drugs, many patients have asthma that is not controlled, as reflected by an increased number of asthma-related hospitalizations and deaths as well as rising costs each year. Failure to achieve adequate control reflects a performance gap and clearly indicates that current asthma management is "missing the mark." There are many reasons for this performance gap and its economic consequences, including poor physician adherence to the 1997 asthma treatment guidelines drafted by the National Heart, Lung, and Blood Institute, inadequate patient and physician education, a communication gap between physicians and patients, and the failure to institute appropriate therapy early enough.

Pharmacologic therapy for asthma.

Pharmacologic therapy is used to prevent and control asthma symptoms, reduce the frequency and severity of asthma exacerbations, and reverse airflow obstruction. Recommendations in this chapter, based on the 1997 National Asthma Education and Prevention Program Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma, reflect the scientific concept that asthma is a chronic disorder with recurrent episodes of airflow limitation, mucus production, and cough. Asthma medications are categorized into two general classes: long-term-control medications taken daily on a long-term basis to achieve and maintain control of persistent asthma (these medications are also known as long-term preventive, controller, or maintenance medications), and quick-relief medications taken to provide prompt reversal of acute airflow obstruction and relief of accompanying bronchoconstriction (these drugs are also known as reliever or acute rescue medications). Patients with persistent asthma require both classes of medication. Selecting the appropriate pharmacologic therapy to achieve and maintain control of asthma involves several considerations: the medications and their routes of administration, a stepwise approach to managing asthma long-term as a chronic disorder, and the development of an effective clinician-patient partnership strategy where patient education is continuously provided.

Providing asthma education in primary care practice.

An educational dialog founded on open communication between clinician and patient is necessary for a successful partnership in asthma care. Educating patients in self-management of asthma has become a major challenge in primary care practice. The process should begin at the time of diagnosis and should be integrated into every step of medical care during office visits and any other clinician-patient interaction. Identifying patients' expectations and concerns about their disease at each office visit helps the clinician focus care. The educational effort should include a discussion of basic asthma facts, and the types and uses of medications, and a demonstration of the skills involved in the proper use of metered-dose inhalers, spacers and peak flow meters. A written asthma self-management plan developed jointly by the clinician and the patient includes recommended daily medications and the specific steps the patient should take to control asthma and achieve the goals of asthma care.

The changing role of theophylline in pediatric asthma.

The mechanism of action of theophylline in the treatment of asthma is not yet fully understood. Theophylline appears to be beneficial in some patients with steroid-dependent or nocturnal asthma. It is recommended as an alternative or additional treatment for patients with chronic mild, moderate or severe disease that does not respond to first- or second-line therapy with beta 2 agonists and anti-inflammatory medications such as cromolyn sodium, nedocromil (in children 12 years of age or older) or inhaled corticosteroids. However, theophylline therapy may cause bothersome side effects, including gastrointestinal distress, anxiety, insomnia and headache. These side effects can be minimized by beginning therapy with a low dosage and increasing the dosage slowly, until a therapeutic blood level is reached. Toxicity is more likely if the blood level exceeds 20 micrograms per mL. Prolonged fever puts patients at especially high risk for toxicity. Appropriate patient selection, careful dosing and regular monitoring are crucial elements of safe theophylline therapy.