The status of asthma control and asthma prescribing practices in the United States: results of a large prospective asthma control survey of primary care practices.

Control of asthma symptoms is, unfortunately, not a reality for many people with asthma. Asthma control is an ongoing challenge, requiring a multidisciplinary treatment approach. The National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute published its Guidelines for the Diagnosis and Management of Asthma in 1997, but the extent of implementation of recommendations in physician's practices remains to be determined. We sought to determine if a systematic implementation of the NAEPP practice guidelines would impact physician's treatment decisions for patients with asthma. The Asthma Care Network is a large, national, point-of-care program developed to assist health care providers in the assessment and management of their patients with asthma. Outcome measurements for the program included level of asthma control, activity limitation, sleep disruption, use of rescue medications, use of controller medications, and urgent care services. A total of 4,901 primary care physicians at 2,876 practice sites enrolled more than 60,000 patients. Nearly three fourths of patients reported symptoms consistent with a lack of asthma control (mean 74%, range 69-81%). Approximately 68% of pediatric patients and 78% of adult patients reported limited activities due to asthma in the past week. Sixty-two percent of pediatric patients and 68% of adult patients reported more than two symptomatic days in the past week. Approximately 40% of the patients surveyed were not using controller therapy. The overall percentage of patients reporting uncontrolled asthma who were prescribed a controller medication increased from 60% to 81%, and the use of inhaled corticosteroids containing medications among these patients increased by 52%. As a result of the assessment of the patients' level of asthma control during the office visit, physicians changed their patterns of prescribing controller therapy in patients with uncontrolled asthma.

Management of seasonal allergic rhinitis: comparative efficacy of the newer-generation prescription antihistamines.

PURPOSE: To discuss the efficacy and safety of second-generation prescription antihistamines, cetirizine, desloratadine, and fexofenadine, and to inform nurse practitioners (NP) who are in a position to optimally manage patients presenting with seasonal allergic rhinitis (SAR). DATA SOURCES: Selected published clinical trials. CONCLUSIONS: NP, who are ideally placed to successfully manage the majority of patients with SAR, should be fully aware of the treatment options available. Although first-generation over-the-counter antihistamines are convenient to use and are readily accessible, patients run the risk of experiencing adverse effects, such as sedation. For this reason, second-generation antihistamines should be considered a better alternative; however, they need to be evaluated individually on the basis of their proven efficacy and safety. Both cetirizine and fexofenadine are equally effective at relieving the symptoms of SAR; however, cetirizine has been shown to be more likely to cause sedation and impairment. IMPLICATIONS FOR PRACTICE: If left untreated, SAR can have a substantial effect on patients' quality of life, resulting in fatigue, irritability, sleep disorders, and cognitive impairment.

General principles of asthma management: pharmacotherapy.

Asthma, a disease of urbanized societies, has been increasing at an alarming rate on a worldwide basis. In recognition of this problem, the NHLBI developed the NAEPP in 1991. An expert panel was appointed that developed guidelines for the diagnosis and management of asthma. The original report has been updated several times, most recently in 2002. In this article the author focuses on the general principles of asthma pharmacotherapy in accordance with the conceptual framework that characterizes drugs as relievers or controllers. The preeminent use of ICS in the management of asthma sufferers who are characterized as having more than mild intermittent disease is emphasized, as is the principle of matching therapy with severity of disease.

Asthma epidemiology: risk factors, case finding, and the role of asthma coalitions.

Asthma has no cure, and given that clinicians still do not understand what causes it in the first place, it is not preventable. With implementation of environmental control measures to minimize exposure to allergens and irritants, appropriate pharmacologic therapy, and patient and health care provider education, the disease can be managed successfully. Health care access and appropriate case management are essential components of any plan to address asthma as a public health problem. Asthma is now one of the most important diseases of childhood in developed countries. In the International Study of Asthma and Allergies in Childhood (ISAAC) study, the highest asthma prevalence was observed in westernized English-speaking countries (e.g., the United Kingdom, Australia, and New Zealand), with much lower prevalence rates in Eastern Europe, India, China, other countries in Asia, and Africa [18]. This observation has led to the belief that the rapid increases in asthma prevalence are more likely to be attributable to environmental than genetic factors. The rising prevalence in the United States and worldwide seems to be correlated with modern industrialization, suggesting that changes in the ambient environment may contribute to this increase in morbidity and mortality. Indoor factors that have been suggested to influence asthma pathogenesis include allergy to house dust mite and cockroaches, poor heating and ventilation, and exposure to cigarette smoke and other irritants. Scientific evaluation of the links between indoor and outdoor air pollution and asthma is incomplete, however. Much work remains to be done in defining the environmental factors that may cause asthma and that may trigger asthma exacerbations in individuals with the disease. Until then, clinicians must focus on developing a hard-hitting, comprehensive, interdisciplinary asthma program and work toward its successful and broad-based implementation. It is the only way to win the "war against asthma."