“The idea is to give physicians a step-by-step process, so it’s not randomly ‘let’s try this, and let’s try that’ in the long-term management of asthma,” explained pulmonologist Oksana Senyk, MD, PhD, FCCP and chief of the pulmonary division at Trinity Medical Center. She’s referring to the newest Guidelines for the Diagnosis and Management of Asthma published by the National Institutes of Health’s National Heart Lung and Blood Institute last July. The first major revision in a decade, the document runs 440 pages, but a summary can be viewed online at http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm. The guidelines are organized around four essential components of asthma care: assessment and monitoring, control of factors contributing to asthma severity, pharmacological treatment and patient education. “That’s something new. They’re emphasizing more the asthma control,” said Shashi A. M. Kumar, MD, with Allergy Asthma Allergy and Immunology Center in Huntsville, “meaning once you initiate the treatment, you see the patient. The guidelines help you to figure out if you have control and make changes to attain control.” To continuously assess the level of control, the guidelines offer a new tool called the Assessment Control Test (ACT). “With diabetes, you test with a simple blood test, and you can easily see if it’s controlled,” said Kumar. “With asthma, you don’t have that simplicity. There’s not just one control. But now we have a tool.” The tool is a simple questionnaire of five questions the patient answers on how much their asthma has kept them from being active at school, work or home in the past four weeks. Each answer rates a score of one to five, so in just a couple of minutes, a physician has a total score that categorizes the level of control into one of three options: well controlled, not well controlled or poorly controlled. (Most pharmaceutical representatives will have copies of the ACT.) “If it’s not well-controlled, you step up the treatment. If it’s well controlled, then step down, so you use the least amount of medications at the lowest dose,” said Kumar. “The guidelines offer step therapy for asthma,” said Senyk. “It answers the bread-and-butter issue of how to increase the intensity of the therapy based on the severity of the disease.” According to Senyk, the guidelines break asthma into four stages based on the severity of the symptoms. A patient at the least severe stage, mild intermittent asthma, exhibits symptoms less than twice per week and nocturnally less than twice per month with measurements FEV1 greater than 80 percent of predicted. For this type of asthma, the guidelines recommend treatment with as-needed use of a short-active beta-agonist. The next stage, mild persistent asthma, exhibits symptoms more than twice per week but less than once a day with nighttime more than twice per month and FEV1 greater than 80 percent. For this, the addition of inhaled cortico-steroids, such as Asmanex, is recommended. “If someone’s leery of steroids,” said Senyk, “another option is a leukotriene pathway modifier, such as Singulair.” Use that as the maintenance medicine, she says, with the addition of a short-acting beta-agonist for quick relief. “When you see a patient in follow-up, and they say they’re using short-acting three times a day, then step up the controller or maintenance therapy,” she explained. “Our goal is to reduce the symptoms, so the patient doesn’t have to use their inhaler several times a day.” The third stage is moderate persistent asthma. Symptoms require daily use of their rescue beta-agonist short-acting inhaler and FEV1 60-80 percent of predicted. At this stage, the guidelines recommend adding a long-acting beta-agonist, such as salmeterol or formoterol inhalers. “If they still have symptoms, you can increase the dose of the long-acting,” explained Senyk. “And if they’re not already on a leuko-modifier, you can add that.” In the fourth stage, severe persistent asthma, patients exhibit continuous symptoms with limited physical activity, frequent nighttime symptoms and FEV1 less than 60 percent. For this, Senyk says, the guidelines recommend you step up to inhaled cortico-steroids, long-acting beta-agonist inhalers. “For these patients, an oral cortico-steroid may be needed for long-term management.” Kumar summarized, “If it’s not controlled on one medicine, like an inhalant on a low dose, then the next step is to increase to medium dose or add a long-acting LABA beta-agonist, like Advair.” “If it’s beyond the first stage of intermittent, then strongly consider evaluating the patient for allergic triggers,” said Adina Knight, MD, an allergist at Alabama Allergy & Asthma Center and an assistant professor at UAB, “and treat appropriately, including allergy immunotherapy.” Consensus was strong that allergy immunotherapy reduces sensitivity and can significantly upgrade the patient’s quality of life. Controlling the triggers obviously controls the asthma. “Twenty percent of those with asthma drain 80 percent of healthcare dollars spent on asthma through hospitalizations and emergency room visits,” said Kumar, who explains that many of those visits come from patients with seasonal triggers that could be desensitized with allergic immunotherapy, alleviating the need for hospitalizations. “The goal of asthma treatment is to achieve asthma control,” said Kumar. “And the new guidelines figure out if you have control and how to make changes to attain control through step-by-step assessment and treatment.” Knight thinks the guidelines’ step approach to treatment only makes sense. “Like with diabetes patients, we don’t expect them to manage the disease using the initial drugs we put them on,” she explained. “We need to continue to look at asthmatics for the same reason.” April 2008