Asthma Guidelines

Spring, 1999

In February 1997, the NHLBI’s revised asthma guidelines were published. These guidelines were developed to bring practitioners to a common ground in terms of communication and treatment of asthma.

The report emphasized that when not managed aggressively, asthma is more likely to result in hospitalizations, ER visits and missed work and school days. The newer, evidence-based guidelines recommend that asthma be diagnosed in its mild, early phases and treated aggressively so that it doesn’t progress causing irreversible remodeling of the airways. These new guidelines layout new categories which anyone who is taking care of asthmatics should use. The categories help remind us how active a patient’s symptoms might be and the appropriate approach to treatment. In a nutshell the criteria for the categories are as follows:

sx< 2x/week, night sx<2x/mos normal PEF

sx>2x/week,<1x/day, night sx>2x/mos, PEF>80%

Moderate Persistent: sx daily, night sx >1x/week, PEF 60-80%

Severe Persistent sx limiting

Treatment of all persistent categories should include an anti-inflammatory agent. For the first time the guidelines point out that inhaled steroids are not equal on a mcg per mcg basis. For example, beclomethasone which is 42mcg/puff is actually twice as strong as triamcinolone which is 100mcg/puff. For a copy of this chart please call our office. We would be happy to send you one. The goal is to always use the lowest amount of inhaled steroid possible.

There is now available a whole new class of anti-inflammatory agents called the leukotriene antagonists. This is the first time in >20 yrs that we have a new option. In the U.S.we have three drugs in this category - Accolate, Singulair and Zyflo. The jury is still out in determining how effective these agents are in preventing lung remodeling secondary to inflammation. At this point they may best be used as an additive therapy to try to reduce the dose of inhaled steroids. Another use suggested by the guidelines is as a first line drug in mild persistent patients. Careful monitoring is required. The most worrisome news is the association of these drugs with the Churg-Strauss Syndrome. This consists of a triad of symptoms; recalcitrant asthma, neuropathy and an elevated eosinophil count. At this point it is unclear whether these drugs are causative or result in an unmasking of the disease with the weaning of prednisone. You will need to keep this in the back of your mind. A local woman was diagnosed with the sease after we first contemplated steroid withdrawal syndrome and post flu myositis. Helpful tests are a CBC with diff looking at the absolute eosinophil count and a sedimentation rate.

Two additional points emphasized in the guidelines are the use of monitoring devices such as peak flow meters and patient education. Patient education should be an ongoing process emphasizing the role of medications, the use of inhaler devices and self monitoring.

As of this past fall we have set up our office for exercise challenges. Our research showed there was no local availability to perform a formal exercise challenge test in children. This test is useful for patients in which the diagnosis of Exercise-Induced Asthma is unclear.

1. Asthma Olympics for children 5-12yr on May 22, 1999.

2. Asthma Camp for children 6-13yrs on June 28 - July 2, 1999.

For further info. on Churg-Strauss Syndrome, an article I co-authored: JAMA Feb.11, 1998, 455-457.