FAMILY CENTER FOR ALLERGY AND ASTHMA

New Asthma Guidelines

On February 24, 1997, the National Asthma Education and Prevention Program (NAEPP) released a report updating the 1991 national guidelines on the classification and treatment of asthma.

Under the new classifications, asthma falls into one of four categories which are based on the frequency of symptoms and exacerbations (worsening of symptoms):

Mild Intermittent (level 1): Asthma symptoms are experienced no more than twice a week and there is a normal Peak Expiratory Flow (PEF) or no symptoms between exacerbations. Periods of symptom exacerbations are brief, ranging from a few hours to a few days, but can range from mild to severe in intensity. Nighttime symptoms occur twice per month or less.
Mild Persistent (level 2): Symptoms occur more than twice a week, but fewer than once per day. Activities may be affected by asthma symptoms, and nighttime symptoms occur more than twice per month.
Moderate Persistent (level 3): Daily symptoms are experienced, requiring daily use of a short-acting beta2-agonist inhaler. Exacerbations of symptoms are common and may last for days, two or more times per week. Activity is limited by the worsening of symptoms. Those with nighttime symptoms more than once a week may also fall into this category.
Severe Persistent (level 4): Asthma symptoms are present continually, physical activity is limited, and there are frequent exacerbations of symptoms. Symptoms also are common at night.

If the asthma falls into more than one category, the NAEPP recommends that the person be assigned to the more severe category. In addition, the guidelines emphasize that people in any of the categories could experience mild, moderate or severe exacerbations of their symptoms.

The treatment recommendations for each level follow a four-step model:

Step 1 (mild intermittent): Quick-relief medication, probably in the form of short-acting beta2-agonist inhaler medications.
Step 2 (mild persistent): One long-term control medication, probably in the form of a daily anti-inflammatory medication such as an inhaled corticosteroid at a low dose. Medications may also include cromolyn or nedocromil or perhaps a leukotriene modifier such as zafirlukast (Accolate). A quick-relief medication to alleviate acute symptoms may also be taken as needed.
Step 3 (moderate persistent): One or more long-term control medications. This may include a medium dose of inhaled corticosteroid alone, a low-to-medium dose of inhaled corticosteroids plus a long-acting bronchodilator, or a low-to-medium dose of corticosteroids plus nedocromil. If these strategies don't work, a physician may recommend a high dose of inhaled corticosteroids, possibly with a long-acting bronchodilator. Quick relief medicine to relieve symptoms should be available at all times.
Step 4 (severe persistent): Multiple long-term control medications, including systemic oral corticosteroids. The guidelines recommend starting off with a low dose of these medications and, once the asthma is controlled, making persistent attempts to reduce the use of systemic corticosteroids.

These guidelines, which are advisory and not mandatory, represent the National Institutes of Health's official revised position on the classification and treatment of asthma.

Additional information is available through the National Heart, Lung and Blood Institute's Information Center (telephone 301-251-1222).

Source:

National Asthma Education and Prevention Program, Second Expert Panel in the Guidelines for the Diagnosis and Management of Asthma, February, 1997.

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