A Synopsis of AFPs "Overview of Changes to Asthma Guidelines: Diagnosis and Screening"

Overview of Changes to Asthma Guidelines: Diagnosis and Screening
SUSAN M. POLLART, MD, MS, andKURTIS S. ELWARD, MD, MPH Department of Family Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
http://www.aafp.org/afp/2009/0501/p761.pdf
Am Fam Physician. 2009 May 1;79(9):761-767.

     I know that I just did an article on asthma thursday,  but I printed this one out at the same time, and it was on top of the pile, so here we go again. Asthma is real common anyway so there is nothing wrong with a little repetition.
    Asthma is categorized by severity and control. Treatment is categorized by current impairment and future risk. Patients with previously treated asthma are hard to classify because the parameters can be skewed by incomplete treatment. Older guidelines that categorized patients based on severity alone did not result in the best management.
     The four asthma classifications are intermittent and three types or persistent (mild, moderate and severe).  So the way that I remember which is which is by the phrase "less than 2, more than 2, daily, constant". What that stands for is that intermittent asthma occurs less than 2x a week, less than 2x a month at night, and short acting betas are needed less than 2x  a week. Persistent/mild asthma occurs more than 2x a week, more than 2x a month at night, and short acting betas are needed more than 2x a week. Persistent/moderate asthma consists of daily symptoms, weekly nighttime symptoms, and daily beta usage. Persistent/severe asthma has symptoms throughout the day, nightly nighttime symptoms, and beta inhaler usage several times a day. For FEV1, it is above 80 for intermittent and persistent/mild. It drops to 60-80 in persistent/moderate and less than 60 in persistent/severe.  FEV1/FCV goes down by 5% in persistent/moderate and persistent/severe.
     All patients with asthma need to recognize when they are not adequately controlled with medication. The patients symptoms need to be classified into "well controlled, not well controlled, or very poorly controlled". This can be further evaluated with several questionnaires, that are provided in the original article (teaser). FEV1 and FVC are also helpful predictors of current impairment.
     This article describes a stepwise treatment approach to determine where to start treatment based on the disease classification. Patients who are not well controlled can go up a step. A patient should be reevaluated 2-6 weeks after starting or changing a step. Those who are very poorly controlled can get a short course of oral steroids, go up 1-2 steps, and be reevaluated in 2-4 weeks.  Patients who are well controlled for three months can step down. Patients with intermittent asthma need only be seen yearly, or 2-3 times if on a rescue inhaler.
    Step 1 begins with an inhaled short acting beta blocker (with a spacer and proper spacer training). Step 1 is where intermittent asthmatics start. After each step, there should be proper patient education, environmental control, and management of comorbidities. Step 2 includes adding a low dose inhaled steroid. Step 3 recommends adding a long-acting beta agonist, or increasing the steriod from a low to a medium dose inhaler. Step 4 includes a medium acting steriod and the long acting beta agonist. With steps 2-4, allergy immunotherapy, a leukotriene antagonist, theophylline, or zileuton can be added. Theophylline and cromolyn are not preferred but are acceptable alternatives. Step 5 requires a high dose steroid, long acting beta agonist, and possibly omalizumab. Step 6 is basically just adding an oral steroid to the previous regimen.
     As mentioned in the previous synopsis, a proper, individualized asthma action plan can help greatly.