Changes in recommended treatments for mild and moderate asthma

Journal of Family Practice, Sept, 2004 by Gregory J. Redding, Stuart W. Stoloff

Consider an adult with the following characteristics. To which disease severity would you assign this patient's asthma?

* Forced expiratory volume in 1 second (FE[V.sub.1]) or peak expiratory flow (PEF) [greater than or equal to] 80%

* PEF variability 20%-30%

* Daytime symptoms less than once a day

* Nighttime symptoms more than 1 night a week.

This patient is said to have moderate persistent asthma based on nighttime symptoms. An accurate classification of a patient's asthma is the foundation for selecting an appropriate treatment strategy.

In 2002 the National Asthma Education and Prevention Program (NAEPP) updated select topics (1) from its 1997 Guidelines for the Diagnosis and Management of Asthma. (2) These evidence-based revisions to the stepwise approach to asthma management were made following a systematic review of the literature (see Search function).

This article reviews the 2002 NAEPP recommendations for the use of controller medications for asthma, including:

* Relative effectiveness of inhaled corticosteroids (ICSs) versus other controller medications

* Safety of long-term ICS use in children

* Potential benefits of early ICS treatment.

We emphasize mild and moderate persistent asthma because the recommended treatments for these levels of severity have been most affected by the recent guideline changes.

We also discuss a recent change by the US Food and Drug Administration (FDA) in its pregnancy category rating for an ICS.

* 2002 STEPWISE APPROACH TO ASTHMA MANAGEMENT

New criteria for classifying asthma severity

The NAEPP classifies asthma severity according to symptoms and lung function in adults and children older than 5 years, and symptoms in children 5 years and younger. (1) Persistent asthma is classified as mild, moderate, or severe according to the feature of greatest severity.

Asthma severity should be assigned according to symptoms before treatment. (1) Because it is difficult to predict which infants and young children who wheeze with acute viral upper respiratory infection will go on to develop persistent asthma, new criteria have been detailed to help distinguish these children from those with transient wheeze (Table 1). (1,4)

Choosing pharmacologic treatment according to asthma classification

Quick-relief medications, which include the short-acting [[beta].sub.2]-agonists (SABAs), are taken as needed to promptly reverse acute airflow obstruction and relieve accompanying symptoms. (2)

Asthma controller medications (ie, ICSs, cromolyn sodium, long-acting [[beta].sub.2]-adrenergic-agonists [LABAs], leukotriene modifiers, nedocromil, and theophylline) are used daily to achieve and maintain long-term control of persistent asthma. All patients with persistent asthma, regardless of disease severity, should use a dally controller. Criteria for determining asthma severity and updated recommendations for the use of controller treatment in mild and moderate persistent asthma are presented in the Figure. (3,5) Levels of evidence justifying NAEPP treatment recommendations are shown in Table 2.

[FIGURE OMITTED]

For use in children. Asthma controller medications approved for use in children younger than 5 years include the fluticasone dry-powder inhalers (Flovent, Rotadisk, and Flovent Diskus), which are approved for children as young as 4 years (Flovent Diskus is not yet commercially available), and nebulized budesonide inhalation suspension (Pulmicort Respules), which is approved for children as young as 12 months.

The LABAs formoterol (Foradil) and salmeterol (Serevent Diskus) are approved for children as young as 5 and 4 years, respectively. Cromolyn sodium nebulizer solution is approved for children as young as 2 years, and theophylline is available for use at any age.

Based on safety and extrapolation of efficacy data in older patients, the oral granule formulation of the leukotriene receptor antagonist (LTRA) montelukast (Singulair) is approved for children as young as 1 year, and the chewable tablets are approved for children 2 to 5 years of age. Zafirlukast (Accolate) is approved for use in children 5 years and older.

New recommendations for mild persistent asthma. Recommendations for the treatment of mild and moderate persistent asthma have changed considerably from the 1997 guidelines. ICSs are now the preferred controller medications, based on greater efficacy. The updated guidelines no longer recommend an initial trim of cromolyn or nedocromil for the treatment of mild persistent asthma; these agents, along with the leukotriene modifiers and slow-release theophylline, are now considered alternatives to low-dose ICSs for adults and children older than 5 years with mild persistent disease (Figure).

According to the NAEPP update, daily low-dose ICS treatment also is preferred for the control of mild persistent asthma in preschool children. As in older children, cromolyn and nedocromil are no longer considered appropriate initial treatments for infants and children 5 years and younger. Cromolyn is considered an alternative controller, whereas nedocromil is no longer recommended for use.