|
ASTHMA CARE Devra K.
Dang, Section Advisor
New asthma assessment guidelines released
Key point: The American Thoracic Society (ATS) and
European Respiratory Society (ERS) released new guidelines on assessing
asthma exacerbations and control in clinical trials and routine
practice.
Finer points: The ATS/ERS guidelines for asthma
evaluation for adults and children (aged 6 years and older) were
published in the July 1 issue of the American Journal of Respiratory
and Critical Care Medicine. An overview of new definitions and key
clinical practice recommendations are presented here; clinical trial
recommendations are beyond the scope of this summary.
In the guidelines, ATS and ERS establish standardized definitions for
asthma exacerbations, control, and severity. Severe asthma exacerbations
are defined as events requiring urgent action to prevent serious
outcomes (e.g., hospitalization), and moderate exacerbations are defined
as events that are troublesome to patients and create need for
modification in therapy; no definition is given for mild exacerbations.
Asthma control is defined as the degree to which treatment has reduced
or eliminated the features of asthma for both current control and future
risks. The inclusion of future risks such as loss of control,
exacerbations, decline in lung function, and adverse events associated
with prescribed treatments is new in the definition of asthma control,
as historic definitions have focused primarily on current control. The
guidelines also define asthma severity as the intensity of treatment
required to achieve good asthma control during treatment; this
definition is substantially different from previous definitions, which
defined asthma severity before a patient started treatment.
According to the guidelines, the absolute severity of exacerbations
will vary considerably from patient to patient, and defining
exacerbations on the basis of systemic corticosteroid use has a low
sensitivity for physician-diagnosed exacerbations in primary care.
Exacerbations should, therefore, be clinically identified by changes in
symptoms, rescue use, or lung function that are outside the
patient’s usual day-to-day range and are associated with an
increase from a stable maintenance dose of medications for 3 or more
days.
For asthma control, ATS/ERS recommend in the guidelines that
physicians in clinical practice monitor symptoms and lung function. The
monitoring device (e.g., peak flow meter) that patients use at home to
assess lung function should also be used in the physician’s office
to allow for an accurate comparison of readings. According to the
guidelines, the majority of patients do not need long-term diaries;
however, these diaries may be useful for patients who have difficulty
sensing airway obstruction or for patients with frequent exacerbations.
Lung function diary monitoring is encouraged when diagnosing asthma. The
use of biomarkers is encouraged in clinical practice because they
provide information about underlying airway inflammation. Induced sputum
is a useful assessment for patients with moderate to severe asthma, and
measurements of the fractional concentration of exhaled nitric oxide
(FENO) can be used as a surrogate marker for eosinophilic airway
inflammation. Clinicians are also encouraged to record indirect measures
of asthma control, such as all scheduled and unscheduled primary care
consultations for asthma management, all hospital referrals and
associated outcomes, all prescriptions for systemic corticosteroids for
asthma exacerbations and when/why patients used the medication, and
copies of medical certificates issued for absence from work because of
asthma. Health-related quality of life measures should also be assessed
because these measures will help identify unmet needs.
What you need to know: The ATS/ERS guidelines help
standardize asthma assessment in clinical trials and in practice.
According to the guidelines, no single outcome measure can adequately
assess asthma control and a multicomponent assessment is needed that
focuses on optimizing clinical control while minimizing future adverse
events. Clinicians are encouraged to review the guidelines; the document
is available online at www.thoracic.org.
What your patients need to know: Educate patients
with asthma about the signs and symptoms of acute exacerbations, how to
manage these exacerbations, and appropriate use of therapies used for
rescue and long-term asthma control.
Source
Related resource on www.pharmacist.com
ADIL, December 2006: Exhaled
nitric oxide: Standardizing the assessment of inflammation in
asthma.
Posted August 4, 2009
Joe Sheffer (jsheffer@aphanet.org)
|
