ALLERGY AND ASTHMA CONNECTIONm f rom the Amer ican Academy of A l le rgy , As thma and Immuno logy

Asthma Treatment Guidel ines: What You Should Know Kathleen Sheerin, MD, FAAAAI

Kathleen Sheerin, MD, FAAAAL is an aller- gist~immunologist in Atlanta, Ga. She is the Vice Chair of the AAAAI Public Education Committee.

Asthma affects more than 17 million Americans, 5 million of whom are children. It is a very costly problem both in terms of dollars and cents as well as quality of life.

The focus of asthma treatment has changed over the past 13 years, thanks to the evolution of the Guidelines for the Diagnosis and Treatment of Asthma, published by the National Heart Lung Blood Institute (NHLBI). These guidelines are designed to help health care providers appro- priately guide their patients to achieve the goals of asthma therapy, which include: Preventing chronic symptoms Establishing normal activity levels Reducing exacerbation rates (number of attacks) Maintaining normal lung function Providing optimal medication with minimal

side effects Meeting patient and family expectations of, and

satisfaction with, asthma care The evolution of the guidelines reflects our

changing knowledge about asthma and the need to treat inflammation early and in a more aggres- sive manner. The first guidelines were released in 1991. Their primary focus was on the treatment of symptoms with bronchodilators--quick-relief medications.

By 1997, with the release of the updated guidelines, data from medical studies had clearly changed the focus of the treatment recommenda- tions. Instead of treating the symptoms as they occur, these guidelines emphasized long-term

control medications to control the inflammation central to the cause of asthma, thereby preventing symptoms from occurring in the first place.

In June 2002, the NHLBI and the National Asthma Education and Prevention Program (NAEPP) released its newest guidelines. For chil- dren of all ages and adults with asthma these newest guidelines overwhelmingly recommend the use of inhaled corticosteroids (ICs) as the first line treatment of persistent asthma no matter what the severity--mild, moderate, or severe. Only the dosing of the medication or the addi- tion of a second controller medication differs depending on severity.

The 2002 guidelines focus on six key topics, particularly giving the health care provider new direction in the treatment of children with asth- ma. These are important new recommendations for the treatment of children with asthma that everyone involved in asthma care from physician to parent to patient needs to know about.

Inhaled Corticosteroids: Safe and Effective in Children

There is now strong evidence from clinical studies that shows that the use of ICs in children is safe. ICs clearly improve health outcomes for children.

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Terms Airway obstruction: A narrowing, clogging, or blocking of the airways that carry oxygen to the lungs.

Allergen: A foreign substance that leads to allergies by triggering an immune response.

Allergist: A physician who has completed medical school and post graduate training sufficient to qualify as a pediatrician or an internist and who has completed at least a 2-year fellowship in the subspecialty of allergy/immunology.

Allergy: A reaction of the immune system of an allergic person to substances, which are harmless to most people.

Asthma: A chronic, inflammatory lung disease charac- terized by recurrent breathing problems. Episodes of asthma can be triggered by allergens, infection, exer- cise, cold air and other factors.

Inflammation: Redness, swelling, heat, and pain in body tissue caused by an infection or a chemical or physical injury. It is a characteristic of allergic reactions in the nose, eyes, lungs, and skin.

Respiratory system: The group of organs responsible for carrying oxygen from the air to the bloodstream and for expelling the waste product carbon dioxide.

_ _ _ .

There is a small risk of delay (not stunting) of growth in the first six months of therapy. (Studies show, however, that if growth is delayed during this period, the children do catch up and reach their normal adult height.) However, this risk is well bal- anced by how well the treatment works! The guide- lines also confirm no adverse effects on eyes (cataracts or glaucoma) or bone (osteoporosis).

Infants and Toddlers Historically, there has been little guidance for

health care providers who treat the youngest patients with asthma. The new guidelines suggest how to approach the infant and toddler with asthma.

Infants and toddlers should be treated with ICs if any of the following applies: Symptoms of asthma occur more than twice a

week They have severe exacerbations that occur fewer

than 6 weeks apart, or they have more than 3 episodes of wheezing per year, lasting more than one day and affecting sleep, and if they also have a parent with asthma

The child has atopic dermatitis (eczema) or one of the following: hay fever (allergic rhinitis); wheezing that occurs in the absence of a cold;

Stat ist ics 20.3 million American report having asthma. Asthma affects more than 6.3 million children under the age of 18.

Asthma rates in children under the age of five increased more than 160% between 1980 and 1994.

More than 14 million school days are missed annually because of asthma. Asthma is 26% more prevalent in African American children than in white children

Approximately 40% of children who have asthmatic par- ents will develop asthma.

In 1999, there were over 190,000 asthma hospitaliza- tions for children under age 15.

Asthma is 26% more prevalent in African American chil- dren than in white children.

Sixty percent of people with asthma suffer specifically from allergic asthma.

The prevalence of asthma increased 75% between 1980 and 1994.

or eosinophils (cells that may indicate allergy) in the blood.

Combination Therapy The new guidelines also discuss the use of

combination therapy. Studies show that the use of a long-acting bronchodilator in addition to ICs

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Resources For Patients The website of the American Academy of Allergy, Asthma and Immunology (www.aaaaLorg) is a strong resource for patients and health care providers looking for information on asthma and other allergic diseases. For more information on childhood asthma, check out the following in the Patients and Consumers section of the website: Asthma Care Guidelines Q&A in the Resources section. Tips to Remember brochures on Childhood Asthma, the Role of the Allergist/Immunologist, Allergy and Asthma Medications, and

Asthma Triggers and Management. (Available in English or Spanish.) Children's book All About Asthma. Fast Facts on Asthma. Easy Reader Sheets on Asthma. (Available in English or Spanish.) ADVOCATE patient newsletter.

For Health Care Providers Pediatric Asthma: Promoting Best Practice Guidelines for Managing Asthma in Children is a comprehensive P E D I AT R I C publication for diagnosing and managing asthma. It was developed in partnership with the National Asthma Education and Prevention Program (NAEPP). The 140-page publication is a resource for family practice physicians, pediatricians, nurse practitioners, school nurses, and others who treat children with asthma. It provides national standards for diagnosing and managing asthma, as well as patient education information. To view the publication online, visit www.aaaaLorg. Or, to order a copy of the publication for $15, contact: Erin Brunell, AAAAI Executive Office, 611 East Wells St., Milwaukee, Wl, 53202; phone: (414) 272-6071; fax: (414) 272-6070; or email: info@aaaaLorg.

The Allergy Report, a three-volume set providing guidance on the clinical management of allergic disorders, examines the barriers to effective care and addresses future research needs. It was written by a 25-member task force that included representatives from the AAAAI, the American Medical Association, the National Institute of Allergy and Infectious Diseases, and other national health organizations. It is available in English or Spanish. To view The Allergy Report online, visit www.theallergyreport.org. Copies of the report can be ordered on the website or by calling 1-800-822-2762.

ASTHMA Promoting Best Practice

can significantly help control asthma symptoms for children older than age 5 and adults who have moderate symptoms (daily symptoms, waking more than 5 times a month, and/or abnormal pulmonary function tests). The use of these med- ications can decrease symptoms, improve lung function, and decrease the use of rescue bron- chodilators. The addition of a secondary medica- tion can also help minimize the dose of ICs nec- essary to control the inflammation of asthma and the symptoms that accompany the inflammation.

Use of Antibiotics The new guidelines address the use of antibi-

otics as treatment during an acute asthma flare. If the health care provider feels that there is little chance that there is a bacterial infection, antibi- otics will not help. The number one trigger for a flare of asthma is a viral illness. Antibiotics do not help if the cause is a virus.

Written Asthma Management Plans Finally, the new guidelines addressed the issue of

a written asthma management plan based on symp- toms versus the use of a plan with a peak flow mon- itor. Studies did not confirm that either improved the outcomes of the patients with asthma. However, most asthma specialists continue to provide written asthma action plans to help their patients self man- age their asthma and many schools are requesting an asthma action plan for their students.

This is a very exciting time in the management of asthma. We have seen the evolution of treat- ment from episodic symptom control to the con- trol of inflammation. The future is bright for pre- vention of long-term changes in the lung that untreated inflammation causes and ultimately for prevention of asthma itself.

doi: 10.1067/S 1088-0712(03)00150-X

The AAAAI is the largest professional medical specialty organization in the United States representing aller- gists, asthma specialists, clinical immunologists, allied health professionals, and others with a special interest in the research and treatment of allergic disease. Established in 1943, the Academy has more than 6000 members in the United States, Canada, and 60 other countries. For more information, visit www.aaaai.org.

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