Wendy Brown believes that inflammation should be treated with ICS for better long-term care.
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For the first time in 10 years, in an effort coordinated by the National Heart, Lung, and Blood Institute (NHLBI), the National
Asthma Education and Prevention Program (NAEPP) has created a comprehensive update to its asthma guidelines in Expert Panel
Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma—Full Report 2007. The new guide emphasizes the importance
of keeping the condition under control and highlights the fact that part of the process means appropriate use of both quick-relief
and long-term-control medications. Patients who have persistent asthma—with symptoms more than twice a week or more than twice
a month at night—require both classes of drugs.
A major take-home message in the revision is that use of medications with anti-inflammatory effects continues to be most effective
in controlling asthma and that inhaled corticosteroids (ICS) comprise the most potent and consistently effective long-term-control
medication for asthma treatment.
"A big key with asthma is the underlying inflammation, and we don't know who is going to be susceptible to the remodeling
effect of that inflammation," said Wendy Brown, Pharm.D., AE-C, assistant professor at North Dakota State University College
of Pharmacy, Nursing, and Allied Health. "The sooner we start treating inflammation with ICS, the better the long-term outcomes
will be."
Stepwise approachEPR-3 continues to recommend the practice of asthma control wherein medications are stepped up or down as needed, allowing
for adjustments to treatment whenever necessary. The new guide also created a new age group for treatment. Previously included
in the adult group, children ages five to 11 years have now been separated out, as emerging evidence suggests that children
in this age range respond differently to medications. "Since the previous guidelines were published, there has been a lot
more research in pediatric asthma," confirmed Brown. Long-acting beta2 agonists (LABAs) are to be used as an adjunct to ICS therapy for providing long-term control of symptoms. According to the
panel, the most significant difference today is that LABAs are the preferred treatment in combination with ICS in patients
12 years of age or older and in adults who have persistent asthma or inadequately controlled asthma on low-dose ICS. However,
the option to increase the dose of ICS should be given equal weight to the alternative of adding on an LABA. "Medium-dose
ICS or combination low-dose ICS along with an LABA are two preferred options," agreed Brown. "Before, you would go ahead and
start them on the low-dose ICS along with the LABA." She believes the new guidelines are being a little more conservative
about the use of LABAs.
Also for long-term control, the expert panel has added omalizumab (Xolair, Genentech/Novartis) as an option for adjunctive
therapy for patients 12 years of age or older who have allergies and severe persistent asthma and who are inadequately controlled
with the combination of high-dose ICS and LABA.
"It's just nice that we now know exactly where Xolair fits into therapy," Brown said. "That is a big key because it's such
an expensive medication. In those patients for whom we've exhausted all other resources, and for severe asthmatics, it now
gives us another option."
Quick relief
For quick relief of bronchoconstriction, the panel recommends a short-acting beta agonist (SABA) as the drug of choice. The
group also advocates using ICS for moderate to severe exacerbations, even though their onset of action is slow (> 4 hours),
due to their ability to prevent progression, speed recovery, and prevent relapses. SABAs should not be regularly scheduled,
used daily, or used long-term.
According to NHLBI, a NAEPP-appointed panel of experts is developing a plan to improve implementation of the new update. The
guide is available on-line at http:// http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
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