Applied Evidence

Changes in recommended treatments for mild and moderate asthma

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Practice recommendations
  • Every patient with persistent asthma, regardless of disease severity, should use a daily controller medication.
  • Consider an inhaled corticosteroid (ICS) first when choosing controller medications for long-term treatment of mild, moderate, and severe persistent asthma in adults and children. Leukotriene modifiers, cromolyn, and nedocromil may be considered as alternative, not preferred, controller medications for patients with persistent asthma.
  • Long-acting β2-adrenergic agonists should not be used as monotherapy.
  • Long-term use of ICSs within labeled doses is safe for children in terms of growth, bone mineral density, and adrenal function; nonetheless, asthma should be monitored and ICS therapy stepped down to the lowest effective dose.
  • Low-to medium-dose ICSs are not associated with the development of cataracts or glaucoma in children, but high cumulative lifetime doses may slightly increase the prevalence of cataracts in adults and elderly patients.
  • ICSs are recommended for use in pregnant women with asthma; budesonide is the only ICS rated Pregnancy Category B.

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

  • Forced expiratory volume in 1 second (FEV1) or peak expiratory flow (PEF) ≥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 topics1from 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).

Search function

A comprehensive search of Medline and EMBASE databases was performed to identify controlled clinical studies relevant to each topic that were published (in English or foreign languages with English abstracts) from 1980 through August 2000. The search included studies published before 1980 if referenced in the post-1980 literature. Studies that did not include control groups were excluded, except for those reporting adverse effects of ICSs. Studies that met the study selection criteria established for each topic were included in a systematic review of the evidence. An expert panel reviewed the evidence, along with additional literature published since August 2000, and reached a consensus on whether the evidence supported 1997 guideline recommendations or indicated a need for revision. Writing committees were then assigned to developed position statements for each topic. The level of evidence for included studies was rated based on the system of Jadad and colleagues,3 where A = randomized controlled trials, rich body of data; B = randomized controlled trials, limited data; C = nonrandomized trials and observational studies; D = panel consensus judgment.

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

TABLE 1
Criteria for children with intermittent wheeze

Infants and young children meeting these criteria should receive controller therapy for asthma:
  • Significant exacerbations that occur <6 weeks apart
  • ≥4 episodes of wheeze in the past year lasting >1 day and affecting sleep,
AND presence of risk factors for development of persistent asthma:
  • Atopic dermatitis or parental asthma,
  • OR 2 of the following:
  • – Diagnosis of allergic rhinitis
  • – >4% peripheral blood eosinophilia
  • – Wheezing apart from colds

Choosing pharmacologic treatment according to asthma classification

Quick-relief medications, which include the short-acting β2-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 β2-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 daily 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.

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