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Effective management of asthma requires accurate identification
and management of symptom triggers, as well as medications
to control symptoms.1,2 Expert
guidelines published by such groups as the National Institutes
of Health (NIH) and American Academy of Family Physicians (AAFP)
recommend a thorough allergy assessment during the asthma workup.
Both groups also recommend the option of specific IgE testing
by primary care clinicians.1,2
The NIH National Asthma Education and Prevention Program (NAEPP)
Expert Panel Report 2: Guidelines for
the Diagnosis and Management of Asthma offers the following
guidance on management and trigger identification1:
- Exposure of asthma patients to irritants or allergens
to which they are sensitive has been shown to increase asthma
symptoms and precipitate asthma exacerbations
- For at least those patients with persistent asthma
on daily medications, the clinician should:
- Identify
allergen exposures
- Use patient history to assess sensitivity
to seasonal allergens
- Use skin testing or in
vitro testing
for IgE antibodies to assess sensitivity to perennial
indoor allergens
- For selected patients with asthma at any level of severity, detection of specific IgE sensitivity
to seasonal or perennial allergens may be indicated as
a basis for avoidance, for immunotherapy, or to characterize
the patient's atopic status
- Assess the significance
of positive tests in the context of the patient's
medical history
- Patients with asthma at any level of severity
should avoid:
- Exposure to allergens to which they are
sensitive
Allergy testing may be conducted along with pulmonary function
testing and other evaluations to aid the diagnostic process.3
In addition to trigger control, medications may be needed
to control asthma symptoms (as needed, based on disease severity).
A recent update to the NAEPP guidelines recommends the
first-line use of chronic inhaled corticosteroids for both
adults and children with persistent asthma (see table below).4 Other
medications, such as cromolyn, theophylline, and leukotriene
modifiers are deemed as alternative treatments to be used only
as needed.
Preferred
Medical Treatment: A Stepwise Approach
for Managing Asthma |
| Clinical
features before treatment or adequate control |
| Asthma Classification |
Symptom Frequency |
Medications Required to
Maintain Long-term Control |
Step 4
Severe persistent |
Daytime: continual
Nighttime: frequent |
High-dosage inhaled corticosteroid
and long-acting beta2 agonist |
Step 3
Moderate persistent |
Daytime: daily
Nighttime: more than
1 night per week |
Children 5 years and younger:
low-dosage inhaled corticosteroid and long-acting beta2 agonist
or medium-dosage inhaled corticosteroid
Adults and children older than 5 years: low- to medium-dosage
inhaled corticosteroid and long-acting inhaled beta2 agonist |
Step 2
Mild persistent |
Daytime: more than 2 days per week, but less than
1 time per day
Nighttime: more than
2 nights per month |
Low-dose inhaled corticosteroid
(delivered by nebulizer or metered-dose inhaler with
holding chamber, with or without a face mask, or by dry
powder inhaler in children 5 years or younger) |
Step 1
Mild intermittent |
Daytime: 2 days per week
or less
Nighttime: 2 nights per month or less |
No daily medication needed |
| Mintz M. Asthma
update: part II. Medical management. Am Fam Physician. 2004;70:1061-1066;
and National Institutes of Health. NAEPP Expert Panel
Report: Guidelines for the Diagnosis and Management of
Asthma: Update on selected topics 2002. Bethesda, Md:
National Institutes of Health [reprinted 2003]. NIH publication
02-5075. |
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