New Asthma Guidelines Emphasize Disease Control and Patient Empowerment

BETHESDA, Md., Aug. 29 --Emphasizing that asthma affects different patients in different ways, the National Asthma Education and Prevention Program has issued new evidence-based guidelines on the disease.

The guidelines include a new emphasis on patient involvement and control of environmental triggers of asthma.

The guidelines are based on evidence from research and clinical experience over the past decade into the mechanisms underlying airway inflammation and into better methods for control, said William Busse, M.D., of the University of Wisconsin at Madison, chairman of the expert panel that drew up the guidelines.

Regarding medication, the guidelines continue the established stepwise approach to asthma control, but with revised and expanded management charts based on three age groups: birth to four years, five to 11,, and 12 and older.

The addition of the five to 11 group is a recognition of differing drug responses between children and adults, Dr. Busse said.

The report reaffirms that patients with persistent asthma require both long-acting control medications and acute rescue therapies as needed, with inhaled corticosteroids recognized as the most effective agents for chronic control in all age groups.

The guidelines also include new recommendations on the use of leukotriene receptor antagonists and cromolyn sodium for chronic asthma control, long-acting beta agonists as adjunctive therapy with inhaled corticosteroids; omalizumab (Xolair) for severe asthma, and on the use of albuterol, levalbuterol, and corticosteroids for acute exacerbations.

The guidelines, weighing in at 487 pages, build on earlier iterations from 1991, 1997 and a 2004 update, but with several key differences, Dr. Busse said. These differences include:

• Further substantiation of the role of inflammation in asthma, with recognition of phenotypic differences resulting in variability in patterns of inflammation
• Recognition of genetic and environmental interactions in asthma expression, with allergic reactions identified as an important environmental factor. Emerging evidence also points to the role of viral respiratory infections.
• Understanding that "the onset of asthma for most patients begins early in life with the pattern of disease persistence determined by early, recognizable risk factors including atopic disease, recurrent wheezing, and a parental history of asthma."
• A finding that anti-inflammatory therapy as currently practiced does not appear to prevent progression of the underlying disease severity

"The new scientific evidence that makes up the guidelines that we're releasing today point to one truth: asthma control is achievable for nearly every patient," said Elizabeth Nabel, M.D., director of the National Heart, Lung, and Blood Institute.

"With appropriate medical care, healthy environments, and well-informed and empowered patients asthma can be controlled and patients can lead full active lives," she said in a media briefing.

The Expert Panel Report 3, as the guidelines are known, focus on four key areas of asthma diagnosis and treatment: assessment and monitoring, patient education, control of environmental factors and other modifiable conditions that can affect asthma, and medications.

The guidelines call for assessing and monitoring asthma with multiple measures of asthma severity, including frequency and intensity of symptoms, lung function, and limitations of daily activities as well as future risk (risk of exacerbations, progressive loss of lung function, or adverse effects from medications). The guidelines emphasize that some patients with intermittent asthma may still be at high risk for frequent severe exacerbations.

The guidelines also stress the importance of educating patients about self-assessment of symptoms and management of asthma, including use of a written action plan with instructions for daily treatment as well as acute and chronic symptoms. New recommendations emphasize bringing asthma education into community setting such as schools, pharmacies, and homes.

The report includes recommendations on control of environmental asthma triggers, with an emphasis on multiple approaches to achieving control, and expands information on treatment of co-morbidities such as rhinitis and sinusitis, gastroesophageal reflux, overweight or obesity, obstructive sleep apnea, stress, and depression.

The report also describes promising new avenues for research into improving asthma management, including tailoring treatment to the asthma phenotype and genotype of individual patients.

"Research is beginning to help us identify genes that influence how well certain patients respond to certain asthma medications," said James Kiley, Ph.D., director of the NHLBI Division of Lung Diseases. "This information is helping us move toward providing personalized treatment for asthma based on a patient's individual characteristics."

A summary report will be released on Oct. 17.

The report, titled Expert Panel Report 3:Guidelines for the Diagnosis and Management of Asthma, is available free of charge at the NHLBI web site