An effort coordinated by the National Heart, Lung, and Blood Institute, the National Asthma Education and Prevention Program has created a comprehensive update to their asthma guidelines. 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.
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."
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."
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.