KEY POINTS: MANAGING ASTHMA LONG TERM IN YOUTHS ≥12 YEARS OF AGE AND ADULTS

• ▪ The goal for therapy is to control asthma by (Evidence A):

  • — Reducing impairment

    • ♦ Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the daytime, in the night, or after exertion)
    • ♦ Require infrequent use (≤2 days a week) of SABA for quick relief of symptoms
    • ♦ Maintain (near) normal pulmonary function
    • ♦ Maintain normal activity levels (including exercise and other physical activity and attendance at work or school)
    • ♦ Meet patients' and families' expectations of and satisfaction with asthma care
  • — Reducing risk

    • ♦ Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations
    • ♦ Prevent progressive loss of lung function; for youths, prevent reduced lung growth
    • ♦ Provide optimal pharmacotherapy with minimal or no adverse effects
• ▪ A stepwise approach to pharmacologic therapy is recommended to gain and maintain control of asthma in both the impairment and risk domains (Evidence A):

  • — The type, amount, and frequency of medication is determined by asthma severity for initiating therapy and by the level of asthma control for adjusting therapy (Evidence A).
  • — Step-down therapy is essential to identify the minimum medication necessary to maintain control (Evidence D).
• ▪ Monitoring and followup is essential (Evidence B).

  • — When initiating therapy, monitor at 2- to 6-week intervals to ensure that asthma control is achieved (Evidence D).
  • — Regular followup contacts at 1- to 6-month intervals, depending on the level of control, are recommended to ensure that control is maintained and appropriate adjustments in therapy are made—step up if necessary and step down if possible. Consider 3-month intervals if a step down in therapy is anticipated (Evidence D).
• ▪ Because asthma is a chronic inflammatory disorder of the airways with recurrent exacerbations, persistent asthma is most effectively controlled with daily long-term control medication, specifically, anti-inflammatory therapy (Evidence A).

  • — ICSs are the preferred treatment option for initiating long-term control therapy (Evidence A).
  • — Selection of an alternative treatment option includes consideration of treatment effectiveness, the domain of particular relevance to the patient (impairment, risk, or both), the individual patient's history of previous response to therapies, the ability of the patient and family to use the medication correctly, and anticipated patient's and family's adherence to the treatment regime (Evidence D).
• ▪ Therapeutic strategies should be considered in concert with clinician-patient partnership strategies; education of patients is essential for achieving optimal pharmacologic therapy (Evidence A).
• ▪ At each step, patients should be advised to avoid or control allergens (Evidence A), irritants, or comorbid conditions that make the patient's asthma worse (Evidence B).
• ▪ A written asthma action plan detailing for the individual patient daily management (medications and environmental control strategies) and how to recognize and handle worsening asthma is recommended for all patients; written asthma action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B). The written asthma action plan can be either symptom or peak-flow based; evidence shows similar benefits for each (Evidence B).
• ▪ Referral to an asthma specialist for consultation or comanagement is recommended if there are difficulties achieving or maintaining control of asthma; if the patient requires step 4 care or higher; if immunotherapy or omalizumab are considered; or if the patient has had an exacerbation requiring hospitalization. Consider referral if the patient requires step 3 care (Evidence D).
• ▪ Special considerations for youths (EPR—2 1997):

  • — Pulmonary function testing should use appropriate reference populations. Adolescents compare better to childhood than to adult predicted norms.
  • — Adolescents (and younger children as appropriate) should be directly involved in establishing goals for therapy and developing their asthma management plans.
  • — Active participation in physical activities, exercise, and sports should be promoted.
  • — A written asthma management plan should be prepared for the student's school, including plans to ensure reliable, prompt access to medications. Either encourage parents to take a copy to the child's school or obtain parental permission and send a copy to the school nurse or designee.
• ▪ Special considerations for older adults (EPR—2 1997):

  • — Chronic bronchitis/emphysema may coexist with asthma. A trial of systemic corticosteroids will determine the presence of reversibility and the extent of therapeutic benefit.
  • — Asthma medications may aggravate coexisting medical conditions (e.g., cardiac disease, osteoporosis); adjustments in the medication plan may be necessary.
  • — Be aware of increased potential for adverse drug/disease interaction (e.g., aspirin, beta-blockers).
  • — Review of patient technique in using medications and devices is essential; physical (e.g., arthritis or visual) or cognitive impairments may make proper technique difficult.