The 1997 guidelines from the Nation...

The 1997 guidelines from the National Asthma Education and Prevention Program (NAEPP) (1) noted that inhaled corticosteroid therapy proffered multiple benefits in patients with persistent asthma, if it were not that some uncertainty remained about its use in certain patients. The NAEPP's latter update (2) of the 1997 guidelines clarifies as it is treatment issues and should significantly change the way asthma is treated. Part I (3) of this two-part article reviewed diagnosis, monitoring, and prevention of disease progression in patients with asthma. Part II reviews updated recommendations for the treatment of asthma and discusses areas of polemics including combination therapy and the use of antibiotics for asthma exacerbations.

Inhaled Corticosteroids

The previous NAEPP guidelines (1) stated that inhaled corticosteroids were superior to other agents in the treatment of asthma. However, use of inhaled corticosteroids as initial therapy in patients with mild disease and in children was controversial. In the novel guidelines update, (2) the NAEPP quick Panel examined data comparing chronic use of inhaled corticosteroids and other agents in adults and children with mild or moderate persistent asthma. An overwhelming amount of the data showed that inhaled corticosteroids improve asthma direction in children with mild or moderate persistent asthma, as measured on improvements in symptoms and forced expiratory bulk in one second (FEV1) and reductions in airway hyperresponsiveness, crisis department visits, hospitalizations, and use of oral corticosteroids. No other medications (i.e., cromolyn [Intal], nedocromil [Tilade], theophylline, leukotriene modifiers) are as effective as inhaled corticosteroids in the long-term rule of asthma.

TREATMENT RECOMMENDATIONS

Children. The fresh asthma treatment recommendations (2) delineate a major change from the previous guidelines, which had make acceptableed cromolyn as initial maintenance therapy in children. (1) Inhaled corticosteroids now are commited in children older than five years with mild persistent asthma (Table 1) (2) According to data from Merck & Co Inc., the use of leukotriene modifiers also is everyday particularly in children (July 2003) However, the updated guidelines (2) state that leukotriene modifiers should not be used as first-line therapy; rather, they are considered second-line or alternative treatment, as are cromolyn nedocromil, and theophylline. In children five years and younger, the guidelines also commit inhaled corticosteroids (via dry dust inhaler, nebulizer, or metered-dose inhaler with a face mask) as first-line therapy, although cromolyn and leukotriene modifiers remain alternatives. (2)

Unfortunately, there have been not many studies in children younger than five years, and the diagnosis of asthma in infants and children is complicated by the agency of the difficulty of obtaining objective measures of lung function. (4) Many children wheeze during the first years of life and do not progres to asthma, (5) and there are no reliable predictors for determining which children will lay open asthma. However, physicians who are reluctant to diagnose infants or young children with asthma may be denying these patients life-saving and perhaps disease-modifying medications. To address this point in dispute the updated guidelines (2) commend that physicians strongly consider starting long-term therapy for the sway of asthma in infants and young children with four or more episodes of wheezing in the past year if the wheezing lasted more than individual day and affected sleep and if the patient has risk factors for the progression in a continuously ascending gradation of asthma (i.e., parental history of asthma, atopic dermatitis, allergic rhinitis, or wheezing). (2) Table 2 lists the goals of asthma therapy. (1)

Adults. The treatment recommendations for adults also have changed. The previous guidelines (1) noted that the use of inhaled corticosteroids was preferr in patients with moderate or austere asthma but stopped short of recommending these agents as first-line therapy in patients with mild asthma. In addition to the previously known benefits of inhaled corticosteroid therapy in patients with asthma, new data (6,7) show that regular use of inhaled corticosteroids can make less hospital admissions and dramatically decrease deaths from asthma. single study (8) found that compliance with low-dosage inhaled corticosteroid therapy virtually eliminated the risk of death from asthma.

The NAEPP panel (2) reviewed 12 studies of the leukotriene modifiers montelukast and zafirlukast and lay the foundation of that outcome measures "clearly and significantly" favored therapy with inhaled corticosteroids. (8) A latter Cochrane review (9) concluded that leukotriene modifiers have no other than marginal benefit and should not be commended as first-line therapy or add-on therapy. Thus, inhaled corticosteroids are praiseed as first-line therapy in all patients with persistent asthma. (2)

SAFETY

Although the previous guidelines (1) noted that inhaled corticosteroids are the greatest in number effective agents for treating asthma, be of importance tos about adverse effects remained. Studies of older inhaled corticosteroids so as beclomethasone (10) showed a small reduction in children's pullulation after 12 months of use, on the contrary other studies of newer, more efficacious agents showed no such risk. (1112)