Magazine article Clinical Psychiatry News

Refractory Asthma Persists despite New Guidelines

Magazine article Clinical Psychiatry News

Refractory Asthma Persists despite New Guidelines

Article excerpt

TORONTO -- A substantial proportion of patients with severe refractory asthma are unable to become well controlled despite the availability of updated guidlines, even in subspecialty care, according to Dr. Amandeep S. Gill of the Medical College of Wisconsin, Milwaukee.

The National Asthma Education and Prevention Program's Guidelines for the Diagnosis and Management of Asthma have been updated periodically since they were first published in 1991, with the latest revision being released in 2007.

However, little is known about the effect of the guidelines on the prevalence of severe refractory asthma, the most morbid phenotype of the disease.

To assess the impact, a study was undertaken of 172 patients referred to subspecialty management programs in two Midwestern cities, comparing disease status at presentation and after 1 year of guideline-based care that included education and minimized barriers to care.

A total of 103 patients were seen in an asthma clinic at Case Western Reserve University, Cleveland, and 69 patients in a disease management program at the Medical College of Wisconsin, Milwaukee. Asthma morbidity was assessed retrospectively for the previous year, while patients were being managed in primary care, and prospectively for the subsequent year while they were receiving subspecialty care.

Well-controlled asthma was defined as follows:

* Symptoms no more than twice a week.

* Nocturnal symptoms fewer than two times per month.

* Short-acting bronchodilator use no more than twice per week.

* No interference with normal activities.

* Forced expiratory volume in 1 second ([FEV.sub.1]) at least 80% of predicted.

* No more than one exacerbation per year requiring oral corticosteriods.

In contrast, severe refractory asthma was classified as the requirement for highdose inhaled corticosteroids and a long-acting [beta]-agonist with or without oral steroids and/or omalizumab (step 5 or 6 pharmacotherapy in the guidelines).

The mean age at entry among patients from both cities was 48 years, and the mean duration of asthma was 17 years.

At presentation, 20% of patients from Cleveland and just over 30% of patients from Milwaukee had severe refractory asthma, yet only 34% and 46%, respectively, were on appropriate medications for their level of disease severity. …

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