Sunday, September 09, 2007

New Asthma guidelines-some more some less

Here is the latest version of asthma guidelines. The full report is 487 pages and is entitled " Guidelines for the diagnosis and management of asthma." Asthma specialists can be appropriately proud because this report is longer than the 304 page tome penned by a joint group (ACC/AHA) dealing with the 2007 guidelines for the management of patients with unstable angina/non-ST segment elevation myocardial infarction. Both overshadow in bulk the rather brief (88 page) guideline publication from GOLD (Global Initiative for Chronic Obstructive Lung Disease) and the 2004 86 page treatise (JNC 7) which still incites seemingly irreconcilable differences between blood pressure experts regarding how to treat blood pressure and can be found here.

Not only are there more guidelines published all the time they seem to get bigger and bigger.The dominate paradigm seems to be "more is better". Recent discussions regarding asthma are suggesting that in regard to mild persistent asthma less may be about as good as more in terms of intensity of therapy even while the guideline verbiage grows and grows.

It will take sometime to contrast the details with earlier versions of the asthma guidelines but one difference I noticed was that there it is permissible ( or mandatory) to not only increase treatment when control is not adequate but it is also allowable to actually decrease treatment intensity when asthma is well controlled.

I will need a little more time to try and wrap my understanding around what I might really need to know after the fluff is filtered out (you can't have a paper that long without some fluff) but here is what the reviewer for Med Page Today had to say about it and here is an overview with some details from Medscape. Long acting beta agonist (LABAs) are not recommended as mono therapy for persistent asthma nor for treatment of acute exacerbations. Lip service is given to long acting theophylline oral medications as an alternative but I suspect the docs using them are hard to find. Fortunately, the panel was not frightened off by the meta-analysis published by the Salpeters,which I ranted about over and over, and continue to recommend the use of the combo treatment of LABA plus inhaled steroids.

The idea that we may not need to treat mild persistent asthma as aggressively (intensely) as we now recommend has been written about recently in two clinical trials in the NEJM and in the form of an editorial in the Annals of Internal Medicine. The NEJM articles can be found here and here.

One of the reason for use of so-controller ( as opposed to rescue therapy) in persistent asthma is the expectation (hope? theory?) that chronic mediation will control or minimize the inflammatory processes so that long term lung function loss will not occur. Short term trials of such therapeutic ploys such as use of rescue combo inhaler of an ICS plus a LABA ( as was done in one such trial ) cannot address the long term concerns and I suspect that ICS will continue to be the mainstay of the treatment of persistent asthma for some time to come.

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