Q: How can repeated visits to the emergency department (ED) for asthma exacerbations best be avoided?
A: The goals of management of chronic persistent asthma are to eliminate symptoms and to achieve maximum functioning. We now have the knowledge and the pharmacologic agents to help attain these goals.1
Most patients who have asthma exacerbations use short- and long-acting bronchodilators for control of symptoms. But these "rescue" medications do not address the fundamental pathology of asthma, which involves inflammation of the airways. Because it drives bronchospasm, inflammation must be suppressed. Inhaled corticosteroids are the mainstay therapy for managing airway inflammation. These agents, such as fluticasone (which does not increase the risk of osteopenia2), have an excellent safety profile.
Nevertheless, a recent study showed that at follow-up visits, primary care physicians infrequently added inhaled corticosteroids to the regimen of asthmatic patients discharged from the ED after an exacerbation.3 Even if these agents were prescribed, their impact was not evident during subsequent visits. This is probably because the prescription was not filled or was not used as intended.
Asthma guidelines stress the long-term use of inhaled corticosteroids because this strategy reduces morbidity.4 A new study suggests a possible alternative for titration of corticosteroid doses in patients with mild to moderate disease (Box). Approximately two thirds or more of patients who have chronic persistent asthma with exacerbations can achieve complete control with step therapy that involves inhaled corticosteroids, leukotriene modifiers, and long-term b2-agonists.5,6
It is a challenge for many clinicians to succeed in having patients adhere to an effective maintenance management program.7 Yet we have the ability to control symptoms--and thus to improve quality of life--in most patients with asthma.
1.Barnes PJ. Scientific rationale for inhaled combination therapy with long-acting beta 2-agonists and corticosteroids. Eur Respir J. 2002;19:182-191.
2. Kemp JP, Osur S, Shrewsbury SB, et al. Potential effects of fluticasone propionate on bone mineral density in patients with asthma: a 2-year randomized, double-blind, placebo-controlled trial. Mayo Clin Proc. 2004;79:458-466.
3. Cydulka RK, Tamayo-Sarver JH, Wolf C, et al. Inadequate follow-up controller medications among patients with asthma who visit the emergency department. Ann Emerg Med. 2005. Epub ahead of print.
4. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed May 25, 2005.
5. Sin DD, Man J, Sharpe H, et al. Pharmacologic management to reduce exacerbations in adults with asthma: a systematic review and meta-analysis. JAMA. 2004;292:367-376.
6. Bateman ED, Boushey HA, Bousquet J, et al. Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma Control study. Am J Respir Crit Care Med. 2004;170:836-844.
7. Reed CE. Inhaled corticosteroids: why do physicians and patients fail to comply with guidelines for managing asthma? Mayo Clin Proc. 2004;79:453-455.
8. Smith AD, Cowan JO, Brassett KP, et al. Use of exhaled nitric oxide measurements to guide treatment in chronic asthma. N Engl J Med. 2005;352:2163-2173.