Current Allergy and Clinical Immunology - March 2008

SNIPPETS FROM THE JOURNALSAllan S Puterman, MB ChB, FCP, FAAAAIThe November 2007 edition of the Journal of Allergyand Clinical Immunology contains the long-awaitedreport of the National Asthma Education andPrevention Program – Expert Panel Report 3.This report entitled Guidelines for the Diagnosis andManagement of Asthma is also supported by the USADepartment of Health and Human Science NationalInstitutes of Health and the National Heart, Lung andBlood Institute.This is one of the most comprehensive guidelines onasthma management currently published. The guidelinesopen with a detailed disclosure of financial interestsby all participants. The guidelines define asthma,explore the diagnosis and expand on long-term management.Management consists of four components including:• assessing and monitoring asthma severity and control• education for a partnership of care• control of environment and comorbid conditions• medication.The panel emphasises the importance of control buttakes into account both the degree that manifestationsof asthma are minimised by therapeutic intervention(control) as well as the intrinsic intensity (severity) ofthe disease process in a particular patient. The panelrecommends that for managing asthma, one should‘assess severity to initiate therapy and assess controlto adjust therapy’.New concepts introduced include ‘Current impairment’which refers to frequency and intensity of symptoms,low lung function and limitations of daily function.Further ‘Future risk’ refers to a likelihood of exacerbations,progressive loss of lung function and adverseeffects of medication. The guidelines stress that somepatients may be at high risk for exacerbations eventhough they have few day-to-day symptoms.The educational aspect confirms the importance ofteaching patients skills to self-monitor and manageasthma. A written asthma action plan is key. New recommendationsencourage expanding education intoschools and also deal with clinician education.The stepwise approach is emphasised with theincrease to 6 steps from the original 4. I have taken theliberty of reproducing Figure 13 ‘Stepwise approach formanaging asthma long-term in children 0 to 4 and 5 to11’, firstly, to show how this guideline is both comprehensiveyet simple, and secondly because it covers theage group that is often the most problematic.This guideline supplement is a timely addition as it mayprovide the answer to a pertinent question asked byHans Bisgaard in the Letters to the Editor section ofthe JACI October 2007 edition, namely ‘What drivesprescription patterns in pediatric asthma management?’He has analysed data from the Danish Asthma Registerof Medicinal Products Statistics which containsrecords from all prescriptions for medicinal productsprescribed in Denmark. His analysis shows anincreased prescription in children of combinationICS/LABA products as well as an increased use ofthese products as first-line treatment in previouslysteroid-naïve children. Both trends are contrary toDanish guidelines. His discussion includes possiblereasons, such as real-life experience may be betterthan clinical trials, and disease severity may be increasing.Pharmacuetical industry pressure and inefficientguideline dissemination are also mentioned.The answer to Bisgaard’s question may lie in a verysimple line that is repeated often in the new Americanguidelines. ‘The stepwise approach is meant toassist, not replace, the clinical decision-makingrequired to meet individual patient needs.’Correspondence: Dr A Puterman, e-mail: putall@global.co.za44 Current Allergy & Clinical Immunology, March 2008 Vol 21, No. 1