Stable Mild Persistent Asthma in a Young Adult
Reviewed By Allergy, Immunology & Inflammation Assembly
Submitted by
Cathy Benninger, RN, MS, CNP
The Ohio State University
Columbus, OH
John Mastronarde, MD
The Ohio State University
Columbus, OH
Submit your comments to the author(s).
History
A 29-year-old man with mild persistent asthma presented to an outpatient office for a follow-up visit. He was originally referred 6 months ago by his primary care provider after having an asthma exacerbation which required treatment in an emergency room.
At his initial visit, he reported wheeze and cough 4 days a week and nocturnal symptoms three times a month. Spirometry revealed forced vital capacity (FVC) 85% predicted, forced expiratory volume in 1 second (FEV1) 75% predicted, FEV1/FVC 65%, and an increase in FEV1 of 220 ml or 14% following an inhaled short-acting bronchodilator. He was placed on a low-dose inhaled corticosteroid twice a day and a short-acting inhaled beta-agonist as needed. He returned 4 weeks later improved, but with continued daytime symptoms 2 days a week. He also had symptoms of rhinitis; therefore he was referred to an allergist for evaluation. Skin testing was positive for trees, ragweed, dust mites, and cats, and he was prescribed a nasal steroid spray and nonsedating oral antihistamine. He presents today and reports no asthma exacerbations since his last visit. Furthermore, during the past 4 weeks, he has not been awakened by his asthma, experienced morning breathing symptoms, missed work, had any limitations in activities due to asthma, or required the use of rescue albuterol. He currently denies shortness of breath or wheezing. He performs aerobic exercise 4 days a week for 45 minutes per session without symptoms, provided he premedicates with a short-acting inhaled beta-agonist. His review of symptoms is otherwise unremarkable. His current medications include low-dose inhaled corticosteroid, 1 puff twice a day; steroid nasal spray, 2 puffs each nostril daily; a nonsedating antihistamine, 1 tablet daily; and inhaled beta-agonist, 2 puffs as needed. His past medical history is significant for intermittent asthma diagnosed at age 13 and frequent “colds.” He has never required hospitalization for an asthma exacerbation. He works as a hospital microbiologist and does not smoke, drink alcohol, or use illicit drugs. He recently moved to a pet-free apartment complex and instituted dust mite protective barriers for his bedding. His family history is noncontributory.
Physical Exam
On physical exam, he is an age-appropriate man in no acute distress. His height and weight are proportionate and resting oxygen saturation as measured by pulse (SpO2) is 98% on room air. Head and neck exam revealed mild erythema of the nasal mucosa. Heart exam revealed normal heart tones, no murmurs, gallops or rubs, and the lungs were clear to auscultation. Extremities were free of edema, cyanosis, or clubbing.
Lab
In the office, spirometry is completely normal. He states he feels great and inquires about stopping his inhalers, particularly his inhaled steroid.
The goal of asthma therapy is to minimize risk and maintain asthma control with the least amount of medication (1). In patients with mild persistent asthma, recent studies have demonstrated several options for "step-down therapy." The American Lung Association Asthma Clinical Research Centers network study found that patients who stepped down from twice daily low-dose fluticasone to once daily combination therapy with fluticasone/salmeterol had equivalent asthma control scores, FEV1, and frequency of exacerbations compared with continued therapy with twice daily fluticasone (2). Once-daily montelukast demonstrated a slightly higher treatment failure compared with either of the regimens containing inhaled steroids. Despite the slight increase in treatment failure with montelukast, each of the treatment groups had equivalent symptom-free days and rates of clinically significant asthma exacerbations. Thus, while either regimen would be appropriate, stepping down to once-daily combination therapy with fluticasone/salmeterol appears to be more beneficial.
Recent studies also suggest that those with mild persistent asthma taking inhaled corticosteroids in combination with either a long-acting beta-agonist or a short-acting beta-agonist when symptomatic, had no increase in adverse outcomes compared with those taking scheduled daily inhaled doses. Boushey et al. (3) compared patients with mild persistent asthma using twice-daily budesonide versus twice-daily zafirlukast verses placebo. All three groups used budesonide as-needed following a symptom-based action plan. The study found that in comparison with patients on a daily controller (budesonide or zafikulast), participants using only as-needed budesonide had no significant difference in morning peak expiratory flow, postbronchodilator FEV1, quality of life, or frequency of asthma exacerbations. Results of this study raise the possibility of treating mild persistent asthmatics with as-needed inhaled corticosteroids. More recently, Papi et al. (4) found as-needed use of an inhaler containing both beclomethasone and albuterol for symptom relief was associated with fewer exacerbations and higher morning peak flow readings than using an inhaler with albuterol alone. The morning peak flow readings in the as-needed combination beclomethasone/albuterol group was equivalent to those taking scheduled daily doses of beclomethasone alone, or scheduled daily doses of beclomethasone/albuterol combined. The combination of an inhaled steroid and a short-acting beta-agonist in a single inhaler is not currently available in the United States.
In the mild persistent asthmatic there is now strong evidence to support multiple treatment approaches which provide good asthma control. Matching the drug regimen with the patient’s preferences, lifestyle, comorbidities, and financial limitations will help ensure drug adherence and maintain asthma control.
All of the elements are important components of an asthma action plan. However, Gibson and Powell (5) found a 40% reduction in hospital admissions and a 20% reduction in emergency room visits when the plan contained personalized instructions regarding the medications to add, criteria for adding the medication, duration of use, and when to seek medical help when patients are symptomatic. An asthma action plan serves as a patient guide for early recognition and treatment of an exacerbation. Treatment guidelines may be based on symptoms, peak flow readings, or both. When peak flow readings are used, personal-best readings were consistently associated with improved health outcomes compared with percentage-predicted readings (5).
Spirometry is a simple test that can be performed in-office and can be used to assist the provider in determining the degree of airway obstruction (1, 6). There are no widely accepted data correlating frequency of spirometry with clinical outcomes in asthmatics, thus one must rely on expert opinion and individual patient needs. Spirometry is recommended during the initial evaluation after treatment is initiated and the patient’s symptoms have stabilized during periods of progressive or prolonged loss of asthma control and at least every 1-2 years (1).
When spirometry is used to diagnose or confirm asthma, testing must include pre- and post-bronchodilator readings (1). A change in FEV1 of >200 ml and ≥ 12% from the baseline measure following the administration of a short-acting bronchodilator is indicative of significant airway reversibility which has been shown to correlate with airway inflammation (7).
The Expert Panel (1) classifies asthma severity by FEV1, FEV1/FVC, short-acting beta-agonist use, or frequency of asthma symptoms. Parameters are measured at baseline with asthma severity determined by the worse parameter, e.g., daily symptoms with normal FEV1 is classified as moderate persistent asthma. Correct identification of asthma severity guides the provider in choosing the appropriate type and amount of therapy.
Inadequate asthma control and a need for step-up therapy is based on two or more daytime symptoms per week, two or more nighttime symptoms per month, interference with activities of daily living, use of short-acting beta-agonist > 2 days/week (excluding use for prevention of exercise-induced bronchospasm),or peak flow or FEV1 <80% predicted/personal best (1).
Asthma symptoms should be assessed at each office visit to determine asthma control. Validated self-assessment tools such as the Asthma Control Test (ACT), Asthma Therapy Assessment Questionnaire (ATAQ), or Asthma Control Questionnaire (ACQ) can facilitate consistent measurement and documentation of asthma symptoms during office visits (1, 8). All asthmatics are at risk for a severe asthma attack regardless of their asthma classification; therefore, providers are encouraged to teach patients to recognize symptoms of inadequate asthma control and provide them with specific instructions for adjusting their medications or seeking medical care (1).
Assessing inhaler technique at each office visit allows the provider an opportunity to assess compliance, reinforce proper use, and identify motor or physical limitations affecting technique (8).
When studied, only approximately 25% of patients are able to properly demonstrate use of a meter dose inhaler when asked. The remaining 75% improved with specific instruction and practice which reinforces the need to incorporate proper inhaler use during the office visit (9,10). The use of a spacer significantly improves accuracy and dose delivery, particularly in patients with poor coordination skills (9,10).
Assessing patient adherence is best approached with a nonjudgmental attitude. Adherence to inhaled corticosteroids is estimated at < 50% (11). Causes of nonadherence are multifactorial but may be improved by providing asthma education, encouraging self management through use of an asthma action plan, and facilitating open communication (11). Financial barriers often transcend all other efforts to improve adherence and must be taken into account when prescribing asthma therapy (11).
Methacholine challenge testing is useful to demonstrate airway hyperresponsiveness in those with normal spirometry and a suspicion of asthma, but is not recommended as a serial procedure. Biomarkers for inflammation such as eosinophils or nitric oxide are being investigated in clinical trials but currently have no indication in routine asthma care (1). Peak flow monitoring is useful for long-term home assessment of asthma control and medication response, but is not indicated for regular office assessment or diagnostic purposes (1).
References
- Expert Panel Report 3 (EPR 3). Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Institutes of Health; 2007. NIH Publication No. 08-4051.
- The American Lung Association Asthma Clinical Research Centers. Randomized comparison of strategies for reducing treatment in mild persistent asthma. N Engl J Med 2007;356:2027-2039.
- Boushey HA, Sorkness CA, King TS, et al. Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med 2005;352:1519-1528.
- Papi A, Giorgio GW, Maestrelli P, et al. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med 2007;356:2040-2052.
- Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2007;59:94-99.
- Miller MR, Hankinson J, Brusasco V, et al. Series ATS/ERS Task Force: Standardization of lung function testing. Eur Respir J 2005;26:319-338.
- Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. N Engl J Med 2005;26:948-968.
- Global Initiative for Asthma. Pocket guide for asthma management and prevention. Bethesda, Md: National Institutes of Health; 2006.
- Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002;19(2):246-251.
- Johnson DH, Robart P. Inhaler technique of outpatients in the home. Respir Care 2000;45(10):1182-1187.
- Elliott RA. Poor adherence to anti-inflammatory medication in asthma reasons, challenges, and strategies for improved disease management. Dis Manage Health Outcomes 2006;14(4):223-233.
