Asma

MANAGING ASTHMA IN PRIMARY CARE

REVIEW

Managing Asthma in Primary Care: Putting New Guideline Recommendations Into Context
M E. W , MD
therefore, they may not always prescribe adequate controller medication therapy.7 Physicians may also have an inadequate understanding of disease etiology or may not communicate well with patients, and these problems make it dif cult to establish apharmacotherapeutic regimen that the patient is willing and able to follow.5 In light of the complexities inherent in the longterm management of asthma, national and international guidelines have been developed over the years to assist clinicians in caring for their patients. The use of guidelinebased treatment strategies has been shown to favorably affect asthma outcomes, but there has also beenincreasing recognition that For editorial previous guidelines were not adequately comment, followed and did not lead to acceptable see page 673 levels of asthma control.8 In 2007, the National Asthma Education and Prevention Program (NAEPP) issued updated guidelines for the diagnosis and management of asthma (the Expert Panel Report 3 [EPR3]),9 which, among other changes, shifted the focus to ongoingassessment of disease control with the goal of improving the management of asthma over time. The current review is intended to assist primary care physicians in improving their patients’ asthma control, in part through an improved understanding of the new guidelines, and to provide a specialist’s perspective on diagnosing asthma and prescribing appropriate therapy, monitoring disease control, andproviding appropriate and timely referrals. As such, this review is based primarily on the NAEPP guidelines, the references therein, and the author’s clinical experience. OVERVIEW OF THE UPDATED NAEPP GUIDELINES The NAEPP, initiated by the National Heart, Lung, and Blood Institute in 1989 in response to the worsening asthFrom the Division of Pulmonary and Critical Care Medicine, Brigham and Women’sHospital, Harvard Medical School, Boston, MA. From 2007 to 2009, Dr Wechsler consulted for or participated in advisory boards or speakers bureaus for AstraZeneca, GlaxoSmithKline, ScheringPlough, Novartis, Genentech, Merck, MediciNova, and Sepracor. This article is freely available on publication, because the authors have chosen the immediate access option. Individual reprints of this article arenot available. Address correspondence to Michael E. Wechsler, MD, Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, 15 Francis St, PBB Lobby, Boston, MA 02115 (mwechsler@partners.org). © 2009 Mayo Foundation for Medical Education and Research

Many patients with asthma are treated in the primary care setting. The primary care physician is therefore in akey position to recognize poorly controlled asthma and to improve asthma management for these patients. However, current evidence continues to show that, for a substantial number of patients, asthma control is inadequate for a wide variety of reasons, both physician-related and patient-related. The most recently updated treatment guidelines from the National Asthma Education and Prevention Programwere designed to help clinicians, including primary care physicians, manage asthma more effectively with an increased focus on achieving and maintaining good asthma control over time. The current review is intended to assist primary care physicians in improving asthma control among their patients; this review clarifies the new guidelines and provides a specialist’s perspective on diagnosis,appropriate therapy, disease control surveillance, and appropriate referral when necessary. This discussion is based primarily on the new guidelines and the references cited therein, supplemented by the author’s own clinical experience. Mayo Clin Proc. 2009;84(8):707-717
ACT = Asthma Control Test; EPR3 = Expert Panel Report 3; FeNO = fractionated exhaled nitric oxide; ICS = inhaled corticosteroid;...