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Chronic Asthma

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Full Title: Management of Chronic Asthma

September 2001

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Structured Abstract

Objectives: Asthma affects over 14 million persons in the U.S. and is the most common chronic disease of childhood. This systematic review addresses 5 key questions:

  1. Whether chronic use of inhaled corticosteroids (ICS) improves long-term outcomes for children with mild to moderate asthma; and whether chronic ICS use in children results in long-term adverse effects.
  2. Whether, for patients with mild-moderate asthma, early initiation of ICS prevents asthma progression. Whether, in patients with moderate asthma, adding other long-term controllers to low-moderate dosages of ICS improves control.
  3. Whether adding antibiotics to standard care improves the treatment of acute asthma exacerbation.
  4. Whether a written asthma action plan improves outcomes, and whether a peak flow monitor-based plan is superior to a symptom-based plan.

Search Strategy: The MEDLINE® and Embase databases were searched from 1980 through August 2000 for articles using the following textwords or Medical Subject Headings (MeSH®) terms in their titles, their abstracts, or their keyword lists: leukotriene antagonists; zileuton; montelukast; zafirlukast; cromolyn; nedocromil; theophylline; adrenergic beta-agonists (including albuterol and salmeterol); "adrenal cortex hormones" OR steroids (including beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone, triamcinolone); OR antibiotics; peak expiratory flow rate; meter* (truncated); monitor* (truncated); action plan* (truncated); self care; patient care planning; patient participation. Results were limited to those articles that were indexed under the MeSH® term "asthma"; addressed studies on human subjects; and were indexed under any of the following study design terms: clinical trials; intervention studies; double-blind method; single-blind method; placebo* (truncated); random allocation; controlled clinical trial; cohort studies. Total retrieval was 4,578 references.

Selection Criteria: Inclusion was limited to controlled trials of efficacy outcomes. Uncontrolled studies of long-term adverse effects of ICS in children were also included. Yield was 87 selected from 668 dually reviewed, full-length articles.

Data Collection and Analysis: Each study was abstracted by two independent reviewers using a prospectively designed protocol. Meta-analysis of outcomes of long-acting beta-2 agonists added to ICS was performed based on calculated effect sizes.

Main Results: Compared to as-needed beta-2 agonists, ICS improves control in children with mild-to-moderate asthma; no alternative long-term controller appears to be superior. ICS therapy at recommended doses does not appear to have frequent, clinically significant, or irreversible effects on vertical growth, bone mineral density, ocular toxicity, or suppression of adrenal/pituitary axis in the short term. However, no studies have sufficient followup or size to assess cumulative effects in later life.

The best available evidence does not support the hypothesis that mild to moderate asthmatics undergo progressive decline in lung function, which might be prevented by early ICS initiation. Adding long-acting beta-2 agonists or leukotriene antagonists to ICS improves asthma control, as may theophylline, but studies in children are lacking. The evidence suggests no benefit to using antibiotics routinely for treatment of acute asthma exacerbation. The evidence is insufficient to demonstrate that use of a written asthma action plan improves outcomes, or that peak flow monitoring-based plans are superior.

Conclusions: A national research agenda for long-term studies to improve effectiveness of asthma management is needed, with high priority to pediatric studies. Future asthma trials should use common definitions for severity, population characteristics, and outcome measures and should comply with recognized standards for reporting and statistical analysis. Research on rational antibiotic use should include explicit study questions and populations relevant to asthma management.

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Management of Chronic Asthma

Evidence-based Practice Center: Blue Cross and Blue Shield Association Technology Evaluation Center (TEC)
Topic Nominators: National Heart, Lung, and Blood Institute, American Academy of Pediatrics, American Association of Family Physicians

Current as of September 2001


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