Research Suggests NIH Asthma Guidelines Need Revision

      IOWA CITY, Iowa, Nov. 3 (AScribe News) -- Asthma is the leading chronic disease of childhood in the United States and the leading cause of hospitalization in children -- despite national guidelines adopted 10 years ago to increase control of the condition.

      Based on outcomes at the University of Iowa Health Care pediatric specialty-based asthma care program, UI researchers see cause for revising asthma guidelines published and disseminated by the National Heart, Lung and Blood Institute within the National Institutes of Health (NIH). Primary care physicians are encouraged to follow those guidelines to treat asthma.

      The findings will be presented Nov. 6 by Miles Weinberger, M.D., UI professor of pediatrics and director of the UI Pediatric Allergy and Pulmonary Division, at the annual meeting of the American College of Allergy, Asthma and Immunology in Seattle. The research was based on asthma care provided by UI specialists to 119 children and adolescents over a one-year period.

      "Despite national attention to the NIH asthma guidelines, which were set in 1991 and revised in 1997, data from the National Center for Health Statistics indicate no decline in hospitalizations or urgent care visits," Weinberger said.

      Even taking into consideration the rise in asthma cases, asthma treatment should be more successful, he added.

      "It''s not that we don''t have effective treatments," Weinberger said. "Asthma health care in primary care settings can be improved based on what we see working in specialty care programs."

      "In primary care settings, the vast majority of asthma treatment is emergency or urgent care; in specialty care programs, less than 10 percent are emergency cases."

      Previous studies by UI and other investigators have shown that specialty care programs can eliminate up to 90 percent of hospitalizations and urgent care visits. The new UI study confirmed this by showing that over a one-year period 735 acute asthma care visits were reduced to 47, and 99 hospitalizations decreased to 10. In addition, nighttime awakening and exercise difficulties from asthma greatly declined.

      The UI study also judged which measures used made the greatest difference in the asthma-related hospitalizations, urgent care visits and interference with sleep or physical activity.

      Weinberger said a key to successful asthma control is to separate treatment for patients with a chronic pattern to their asthma from treatment for those who have recurrent asthma triggered by viral respiratory illness. He suggested the guidelines need to better recognize intermittent asthma, which is a frequent cause of urgent care visits and hospitalizations.

      "Intermittent asthma triggered by common cold viruses is the most common pattern among younger children," Weinberger said. "These patients don''t benefit from the regular medication that is an essential component of treating chronic asthma. Instead, the family can be instructed to intervene sufficiently early with effective medications to avoid urgent medical care or hospitalization."

      The study also showed that effective asthma treatment often requires using less, yet better selected medication. In particular, the investigators saw that for patients with intermittent asthma antibiotics were frequently prescribed before these patients entered the specialty program, with no such usage the subsequent year. For children with chronic asthma, inhaled corticosteriods were used twice as often after the patients had entered the specialty program than during the prior year.

      "The guidelines are currently lengthy and complex," Weinberger said. "It''s unrealistic to think that primary care physicians will use a nearly 140-page document to follow these guidelines. To have a chance of effectively guiding community care of asthma, guidelines should focus on the simplest measures that have the greatest effect rather than attempting to be all inclusive."

      He suggested this could be accomplished in a text of no more than four pages.

      The study also confirmed earlier findings that exposure to tobacco smoke at home makes it significantly more difficult to control asthma in children with either chronic or intermittent asthma.

      Overall, revision of national asthma guidelines with a focus on a few highly effective measures in a brief document could help primary care physicians, who handle more asthma cases than specialists do, be more effective in their management of this common problem, Weinberger said.

      "With currently available measures, there should be zero tolerance for uncontrolled asthma," he said.

      In addition to Weinberger, the study investigators included Abdelhammed Najada, M.D., who was a UI visiting fellow in pediatrics, and Mutasim Abu-Hasan, M.D., UI assistant professor of clinical pediatrics.

      The study was supported in part by funding from the UI Foundation Pediatric Allergy and Pulmonary Education and Research Fund.

      University of Iowa Health Care describes the partnership between the UI College of Medicine and the UI Hospitals and Clinics and the patient care, medical education and research programs and services they provide.

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