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Achieving Quality Outcomes in the Treatment of Asthma  
By Scott E. Bagenstose, MD

Treatment of any chronic disease state requires considerable investment of time and effort by both physicians and patients alike. The challenge is to offer efficacious, safe, well-tolerated treatments that are affordable and cost-effective. Of course few, if any, medications can completely satisfy all of these concerns.

Perhaps no condition illustrates this challenge better than asthma. Despite an extensive array of available maintenance medications, many patients experience inadequate control of their disease. In fact, asthma controller medications are among the least refilled of any chronic disease state.1   Evidence supports that this is largely not a factor of cost and accessibility.2 Given the high prevalence of asthma, direct and indirect expenditures related to inadequately controlled asthma are astoundingly high.3

MGO’s asthma clinical guidelines were developed to address these very concerns. Through the development, implementation, and use of such guidelines, organizations such as MGO strive to enhance asthma control among our patients while reducing costs of treatment and improving patient satisfaction with asthma care. Essential points in the guideline set include careful attention to making a proper diagnosis, effective and efficient implementation of the right maintenance therapies, and appropriate monitoring.

Many patients present with respiratory symptoms such as coughing, wheezing, and difficulty breathing. Differentiating asthma from other potential diagnoses can be complex. The improper diagnosis of asthma has been shown to lead to higher treatment-related costs as well as patient dissatisfaction with care.4 I would encourage all physicians to try to objectify this process whenever possible. Office spirometry represents the best place to start.3   Patients without a diminished FEV1/FVC ratio should be considered for other diagnoses. Methacholine challenge testing represents a valuable tool to effectively rule out asthma when the result is negative. However, due to the relatively lower positive predictive value, a positive result does not necessarily rule in asthma.5

Ideally, asthma controller medications should be efficacious and have few associated adverse effects. Evidence has consistently demonstrated that inhaled corticosteroids (ICS) remain the most effective first-line therapy for asthma control, and that systemic effects are negligible with the usual doses.3,6,7 I would encourage avoiding high-dose ICS whenever possible to avoid potential systemic effects - also data has not consistently demonstrated better outcomes with higher doses.8 Additionally, patients may express concern regarding the “black box” warning affixed to labels of products containing long-acting bronchodilators (LABDs). Although evidence does support that these medications should not be utilized as monotherapy, their use in combination with ICS appears safe, effective, and well-tolerated in the vast majority of patients.9

Given the diversity of asthma phenotypes, no single treatment paradigm will be sufficient for all patients. New diagnostic tests (e.g., measurement of exhaled nitric oxide) should be helpful in making a more precise diagnosis of asthma in the clinical setting. Similar tests will predict which specific therapies will be more likely to be of value for our patients. Updated guidelines, issued at intervals, will incorporate such advances and allow clinicians to continue to achieve better quality outcomes in asthma management.

1. Balkrishnan R, Nelson LM, Kulkrani AS, Pleasants RA, Whitmire JT, Schecter MS. Outcomes associated with initiation of different controller therapies in a Medicaid asthma population: a retrospective data analysis. J Asthma 2005;35-40.

2. Peters SP, Jones CA, Haselkorn T, Mink DR, Valacer DJ, Weiss ST. Real-world Evaluation of Asthma Control and Treatment (REACT): findings from a national web-based survey. J Allergy Clin Immunol 2007;116:1454-61.

3. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. US Department of Health and Human Services 2007. Available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

4. LindenSmith J, Morrison D, Deveau C, Hernandez P. Overdiagnosis of asthma in the community.  Can Respir J 2004;11:111-6.

5. Hopp RJ, Bewtra AK, Nair NM, Townley RG. Sensitivity and specificity of methacholine inhalation challenge in normal and asthmatic children. J Allergy Clin Immunol 1984;74:154-8.

6. Guevara JP, Ducharme FM, Keren R, Nihtianova S, Zorc J. Inhaled corticosteroids versus sodium cromoglycate in children and adults with asthma. Cochrane Database Syst Rev 2006 Apr 19;(2):CD003558.

7. Ducharme FM Inhaled corticosteroids versus leukotriene antagonists as first-line therapy for asthma: a systematic review of current evidence. Treat Respir Med 2004;3:399-405.

8. Greenstone IR, Ni Chroinin NM, Masse V, Danish A, Magdalinos H, Zhang X, Ducharme FM. Combination of inhaled long-acting beta2-agonists and inhaled steroids versus higher dose of inhaled steroids in children and adults with persistent asthma. Cochrane Database Syst Rev 2005 Oct 19;(4):CD005533.

9. Nelson HS, Weiss ST, Bleeker ER, Yancy SW, Dorinsky PM: SMART study group. The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest 2006;129:15-26.

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