Asthma Management: Optimizing Treatment for a Disease of Variable Intensity

National and international asthma management guidelines advocate a stepwise approach to asthma treatment based on severity-based classification of patients. Although this approach serves an important purpose in guiding therapeutic decision making and decreasing unnecessary variation in care, it has limitations— particularly with respect to the management of what the guidelines define as mild and moderate persistent asthma. The diagnosis of persistent asthma is confounded both by the variable pattern of asthma severity and by patients’ failure to recognize and report symptoms, with a consequent underassessment of symptom severity by the healthcare provider. This paper reviews the data supporting these points and discusses the implications for the management of asthma. (Advanced Studies in Medicine. 2002;2(14):504-510) A sthma management guidelines, including those of the National Asthma Education and Prevention Program (NAEPP), classify asthma according to severity. Asthma severity is determined by the frequency of symptoms, history of exacerbations, and the results of pulmonary function tests. The most severe finding is used as the basis for classification and initial stepwise therapy in the management of the disease. The guidelines have no specific modification for previous or current controller therapy. Although severity-based stratification of patients serves an important purpose in guiding therapeutic decision making, evidence suggests significant limitations to this approach—particularly in attempts to distinguish patients with mild and moderate persistent asthma. These 2 categories often overlap in patients with asthma. Normal lung function may cause a physician to not question a patient about possible symptoms and therefore underclassify the patient's asthma severity. Furthermore, patients tend to underrecognize the presence and severity of symptoms and therefore do not report their symptoms to their caregivers. Finally, asthma severity is variable and may be mild in intensity unless the patient is exposed to allergens or develops a respiratory infection. These isolated flares are accounted for in the guidelines for young children (<5 years) but not in the NAEPP recommendations for adolescents and adults. One of the goals of asthma treatment is the prevention of exacerbations. Proper controller therapy is needed to prevent exacerbations. Proper diagnosis is therefore needed to ensure that the appropriate level of medication is prescribed, "Because asthma is a chronic disease characterized by differing frequencies of daily symptoms, exacerbations, and remissions, characterizing disease severity is problematic." REVIEW