Clinical practice guidelines: Medical follow-up of patients with asthma-Adults and adolescents

The follow-up of patients with asthma should focus on asthma control (disease course over a number of weeks)→ There are 3 levels of asthma control
- Acceptable:All control criteria (Table 1 below) are met
- Unacceptable:One or more criteria are not met
- Optimal:All control criteria are normal or, in a patient with acceptable control, the best compromise has been achieved between degree of control, acceptance of treatment and possible side effectsTable 1 Criteria defining acceptable asthma control.CriterionValue or frequency*Day-time symptoms<4 days/weekNight-time symptoms<1 night/weekPhysical activityNormalExacerbationsMild, infrequentAbsence from work or schoolNoneUse of short-acting β2-agonists<4 doses/weekFEV1 or PEF>85% of personal bestPEF diurnal variation (optional)<15%*Mean during control assessment period (1 week-3 months).FEV: forced expiratory volume; PEF: peak expiratory flow.→ Follow-up includes monitoring of treatment side effects and adherence.→ Treatment should be adjusted to level of control and current long-term therapy.
- If control is unacceptable:○Check: that the disease is asthma, adherence, correct use of inhalation devices.○Look for and treat: aggravating factors, concomitant disease, specific clinical forms.○Adjust long-term therapy (see Table 2 below) in steps of 1-3 months.
- If control is acceptable or optimal:○Find the minimum effective treatment to maintain at least acceptable and ideally optimal control. Each step should last 3 months.Table 2 Adjusting long-term therapy if control is unacceptable.Current therapyNew treatmentaOption 1Option 2No ICSAverage-dose ICSAverage ICS dose+AMbPatients on ICS onlyLow- or average-dose ICSAdd AMIncrease ICS dose with or without AMHigh-dose ICSAdd AMPatients on ICS and additional medication (AM)Low dose of ICS (+1 AM)Increase ICS doseAverage dose of ICS (+1 AM)Increase ICS doseAdd second AM with or without increasing ICS doseHeavy dose of ICS (+1 AM)Add second AMOral corticosteroidscHeavy dose of ICS (+2 AMs)Oral corticosteroidscAdd third AMaThe choice between options will depend on symptom frequency and respiratory function (particularly post-bronchodilator FEV1).bAdditional medication (AM) covers long-acting β2-agonists, cysteinyl-leukotriene receptor antagonists, theophylline and its derivatives (bamiphylline).cOral corticosteroids are rarely used in adolescents.→ Frequency of follow-up visits (V) and lung function tests (LFTs) according to the dose of inhaled corticosteroids (ICS) needed for acceptable control (see Table 3 below)Table 3 Frequency of follow-up visits and LFTs.ICS doseV (months)LFT (months)High33-6Low or average66-12None1212 or +Low, average and high daily dose of ICS (μg/day) in adults.Low doseAverage doseHigh doseBeclomethasonea<500500-1000>1000Budesonide<400400-800>800Fluticasone<250250-500>500aDose should be halved for QVAR® and NEXXAIR®SynopsisTitleMedical follow-up of patients with asthma-adults and adolescentsPublication dateSeptember 2004Requested byFrench National Health DirectorateProduced byAnaes-French National Agency for Accreditation and Evaluation in Healthcare (Guidelines Department)Intended forAll health professionals who manage patients with asthmaAssessment method
- Systematic review of the literature (with evidence levels)
- Discussion among members of an ad hoc working group
- External validation by peer reviewers (see Anaes guide “Recommandations pour la pratique clinique-base méthodologique pour leur réalisation en France-1999”)ObjectivesAddress the practical aspects of long-term medical follow-up of patients with asthma (adults and adolescents only)Literature searchJanuary 1997-December 20032957 articles identified of which 696 analysedEconomic studyNoneAnaes project leader(s)Dr. Philippe Martel (Department head: Dr. Patrice Dosquet)(Literature search: Emmanuelle Blondet with the help of Maud Lefèvre (Department head: Rabia Bazi); secretarial work: Elodie Sallez)Authors of draft reportDr. Hugues Morel, chest physician, DinanDr. Nicolas Roche, chest physician, ParisCollaborations and participants
- Learned societies
- Steering committee
- Working group (Chair: Professor Philippe Godard, chest physician/allergologist, Montpellier)
- Peer reviewers(Appendix A)Internal validationAnaes Scientific Council (Referees: Professor Bruno Housset, chest physician, Créteil; Michel Paparemborde, Head of physiotherapy training college, Lille)Validated on September 2, 2004Other Anaes publications on the topicMedical follow-up is complemented by ongoing patient education, which is dealt with in the guidelines “Therapeutic education for patients with asthma-adults and adolescents” (Anaes 2001)