New findings add to complexity of asthma treatment: coverage from AAAAI clinical meeting

Washington -- With each new insight about asthma, it becomes increasingly clear how much remains unknown. That message was one of the themes at the American Academy of Allergy, Asthma & Immunology's annual meeting.

"Asthma is a diverse, complicated disease with many presentations, outcomes and variability in responses to treatment. It's not just one disease," said William Busse, MD, chair of the Dept. of Medicine at the University of Wisconsin's School of Medicine and Public Health. He was speaking at a news briefing during the meeting held in Washington, D.C., March 13-17.

Coughing, wheezing and shortness of breath are all common factors, but the interplay of allergens and responses to medications varies dramatically. With triggers including cats, cockroaches, stress and obesity, treatments often must be tailored for each patient.

The difficulties doctors and patients face in striking this chord are demonstrated by statistics. For instance, asthma continues to be one of the most common reasons for hospital admission and emergency department care even though most asthma cases can be managed on an outpatient basis, according to research presented by scientists from the federal Agency for Healthcare Research and Quality, and others.

From 2000 to 2005, the number of adults hospitalized with asthma as a secondary condition increased by 113%, the scientists said. From 1997 to 2006, the number of pediatric hospitalizations with asthma noted as a secondary reason rose by about 54%.

Many treatment challenges begin long before a patient lands in an acute situation. Sometimes they start with the illnesses' varying forms of presentation. Although asthma is most commonly recognized in children, it also can begin in adulthood. And asthma among the elderly may be an entirely different disease, as well as one that is hard to diagnose. Its presence among 60-, 70- and 80-year-olds may be mistaken for something else, Dr. Busse said. He also headed the panel that developed the 2007 federal "Guidelines for the Diagnosis and Management of Asthma," which the AMA encourages physicians to follow.

Science continues to offer additional possible underlying causes. Dr. Busse noted that a new, type C rhinovirus, identified about a year ago, seems to play a role in triggering about two-thirds of the asthma attributable to cold viruses. But it's too early in the research to know why.

"Are these new cold viruses more virulent and more likely to cause disease? Or, maybe they have characteristics that lead to airway changes?" he asked.

Steps toward disease control

Although the disease is far from conquered, research presented at the meeting shows progress, said Stanley Szefler, MD, head of pediatric clinical pharmacology at the National Jewish Health hospital system in Denver.

For one thing, asthma mortality has dropped, he noted, and the number of patients incapacitated by medication-induced hypertension, osteoporosis or cataracts has declined.

But in a less promising finding, researchers at National Jewish Health determined that even families with health insurance and a regular source of care for children often come to emergency departments when they have flare-ups.

Conventional wisdom holds that adequate insurance with access to physicians should lead to successful outpatient asthma control. That was not the case for many of the 153 asthmatic students who completed questionnaires. Fifty-eight percent reported getting care from a physician or other health care professional but said they used emergency department care for treatment regardless.

Dr. Szefler also described research on promising ways to educate children and teens about asthma control. "That's a new opportunity that we have in the schools."

In one effort, Pittsburgh physicians linked basketball camp to asthma education in a pilot study of 21 children age 6 to 12 who all had asthma. A comparison between pre- and post-camp behavior revealed a significant decrease in emergency department visits and physician contacts after the study.

In another pilot study, Chicago physicians sent text messages to teens reminding them to take their medications. At the conclusion of this small, four-student initiative, researchers noted increased adherence to medications.

During a symposium, Peter J. Gergen, MD, MPH, medical officer at the National Institute of Allergy and Infectious Diseases, examined research on children and teens in urban environments and elsewhere.

"Asthma morbidity and mortality remain high in the inner city, but biologically the asthma in the city is the same disease we are seeing across the United States," Dr. Gergen said. It also is just as responsive to treatment.

Differences in risk factors play a role, though. For example, cockroaches are the most prevalent inner-city allergens, according to most research, while cats prompt the most allergies in the suburbs, Dr. Gergen said.

The obesity trigger is an even bigger problem in cities where more children are overweight. The psychosocial burden, including stressful life events, also is much higher.

All of these factors affect treatment, Dr. Gergen said, and interventions must be tailored accordingly.

Physicians and their patients soon should hear much more about asthma and its treatment as plans are being developed to better utilize the 2007 guidelines, said Gary Rachelefsky, MD, professor of Allergy and Immunology at the University of California, Los Angeles, Geffen School of Medicine.

The guidelines include several messages: Inhaled corticosteroids are the most effective anti-inflammatory medications for long-term asthma management, and all patients with asthma should have a written action plan. In addition, reviews of disease control should be made at follow-up visits, and subsequent visits should be scheduled regularly to be proactive. Lastly, every patient should have a plan to reduce exposure to allergens at home, school, day care or work.