Title: Clinical practice guidelines: Medical follow-up of patients with asthma—Adults and adolescents
Abstract: The follow-up of patients with asthma should focus on asthma control (disease course over a number of weeks)Tabled 1→ 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 effects Open table in a new tab Table 1 Criteria defining acceptable asthma control.Tabled 1CriterionValue 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% Open table in a new tab *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.Tabled 1Current 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. Open table in a new tab → 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.Tabled 1ICS doseV (months)LFT (months)High33–6Low or average66–12None1212 or + Open table in a new tab Low, average and high daily dose of ICS (μg/day) in adults.Tabled 1Low doseAverage doseHigh doseBeclomethasonea<500500–1000>1000Budesonide<400400–800>800Fluticasone<250250–500>500 Open table in a new tab aDose should be halved for QVAR® and NEXXAIR®SynopsisTabled 1TitleMedical 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) Open table in a new tab