Guidelines for Managing Patients With Asthma

Neal Jain, MD, FAAP, FAAAAI, FACAAI: We have these guidelines that are out there, that tell us how we should manage our patients. There are several guidelines out. There’s GINA [Global Initiative for Asthma], there’s NHLBI [National Heart, Lung, and Blood Institute], and there’s the “Asthma Yardstick” reports, which I think has become increasingly something that people are adopting, just from a practical standpoint. Brad, do you want to lead off? I know you’ve had some involvement in some of these.

Bradley Chipps, MD: Just a little. There are 3 Yardsticks now. The last 1 just published 2 days ago: “The [Asthma Controller] Step-down Yardstick.” So we have “Step-up” for adults and pediatrics [“The Adult Asthma Yardstick” and “The Pediatric Asthma Yardstick”] and then “Step-down” just published. Somebody mentioned earlier that it was an important thing to think about. When trying to make the case for what the determinants of asthma control are, in both the impairment and risk domains, and then have us rationally plan to step down on therapy if and when it may be appropriate for a particular patient. We dealt with all the currently available interventions and trying to get some guidelines for that. Since the US guidelines that came out in 2007 are not going to be updated, except for the 5 questions that the expert panels are going to answer, part of my presidential initiatives for the last year were to rewrite the guidelines for the federal government at a reduced cost for what they would have spent to do it. That was what we did.

Aidan A. Long, MD: In contrast to the GINA guidelines—the Global Initiative for Asthma.

Bradley Chipps, MD: Which are every year.

Aidan A. Long, MD: Those are updated every year, which incorporates a lot more of what we currently have available than the 2007 guidelines, because of the anticholinergics and the biologics.

Bradley Chipps, MD: In the “Yardsticks” we also have considered expert opinion, which GINA does not allow. They require 2 studies to reinforce their guidelines.

Aidan A. Long, MD: But it’s a really interesting question. Do you routinely refer to guidelines in your daily practice? And who should refer to them? To whom are they addressed? It’s really interesting. We discuss them all the time, but we do what we think is right without necessarily turning to this document to guide us.

Bradley Chipps, MD: It depends what you have behind you, in terms of what you’ve read and what your experience shows. As you said, it’s all over the board.

Nicola A. Hanania, MD, MS: We do asthma on a day-to-day basis, so we are very familiar with these guidelines or strategies. But when you look at, overall, the clinicians, our colleagues in primary care, they have to deal with so many other diseases. And often you talk to them and they’re not familiar with these. So I think having a practical way to translate these guidelines in a practical, quick type of way is important. We’re dealing with this horrible disease, which is affecting 5% to 8% of the population. And 5% to 10% of the whole asthma population has severe disease. At the same time, most of them are seen in primary care, which is appropriate. But for those 5% to 10%, the primary care colleagues should have a way to determine and then send them to us to deal with. I think that’s where there is a need for implementing these guidelines in a much simpler way. Disseminating what these guidelines talk about in the primary care setting is very important.

Transcript edited for clarity.