Guidelines for pediatric patients on adherence and monitoring of asthma
Asthma is a common chronic respiratory disease that affects 1-29% of the population in different countries.¹ It is defined by symptoms that include wheezing, shortness of breath, chest tightness and/or coughing associated with variable limitation of expiratory airflow.
An asthma attack is triggered by exposure to allergens or irritants, such as dust, mites, pollen and cigarette smoke, viral infections, climate changes or exercise.¹ Its symptoms may resolve spontaneously and disappear for weeks or months, but exacerbation episodes have the potential to be serious and life-threatening, interfering with the patient’s quality of life.
The concept of controlled asthma includes minimizing symptoms during the day and their absence at night, reduced need for rescue medications, no limitation on physical activities and reduced future risks, such as crises, accelerated loss of lung function and adverse effects of treatment.
How to identify and treat
Some of the causes that influence successful asthma control and response to treatment include lack of adherence to the proposed therapy, exposure to allergens and irritants at home, and smoking. Regular monitoring of these factors and their influence on symptoms should always be performed before any modification of maintenance treatment is considered.
Low adherence resulting from fears and myths about medications and difficulty in using the inhaler device are important reasons for therapeutic failure. It is necessary to demystify the belief that “pumps are bad for the heart”³. Fear of medication can delay the start of treatment and cause the patient to take smaller doses than those recommended by the doctor, with consequent worsening and/or lack of improvement of symptoms.
House dust mites are the largest source of allergens in homes. Humidity is a critical factor for the proliferation of mites and fungi inside and outside homes. Strategies such as keeping homes clean, promoting good ventilation, regularly washing bedding with detergent and at high temperatures (> 55°C), using waterproof covers for mattresses and pillows, daily vacuuming of surfaces, removing rugs and replacing carpets with hard or laminate flooring have been shown to be effective in reducing the population of mites present in house dust.4 As an environmental control strategy, there is also a clinically relevant reduction in the levels of animal allergens, often requiring the removal of the animal from the home.
Furthermore, cigarette smoke is one of the main sources of indoor pollutants and leads to increased morbidity from respiratory diseases. Both active and passive smoking are harmful, and it is essential to recommend that asthmatic patients and their families stop smoking as early as possible in order to reduce the duration and final amount of exposure, improve disease control and, thus, provide a lower frequency of exacerbations and a reduced need for medication.
Pharmacological maintenance treatment for asthma is based on the use of inhaled corticosteroids, associated or not with long-acting bronchodilators, and is divided into stages I to V, in which the doses of inhaled corticosteroids can be increased and/or other treatments can be added depending on the evolution and improvement of the patient’s symptoms.
One of the most widely used inhaled corticosteroids is fluticasone, and specifically fluticasone propionate has high affinity for glucocorticoid receptors and good pulmonary retention. Furthermore, the association of fluticasone propionate with salmeterol (the latter being characterized as a long-acting medication that dilates the bronchi) demonstrates greater efficacy, with a lower dose of inhaled corticosteroid in controlling asthma symptoms when compared to fluticasone alone.
The choice of the best drug should be based on the patient’s inherent characteristics, such as risk factors, device preference, in addition to the effectiveness and safety of the therapeutic approach.
The partnership between the doctor and the asthmatic patient (and parents/caregivers, in the case of a child with asthma) is of fundamental importance in controlling the disease and aims to allow the patient to acquire knowledge, confidence and ability to assume the main role in managing their disease. This approach, called guided asthma self-management, reduces morbidity in both adults and children.
A personalized action plan for each person with the disease must be drawn up and must include specification of maintenance treatment, control monitoring, guidelines on how to change the therapeutic regimen, recognition of early signs and symptoms of exacerbation, home treatment of mild attacks and clear indications of when to seek medical attention or an emergency service.
Symptoms may improve within days after starting treatment with most controller medications, but the medication is expected to be effective in three to four months. In severe, chronically untreated or inadequately treated asthma, this expected time to improvement may be longer.
The assessment of control is generally based on symptoms from the four weeks prior to the consultation and can be classified as: controlled, partially controlled and uncontrolled. Currently, we have the Global Initiative for Asthma Treatment (GINA) questionnaire, the Asthma Control Questionnaire (ACQ) and the Asthma Control Test (ACT), the latter two of which have already been validated for use in Brazilian Portuguese. The tests consist of four to seven questions with varying scores and results depending on the assessment being used. Their purpose is to classify the patient’s level of disease control.
The frequency of medical visits depends on the patient’s initial level of control, response to treatment, and the asthmatic’s engagement in self-management of the disease. Ideally, asthmatics should be reviewed between one and three months after starting treatment and then every three to 12 months. In the event of an exacerbation, the patient should be evaluated by a physician within one week.
To assess the need for reduction of inhaled corticosteroids, asthma symptoms must be controlled and lung function must remain stable for three or more months. Choosing the appropriate time is essential, and should consider the absence of viral infections, changes in routine, such as travel, or pregnancy in women. The patient must be informed and instructed about the attempt to reduce the medication and an action plan in case of worsening. Reducing the inhaled corticosteroid by 25 to 50% every three months has proven to be feasible and safe for most patients.
Taking into account the objective of asthma treatment to achieve and maintain control, prevent the risk of exacerbations, loss of lung function and side effects of the drug, a personalized approach to the patient with education, a written action plan, training in the inhalation technique and regular review is essential for the successful maintenance and management of the disease.
^Randomized, double-blind, parallel-group study to compare the efficacy of escalating doses of fluticasone propionate alone or fluticasone propionate and salmeterol in achieving asthma control. P values for well-controlled asthma are P = 0.005, 64% vs 56% stratum 1; stratum 2 59% vs 41%;