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# Management of Chronic Asthma

*Evidence Reports/Technology Assessments, No. 44*

Investigators: Naomi Aronson, PhD, Principal Investigator, Frank Lefevre, MD, Margaret Piper, PhD, MPH, David Mark, MD, MPH, Rhonda Bohn, PhD, Theodore Speroff, PhD, and Beth Finkelstein, PhD.

Agency for Healthcare Research and Quality (US)2001 Sep
Report No.: 01-E0441-58763-069-9

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## Structured Abstract

#### Objectives:

            Asthma affects over 14 million persons in the U.S. and is the most common chronic disease of childhood. This systematic review addresses 5 key questions: (1) whether chronic use of inhaled corticosteroids (ICS) improves long-term outcomes for children with mild to moderate asthma; and whether chronic ICS use in children results in long-term adverse effects; (2) whether, for patients with mild-moderate asthma, early initiation of ICS prevents asthma progression; (3) whether, in patients with moderate asthma, adding other long-term controllers to low-moderate dosages of ICS improves control; (4) whether adding antibiotics to standard care improves the treatment of acute asthma exacerbation; and (5) whether a written asthma action plan improves outcomes; and whether a peak flow monitor-based plan is superior to a symptom-based plan.

#### Search Strategy:

            The MEDLINE and Embase databases were searched from 1980 through August 2000 for articles using the following textwords or Medical Subject Headings (MeSH®) terms in their titles, their abstracts, or their keyword lists: leukotriene antagonists; zileuton; montelukast; zafirlukast; cromolyn; nedocromil; theophylline; adrenergic beta-agonists (including albuterol and salmeterol); "adrenal cortex hormones" OR steroids (including beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone, triamcinolone); OR antibiotics; peak expiratory flow rate; meter* (truncated); monitor* (truncated); action plan* (truncated); self care; patient care planning; patient participation. Results were limited to those articles that were indexed under the MeSH® term "asthma"; addressed studies on human subjects; and were indexed under any of the following study design terms: clinical trials; intervention studies; double-blind method; single-blind method; placebo* (truncated); random allocation; controlled clinical trial; cohort studies. Total retrieval was 4,578 references.

#### Selection Criteria:

            Inclusion was limited to controlled trials of efficacy outcomes. Uncontrolled studies of long-term adverse effects of ICS in children were also included. Yield was 87 selected from 668 dually reviewed, full-length articles.

#### Data Collection and Analysis:

>Each study was abstracted by two independent reviewers using a prospectively designed protocol. Meta-analysis of outcomes of long-acting beta-2 agonists added to ICS was performed based on calculated effect sizes.

#### Main Results:

            Compared to as-needed beta-2 agonists, ICS improves control in children with mild-to-moderate asthma; no alternative long-term controller appears to be superior. ICS therapy at recommended doses does not appear to have frequent, clinically significant, or irreversible effects on vertical growth, bone mineral density, ocular toxicity, or suppression of adrenal/pituitary axis in the short term. However, no studies have sufficient followup or size to assess cumulative effects in later life. The best available evidence does not support the hypothesis that mild to moderate asthmatics undergo progressive decline in lung function, which might be prevented by early ICS initiation. Adding long-acting beta-2 agonists or leukotriene antagonists to ICS improves asthma control, as may theophylline, but studies in children are lacking. The evidence suggests no benefit to using antibiotics routinely for treatment of acute asthma exacerbation. The evidence is insufficient to demonstrate that use of a written asthma action plan improves outcomes, or that peak flow monitoring-based plans are superior.

#### Conclusions:

            A national research agenda for long-term studies to improve effectiveness of asthma management is needed, with high priority to pediatric studies. Future asthma trials should use common definitions for severity, population characteristics, and outcome measures and should comply with recognized standards for reporting and statistical analysis. Research on rational antibiotic use should include explicit study questions and populations relevant to asthma management.

## Contents

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                        - Preface
                        - Summary
                        - 1. Introduction                           - Definition of Asthma
                          - Outcome Assessment of Asthma
                          - Medications
                          - Rationale and Background for Key Questions
                        - 2. Methodology                           - Overview
                          - Search Strategy for the Identification of Articles
                          - Methods of the Review
                          - Meta-Analysis
                          - Meta-Analysis Methods
                          - Meta-Analysis Technical Supplement
                        - 3. Results and Conclusions Part 1: Long-Term Management of Asthma in Children                           - Overview
                          - Results
                          - Conclusions
                          - Overview
                          - Conclusions
                        - 3. Results and Conclusions Part 2. Effects of Delayed ICS on Progression and Reversibility                           - Overview
                          - Patient Populations
                          - Outcomes
                          - Study Quality
                          - Critical Review of Studies
                          - Conclusions
                        - 3. Results and Conclusions Part 3. Addition of Other Long-Term Controller Medications to ICS                           - Overview
                          - Study Quality
                          - Results. Addition of Long-Acting Beta-2 Agonists to ICS
                          - Results. Addition of Theophylline to ICS
                          - Results. Addition of Leukotriene Antagonists to ICS
                          - Conclusions
                        - 3. Results and Conclusions Part 4. Effect of Antibiotics on Acute Asthma Exacerbations                           - Overview
                          - Results
                          - Conclusions
                        - 3. Results and Conclusions Part 5. Asthma Management Plans                           - Overview
                          - Study Quality
                          - Results
                          - Comparison of These Results with Others
                          - Conclusions
                        - 4. Future Research Priorities
                        - Evidence Tables
                        - Appendixes                           - Appendix A. Technical Advisory Group Peer Reviewers Medical Advisory Panel
                          - Appendix B. Search Strategy Details
                          - Appendix C. Acronyms and Abbreviations
                        - References
                        - Bibliography

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Prepared for: Agency for Healthcare Research and                            Quality, U.S. Department of Health and Human Services.1             Contract No. 290-97-0015. Prepared by: Blue Cross and Blue Shield Association Technology Evaluation Center.

#### Suggested citation:

Aronson N, Lefevre F, Piper M, et al. Management of Chronic Asthma. Evidence Report/Technology Assessment Number 44. (Prepared by Blue Cross and Blue Shield Association Technology Evaluation Center under Contract No. 290-97-0015.) AHRQ Publication No. 01-E044. Rockville, MD: Agency for Healthcare Research and Quality. September 2001.

On December 6, 1999, under Public Law 106-129, the Agency for Health Care Policy and Research (AHCPR) was reauthorized and renamed the Agency for Healthcare Research and Quality (AHRQ). The law authorizes AHRQ to continue its research on the cost, quality, and outcomes of health care and expands its role to improve patient safety and address medical errors.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of health care, reduce its cost, address patient safety and medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decisionmakers -- patients and clinicians, health system leaders, and policymakers -- make more informed decisions and improve the quality of health care services.

The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service.

                        - 1
                        - 
2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Copyright Notice

Bookshelf ID: NBK33814

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