Is it time to revise the current asthma guidelines?

A JACI article makes the case for revising the current asthma guidelines based on new evidence accumulated since 2007:

- use of tiotropium as add-on therapy to inhaled corticosteroids (ICSs)
- role of omalizumab in managing asthma in inner-city children
- association of low levels of vitamin D with inadequate asthma control
- managing asthma in children, including the use of biomarkers to select long-term controller therapy, stepping down and stepping up of ICSs

Severe asthma - differential diagnosis and management (click to enlarge the image). Related: Common Asthma-related Comorbidities. Medscape, 2011, (figure)

A World Health Organization panel proposed a uniform definition of severe asthma that includes 3 groups:

- untreated severe asthma
- difficult-to-treat severe asthma
- treatment-resistant severe asthma

We also have information that helps us to predict the developement of asthma in children. Skin prick test responses to individual allergens up to 2 years of age could predict wheeze in children aged 12 years (JACI, October 2011 issue, Lodge et al). House dust mite sensitization at ages 1 or 2 years in wheezing and eczematous children at increased familial allergy risk might predict asthma in these high-risk groups.

Modified Asthma Predictive Index (mAPI) (click to enlarge the image):

A positive mAPI greatly increased future asthma probability (eg, 30% pretest probability to 90% posttest probability)


Is it time to revise the asthma guidelines? The Journal of Allergy and Clinical Immunology
Volume 128, Issue 5 , Pages 937-938, November 2011.

Comments from Google Plus:

Robert Silge - Some of those are ready for prime-time, but to suggest that we change guidelines now, as regards Vit D or Tiotropium seems premature. We're going to recommend adding tiotropium on the basis of a couple of small studies?

Ves Dimov, M.D. - Good point. I think the idea is to start thinking about revising them rather than change the guidelines next year. There is no current evidence that vitamin D supplementation helps any allergic disease at this point. The studies are ongoing.

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