Clinical practice guidelines: Medical follow-up of patients with asthma—Adults and adolescents

Summary

The follow-up of patients with asthma should focus on asthma control (disease course over a number of weeks)

→ 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

Table 1 Criteria defining acceptable asthma control.

Criterion	Value or frequency*
Day-time symptoms	<4 days/week
Night-time symptoms	<1 night/week
Physical activity	Normal
Exacerbations	Mild, infrequent
Absence from work or school	None
Use of short-acting β2-agonists	<4 doses/week
FEV1 or PEF	>85% of personal best
PEF diurnal variation (optional)	<15%

*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.

Current therapy	New treatmenta
	Option 1	Option 2
No ICS	Average-dose ICS	Average ICS dose+AMb
Patients on ICS only
Low- or average-dose ICS	Add AM	Increase ICS dose with or without AM
High-dose ICS	Add AM
Patients on ICS and additional medication (AM)
Low dose of ICS (+1 AM)	Increase ICS dose
Average dose of ICS (+1 AM)	Increase ICS dose	Add second AM with or without increasing ICS dose
Heavy dose of ICS (+1 AM)	Add second AM	Oral corticosteroidsc
Heavy dose of ICS (+2 AMs)	Oral corticosteroidsc	Add third AM
aThe 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.

→ 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.

ICS dose	V (months)	LFT (months)
High	3	3–6
Low or average	6	6–12
None	12	12 or +

Low, average and high daily dose of ICS (μg/day) in adults.

	Low dose	Average dose	High dose
Beclomethasonea	<500	500–1000	>1000
Budesonide	<400	400–800	>800
Fluticasone	<250	250–500	>500

^aDose should be halved for QVAR^® and NEXXAIR^®

Synopsis

Title	Medical follow-up of patients with asthma—adults and adolescents
Publication date	September 2004
Requested by	French National Health Directorate
Produced by	Anaes—French National Agency for Accreditation and Evaluation in Healthcare (Guidelines Department)
Intended for	All health professionals who manage patients with asthma
Assessment 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”)
Objectives	Address the practical aspects of long-term medical follow-up of patients with asthma (adults and adolescents only)
Literature search	January 1997–December 2003
	2957 articles identified of which 696 analysed
Economic study	None
Anaes 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 report	Dr. Hugues Morel, chest physician, Dinan
	Dr. Nicolas Roche, chest physician, Paris
Collaborations and participants	Learned societies Steering committee Working group (Chair: Professor Philippe Godard, chest physician/allergologist, Montpellier) Peer reviewers
(Appendix A)
Internal validation	Anaes Scientific Council (Referees: Professor Bruno Housset, chest physician, Créteil; Michel Paparemborde, Head of physiotherapy training college, Lille)
	Validated on September 2, 2004
Other Anaes publications on the topic	Medical 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)