Chest
Volume 115, Issue 1, January 1999, Pages 210-217
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Reviews
The 1997 Asthma Management Guidelines and Therapeutic Issues Relating to the Treatment of Asthma

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In 1997, the National Heart, Lung, and Blood Institute released the Second Expert Panel Report on the Guidelines for the Diagnosis and Management of Asthma as a follow-up to the first report issued in 1991. Implementation of the recommendations from this report could have a potentially huge impact on care and treatment of asthma in the United States. Even though the Guidelines are expansive, there are some areas related to the pharmacologic component that warrant further discussion and clarification. These are: (1) safety and efficacy of available asthma medications, (2) clinical efficacy comparisons of inhaled corticosteroids, (3) comparative risks among inhaled corticosteroids, and (4) expectations of different delivery systems used with inhaled corticosteroids.

Section snippets

Nedocromil

One of the new asthma medications, nedocromil, has an anti-inflammatory action similar to that of cromolyn.1, 2 The drug's mechanism of action appears to be inhibiting inflammation on the molecular level by blocking chloride channels and modulating mast cell mediator release and eosinophil recruitment.1, 3, 4 Nedocromil is effective in reducing bronchospasm brought on by cold, dry air,5 bradykinin aerosol,2 and exercise.6 It is also proven to reduce the need for quick-reliefβ 2-antagonists,

Clinical Efficacy Comparisons of Inhaled Corticosteroids: Factors Influencing Efficacy

The physiochemical properties of the glucocorticoid molecules determines the pharmacokinetics of inhaled corticosteroids. Due to the various properties of the different molecules, the Expert Panel points out that data suggest “… that different inhaled corticosteroid preparations are not equivalent on a per puff or microgram basis.”1

Although not well defined, some of the factors thought to influence efficacy are topical potency; lipophilicity; the rate of dissolution; receptor-binding affinity;

Comparative Risks Among Inhaled Corticosteroids: Hypothalamic-Pituitary-Adrenal Axis Suppression

For more than two decades, clinical investigators have questioned whether the use of inhaled corticosteroid therapy suppresses the hypothalamic-pituitary-adrenal (HPA) axis. The Expert Panel states that this issue is “complex and requires further study,”1 but two studies cited by the Expert Panel illustrate that not all inhaled corticosteroids carry the same amount of risk.

The first study found no HPA axis suppression in asthmatic children receiving BDP (mean dose, 490 μg/d) compared with

Expectations With Different Delivery Systems Used With Inhaled Corticosteroids

Other factors that can influence the efficacy of inhaled corticosteroids are the devices used to deliver the drug directly to the lungs via inhalation. When used properly, spacers or holding chambers decrease the amount of oropharyngeal deposition of the drug and increase the amount of deposition in the lung.37 The Expert Panel does not recommend one delivery device over another, but instead communicates the optimal technique and therapeutic issues with each device.

A majority of inhaled

Summary

In the 6 years since the 1991 Expert Panel Report was released, an increasing number of therapeutic choices have been introduced to treat and control asthma. The pharmacologic component of the 1997 Expert Panel Report provides clinicians with a detailed, annotated guide on how and when to use these medications.

It is hoped that clinical research will become available so that the next Expert Panel Report can include definitive data on the safety and efficacy of newer asthma medications (eg,

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