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Asthma panel urges vigilant treatment

The Baltimore Sun

A panel of health experts updated federal guidelines yesterday for treating asthma - a disease that continues to beleaguer Maryland and hits particularly hard in African-American communities.

The National Institutes of Health report, containing the first new guidelines in a decade, urges doctors to treat underlying problems that can worsen asthma, such as obesity, and make sure that patients continue taking medications even when symptoms abate.

The panel recommends that patients use two kinds of drugs: emergency medications to relieve temporary symptoms and long-term controllers to reduce the risk of life-threatening asthma attacks.

It also urged anyone who experiences asthma symptoms more than twice in the same week to take a long-term medication - and said inhaled steroids remain the best option for more lasting control.

"They are effective, and they are safe. And we should be comfortable prescribing them and encourage their use," said Dr. Homer A. Boushey Jr., a member of the panel and an asthma expert at the University of California, San Francisco.

Asthma's symptoms include recurrent inflammation of the lungs that makes breathing difficult. The disease affects more than 22 million people in the United States, including 6.5 million children, according to the Centers for Disease Control and Prevention.

In Maryland, about 325,000 people have asthma, with the worst spikes in September and October, when children return to school, spend more time indoors and are exposed to the viral infections common in crowded classrooms.

Asthma attacks can be occasional or frequent. They can be triggered by exertion, dirty air, high humidity, ragweed or a range of common allergens, including dust mites, cockroaches, mice and the dander of cats and dogs.

The disease takes a disproportionate toll on minorities, with African-Americans in Maryland being 20 percent more likely to have the disease, according to city and state health officials, and they are at least twice as likely to be hospitalized or die from it.

"A lot of the problem has to do with access to health care," said Valerie Nozea, director of education for the American Lung Association of Maryland. "People are living in situations where they're exposed to asthma triggers, they're being seen in emergency rooms and they're being under-diagnosed and under-treated."

In Baltimore, the disease causes a disproportionate number of emergency room visits, hospitalizations and deaths, said Dr. Joshua M. Sharfstein, the city health commissioner.

On average, asthma kills 86 people statewide each year, with about 26 of those deaths in Baltimore, according to state health statistics.

Asthma also sent 12,259 people in Baltimore to hospital emergency rooms in 2004, more than a third of the statewide total that year for asthma-related emergency room visits.

City and state health officials are working with area schools and community groups to identify children who might have asthma and encourage their parents to have the children evaluated by a physician.

"The general consensus is that asthma is becoming an increasingly important condition that, from a public health standpoint, needs to be addressed," said Dr. Cheryl De Pinto, medical director for the state health department's asthma control program.

The asthma recommendations released yesterday are part of a 440-page report by the National Heart, Lung and Blood Institute, a division of the NIH.

The report calls for doctors to work harder to educate patients about the importance of closely monitoring their conditions. It also creates a new age grouping of children, ages 5 to 11, for doctors considering medications for youngsters.

Panel members say some medications work for children 12 and older but don't work in younger children. They said that school-age youngsters are more likely to respond to steroids and don't need the combination of steroid and emergency relief medications recommended for adults.

Experts not involved in the report say most of its recommendations confirm the effectiveness of practices developed since previous federal guidelines were issued 10 years ago.

"I think the take-home message is, asthma is a disease that's chronic. It gets better and worse over time, and you need to keep constantly monitoring and assessing it," said Dr. Giora Netzer, a lung disease specialist who treats asthma patients at the University of Maryland Medical Center.

The call for doctors to do a better job educating patients, and for patients to insist on quality care, is a step in the right direction, he said.

"There is often a disconnect, because doctors don't do a good job of explaining things. Patients aren't empowered and don't feel they can take control of their disease, and they should," he said.

The disease can be difficult to treat, because attacks can occur with no apparent warning - and it's largely up to patients to monitor themselves, doctors say.

"The point is, even if someone is well controlled, they're still at risk of severe asthma" that could lead to hospitalization or become life threatening, said Dr. Mark Liu, a physician with Johns Hopkins Asthma and Allergy Center. "People who've lived with respiratory problems a long time, they can't always tell when they're in trouble."

Kelly Kesler, 32, of Columbia, knows that from experience. "The thing that happens is, the problems will just come out of nowhere, or what seems like nowhere," she said.

Diagnosed as a child, Kesler had coughing fits and asthma attacks two or three times a week until she began inhaling a steroid preparation about three years ago. She had thought those frequent attacks were normal and had limited her medication to Albuterol, an emergency medication that relaxes muscles in the airway.

When she began taking a regular steroid medication, her problems seemed to be under control until she entered the final weeks of her pregnancy last year. She had to have labor induced three weeks early, because the asthma made it hard to breathe.

"I couldn't even go up and down the stairs without using my inhaler," she said.

She gave birth to a healthy baby boy and now takes an inhaled steroid twice a day. She also stays indoors when it gets extremely cold, hot or humid, changes the air filters in her home every two months and stays away from cleaning solutions with fumes that can trigger an attack.

The disease also keeps 5-year-old Kaeley Hitchings from going into homes with cats - or from ever going to the circus - because the animals might trigger an attack. But there is no problem with the dogs the family keeps at their home in Havre de Grace.

The child also can't be anywhere near cigarette smoke, said her mother, Shannon Hitchings. She regularly takes Flovent, an inhaled steroid, to stay healthy, and keeps Albuterol handy in case of an asthma attack.

"If we are going to be in a situation where there might be a problem - such as a restaurant we don't know - we medicate ahead of time," her mother said.

Before Kaeley started kindergarten this month, the Hitchingses made sure the school would keep her inhalers on hand and provided written instructions on what to do for an asthma attack, the mother explained.

"It's something we constantly have to think about," she said.

dennis.o'brien@baltsun.com

Find the full report at www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.

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