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Childhood Asthma: Treatment Update - Article
ABSTRACT: The prevalence of childhood asthma has risen significantly over the past four decades. A family history of atopic disease is associated with an increased likelihood of developing asthma, and environmental triggers such as tobacco smoke significantly increase the severity of daily asthma symptoms and the frequency of acute exacerbations. The goal of asthma therapy is to control symptoms, optimize lung function, and minimize days lost from school. Acute care of an asthma exacerbation involves the use of inhaled beta2 agonists delivered by a metered-dose inhaler with a spacer, or a nebulizer, supplemented by anticholinergics in more severe exacerbations. The use of systemic and inhaled corticosteroids early in an asthma attack may decrease the rate of hospitalization. Chronic care focuses on controlling asthma by treating the underlying airway inflammation. Inhaled corticosteroids are the agent of choice in preventive care, but leukotriene inhibitors and nedocromil also can be used as prophylactic therapy. Long-acting beta2 agonists may be added to one of the anti-inflammatory medications to improve control of asthma symptoms. Education programs for caregivers and self-management training for children with asthma improve outcomes. Although the control of allergens has not been demonstrated to work as monotherapy, immunotherapy as an adjunct to standard medical therapy can improve asthma control. Sublingual immunotherapy is a newer, more convenient option than injectable immunotherapy, but it requires further study. Omalizumab, a newer medication for prevention and control of moderate to severe asthma, is an expensive option.
The Role of Allergens in Asthma - Article
ABSTRACT: The National Asthma Education and Prevention Program Expert Panel guidelines for the management of asthma recommend that patients who require daily asthma medications have allergy testing for perennial indoor allergens and that, when triggers are found, exposure to allergens and pollutants be controlled through avoidance and abatement. For patients whose symptoms are not controlled adequately with these interventions and who are candidates for immunotherapy, the guidelines recommend referral to an allergist. However, the data supporting these recommendations are not consistent. Although there is evidence that simple allergen avoidance measures are ineffective, there is good evidence for the effectiveness of a comprehensive approach based on known sensitization. Thus, allergen avoidance may include removal of pets, use of high-efficiency particulate air filtration and vacuum cleaners, use of allergen-impermeable mattress and pillow covers, cockroach extermination, smoking cessation, and measures to control mold growth in the home. All allergen-specific treatment is dependent on defining sensitization. This can be achieved through serum assays of immunoglobulin E antibodies or skin tests with aeroallergens. Information on sensitization can be used to educate patients about the role of allergens in their symptoms, to provide avoidance advice, or to design immunotherapy.
ABSTRACT: Immunotherapy has been used for over 80 years. It is a safe and effective therapeutic intervention for allergic rhinitis, but its use in the treatment of asthma is more controversial. Patients with unstable asthma are at increased risk of adverse effects from immunotherapy; therefore, if immunotherapy is used in such patients, it should be instituted cautiously. Indications for immunotherapy include evidence of IgE-mediated disease and positive results on skin tests or radioallergosorbent test (RAST). In addition, before immunotherapy is considered, measures to avoid exposure to offending agents and drug therapy should have failed to provide relief of symptoms. Before administering immunotherapy in the office, physicians should be knowledgeable about the use of immunotherapy and the treatment of anaphylaxis, and should have ready access to the equipment needed to avert anaphylaxis.
AHRQ Releases Review of Treatments for Allergic and Nonallergic Rhinitis - Practice Guidelines