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Am Fam Physician. 2003;67(10):2220-2223

The burden of asthma in children is considerable, but it can be reduced by following the standards developed by the National Asthma Education and Prevention Program. These recommendations include the use of inhaled anti-inflammatory medications (controller medications) for persistent asthma symptoms to reduce the reliance on inhaled beta agonists (reliever medications). The choice of medication and dosage depends on the severity of the patient's asthma. With the publication of these guidelines, the use of controller medications has increased over the past few years, but patients still rely too heavily on reliever medications. Studies that have reviewed the use of controller medications in asthma have been hampered because of the lack of symptom data to help classify asthma. Lozano and associates studied the use of asthma medication and disease burden, the use of controller and reliever medications, and whether their use is consistent with national guidelines, and estimated the adequacy of asthma control in children with persistent asthma.

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The trial was a cross-sectional cohort study of patients enrolled in the Pediatric Asthma Care Patient Outcomes Research Team II (PAC-PORT), a multicenter randomized trial of asthma care improvement strategies. PAC-PORT included 42 different practices in three geographic locations. Participants were identified through searches for pharmacy claims for asthma medication use and claims that identified hospitalizations, emergency department visits, and ambulance encounters in children three to 15 years of age who were diagnosed with asthma.

Children who met the criteria for mild or moderate persistent asthma were included in the study. The main outcome measures were asthma symptom days, use of reliever and controller medications, and adequacy of control as determined by face-to-face interviews. The term “asthma symptom days”was defined as the number of days in the preceding two weeks on which the child had cough, wheezing, or limitation in activity.

Of the 638 children who qualified for the study, 67.5 percent had zero to four symptom days, 15.8 percent had five to nine, and 16.6 percent had 10 to 14 in the preceding two weeks (see accompanying figure). Approximately one third of the children had high use of reliever medications, and one third used their controller medications only four or fewer days per week. Almost two thirds of the participants were inadequately controlled when compared with national standards. Those who were inadequately controlled used less controller medication than was recommended or did not receive controller medications even though they met the standards for mild or moderate persistent asthma.

The authors conclude that even in insured populations, there is inappropriate reliance on reliever medications for symptom relief and poor compliance with controller medications. They add that inadequate control of mild or moderate persistent asthma may contribute to the burden asthma may have in children.

editor's note: The National Asthma Education and Prevention Program has provided physicians with tools for managing this complex disease. Use of these tools has been shown to reduce morbidity from asthma and improve the quality of patients' lives. Despite the literature and various programs that are available, the study by Lozano and colleagues demonstrates that we still fall short of treatment goals. This failure occurred in the study despite the fact that patients were insured and had access to medical care and appropriate medications. Physicians who provide care for patients with asthma should continue to develop office procedures that identify their asthma classification and implement appropriate medication management. The goal is to reduce morbidity in patients with poorly controlled asthma.—k.e.m.

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