Canadian Thoracic Society Asthma Management Continuum--2010 Consensus Summary for children six years of age and over, and adults

Abstract

Background/objective: To integrate new evidence into the Canadian Asthma Management Continuum diagram, encompassing both pediatric and adult asthma.

Methods: The Canadian Thoracic Society Asthma Committee members, comprised of experts in pediatric and adult respirology, allergy and immunology, emergency medicine, general pediatrics, family medicine, pharmacoepidemiology and evidence-based medicine, updated the continuum diagram, based primarily on the 2008 Global Initiative for Asthma guidelines, and performed a focused review of literature pertaining to key aspects of asthma diagnosis and management in children six years of age and over, and adults.

Results: In patients six years of age and over, management of asthma begins with establishing an accurate diagnosis, typically by supplementing medical history with objective measures of lung function. All patients and caregivers should receive self-management education, including a written action plan. Inhaled corticosteroids (ICS) remain the first-line controller therapy for all ages. When asthma is not controlled with a low dose of ICS, the literature supports the addition of long-acting beta2-agonists in adults, while the preferred approach in children is to increase the dose of ICS. Leukotriene receptor antagonists are acceptable as second-line monotherapy and as an alternative add-on therapy in both age groups. Antiimmunoglobulin E therapy may be of benefit in adults, and in children 12 years of age and over with difficult to control allergic asthma, despite high-dose ICS and at least one other controller.

Conclusions: The foundation of asthma management is establishing an accurate diagnosis based on objective measures (eg, spirometry) in individuals six years of age and over. Emphasis is placed on the similarities and differences between pediatric and adult asthma management approaches to achieve asthma control.

Figure 1)

Very mild, intermittent asthma may be treated with fast-acting beta₂-agonists taken as needed. Inhaled corticosteroids (ICS) should be introduced early as the initial maintenance treatment for asthma, even in individuals who report asthma symptoms less than three times a week. Leukotriene receptor antagonists (LTRAs) are second-line monotherapy for mild asthma. If asthma is not adequately controlled by low doses of ICS, additional therapy should be considered. In children six to 11 years of age, the ICS should be increased to a moderate dose before an additional agent such as a long-acting beta₂-agonist (LABA) or LTRA is added. In children 12 years of age and over, and adults, a LABA should be considered first as add-on therapy only in combination with an ICS. Increasing to a moderate dose of ICS or addition of a LTRA are third-line therapeutic options. Theophylline may be considered as a fourth-line agent in adults. Severely uncontrolled asthma may require additional treatment with prednisone. Omalizumab may be considered in individuals 12 years of age and over with poorly controlled atopic asthma despite high doses of ICS and appropriate add-on therapy, with or without prednisone. Asthma symptom control and lung function tests, inhaler technique, adherence to asthma treatment, exposure to asthma triggers in the environment and the presence of comorbidities should be reassessed at each visit and before altering the maintenance therapy. After achieving proper asthma control for at least a few weeks to months, the medication should be reduced to the minimum necessary to achieve adequate asthma control. HFA Hydrofluoroalkane; IgE Immunoglobulin E; mcg Micrograms; PEF Peak expiratory flow; yrs Years