The role of the primary care physician in helping adolescent and adult patients improve asthma control

Abstract

Many adolescents and adults with asthma continue to have poorly controlled disease, often attributable to poor adherence to asthma therapy. Failure to adhere to recommended treatment may result from a desire to avoid regular reliance on medications, inappropriate high tolerance of asthma symptoms, failure to perceive the chronic nature of asthma, and poor inhaler technique. Primary care physicians need to find opportunities and methods to address these and other issues related to poor asthma control. Few adolescents or adults with asthma currently have asthma "checkup" visits, usually seeking medical care only with an exacerbation. Therefore, nonrespiratory-related office visits represent an important opportunity to assess baseline asthma control and the factors that most commonly lead to poor control. Tools such as the Asthma Control Test, the Asthma Therapy Assessment Questionnaire, the Asthma Control Questionnaire, and the Asthma APGAR provide standardized, patient-friendly ways to capture necessary asthma information. For uncontrolled asthma, physicians can refer to the stepwise approach in the 2007 National Asthma Education and Prevention Program guidelines to adjust medication use, but they must consider step-up decisions in the context of quality of the patient's inhaler technique, adherence, and ability to recognize and avoid or eliminate triggers. For this review, a literature search of PubMed from 2000 through August 31, 2010, was performed using the following terms (or a combination of these terms): asthma, asthma control, primary care, NAEPP guidelines, assessment, uncontrolled asthma, burden, impact, assessment tools, triggers, pharmacotherapy, safety. Studies were limited to human studies published in English. Articles were also identified by a manual search of bibliographies from retrieved articles and from article archives of the author.

FIGURE 1.

Assessing asthma control and adjusting therapy in youths aged 12 years and older and in adults. The level of control is based on the most severe impairment or risk category. Assessment of the impairment domain is based on the patient's recall of the previous 2 to 4 weeks and by spirometry or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit. Before a step-up in therapy: (1) Review adherence to medication, inhaler technique, environmental control, and comorbid conditions. (2) If an alternative treatment option was used in a step, discontinue and use the preferred treatment for that step. ACQ = Asthma Control Questionnaire; ACT = Asthma Control Test; ATAQ = Asthma Therapy Assessment Questionnaire; EIB = exercise-induced bronchconstriction; FEV₁ = forced expiratory volume in 1 second. Minimal Important Difference: 1.0 for the ATAQ; 0.5 for the ACQ; not determined for the ACT.

FIGURE 2.

Asthma APGAR questionnaire. From J Asthma Allergy, with permission.

FIGURE 3.

Stepwise approach for managing asthma in youths aged 12 years and older and in adults. EIB = exercise-induced bronchospasm; ICS = inhaled corticosteroid; LABA = long-acting inhaled β₂-agonist; LTRA = leukotriene receptor antagonist; PRN = as needed; SABA = inhaled short-acting β₂-agonist.