Madeline - medscape piece

[Guest guest]

Madeline - medscape piece

Madeline, I am going to post it in sections, because I think its too long for

one post -

I'm not sure how much will fit -

I'll do the best I can.

Pharmacotherapy of Asthma: Regular Treatment or On Demand?

Abstract

Some studies have raised the question of the need for chronic controller therapy

in mild persistent asthma as suggested by international guidelines. Although the

Improving Asthma Control (IMPACT) and Beclomethasone plus Salbutamol (BEST)

studies suggest that on-demand therapy in some patients with mild persistent

asthma achieves a similar degree of asthma control based on symptoms and

functional outcomes, the IMPACT study indicates that regular and on-demand

therapy is not equivalent for controlling airway inflammation. Persistent airway

inflammation might lead to airway remodelling with onset or worsening of

symptoms, deterioration in lung function, and reduced response to

pharmacological therapy. However, the relationships between chronic airway

inflammation and airway remodelling need to be clarified. Choosing the 'right'

pharmacological strategy (regular versus on-demand treatment) for asthma control

is currently difficult due to the fact that (1) inflammatory outcome measures

were not generally incorporated into asthma clinical trials; (2) the

relationships between chronic airway inflammation and airway remodelling are

largely unknown; (3) current clinical asthma trials that are generally based on

symptomatic and functional outcome measures are too short to assess the impact

of regular anti-inflammatory therapy on natural history of asthma; (4) asthma is

an heterogeneous disease and different phenotypes of asthma patients likely

requiring a different therapeutic approach can be identified, even in the same

class of asthma severity. Guidelines for asthma management are valuable tools,

although they are necessarily based on a strategy directed to the best outcome

in a group of patients. Asthma phenotyping is becoming central for asthma

management. The issue of regular versus on-demand treatment of intermittent and

mild persistent asthma would be better addressed if considered within an

individualized approach to asthma management and assessment. Identification of

clinical, functional, morphological and biochemical phenotypes of patients with

asthma and its clinical implications is likely to lead to a tailored,

individualized, pharmacological therapy and asthma management.

Introduction

Pharmacological treatment is the mainstay of management in most patients with

asthma. The primary goals of treatment of asthma are relief of symptoms,

normalization of pulmonary function, prevention of acute exacerbations,

reduction of airway hyper-reactivity, and improvement of quality of life (Figure

1). A primary objective is to prevent airway remodelling; that is, structural

changes in the airways, by preventing the putative long-term consequences of

airway inflammation. However, the evidence that supports the concept that

pharmacological control of airway inflammation positively influences the natural

history of asthma is currently inadequate partially due to relative short

duration of clinical asthma trials.