Developing and communicating a long-term treatment plan for asthma

Learning points from paper

40 to 50 percent of prescriptions are not followed correctly and that physicians cannot accurately predict who will adhere to the therapeutic regimen. (See: Mellins RB, Evans D, Zimmerman B, Clark NM. Patient compliance. Are we wasting our time and don't know it? [Editorial] Am Rev Respir Dis 1992; 146:1376-7.)
Must develop a long-term treatment plan for asthma that involves the patient and the family so that they will agree to follow it

Given the reluctance of many patients (including their parents) to agree to continuous use of medications, and because it is difficult to manage several medicines at once, a long-term plan needs to be developed. It should be easy to follow, be consistent with the patient's personal goals and daily activities, outline the circumstances that will lower the requirement for medication and be one that the patient and family agree to follow once the risks and benefits are discussed.
Without specific recommendations, patients often adjust or stop medications on their own.
The treatment algorithms published by the expert panel on asthma are medically sound, but it can be difficult to adapt them to written instructions that are easy for patients and families to follow.

Need a practical way to communicate such a plan, using charts to make it easier to understand and use.

Critique of paper

Other comments

FIGURE 1. Sample long-term treatment plan for mild-intermittent asthma

Name		Date	Spacer
Clinical condition or patient status	Baseline plan and when asthma is under control	At the first sign of a cold or mild attack†	For rapidly worsening asthma (severe attack)	For cough or wheeze with exercise
Peak flow (% personal best)	80% or above	50 to 80%	Below 50%	2 puffs 5 to 10 minutes before exercise
Medication Reliever: Inhaled short-acting beta₂ agonist* Albuterol	2 puffs as needed	2 puffs every 4 hr‡,¶	2 to 4 puffs every 20 minutes for 3 doses\|\| then 2 to 4 puffs every 4 hours
Corticosteroid tablet or syrup	0	0	Begin with 1 to 2 mg per kg per day§ Notify doctor

NOTE: Footnotes are for clinicians only.
*--Use more than twice per week may indicate need to initiate long-term controller (anti-inflammatory) therapy. See long-term treatment plan for mild persistent asthma.
†--If viral infections provoke severe attacks (exacerbations), consider short course of steroid tablets or syrup at the first sign of a cold or viral illness; see dose next column.
‡--The need for beta₂ agonist for more than 24 to 48 hours indicates at least a moderate attack; consider short course of corticosteroid tablets or syrup.
§--Maximum corticosteroid dose: 60 mg per day, 3- to 11-day course.
||--If there is not a good response, patient should be instructed to seek emergency care immediately. If there is a good response, patient should continue in this column and notify doctor.
¶--If beta₂ agonist needs to be given for 24 hours or longer more often than every 6 weeks, initiate long-term controller (anti-inflammatory) therapy. See sample long-term treatment plan for mild-persistent asthma.

FIGURE 2. Sample long-term treatment plan for mild-persistent asthma.

Name			Date	Spacer
Clinical condition or patient status	Baseline plan and when asthma is under control	At the first sign of a cold or mild attack	For rapidly worsening asthma (severe attack)	When there is no cough or wheeze for 2 months	For cough or wheeze with exercise
Peak flow (% personal best)	80% or above	50 to 80%	Below 50%	Over 80% for 2 months	2 puffs 5 to 10 minutes before exercise**
Medication Reliever: Inhaled short-acting beta₂ agonist* Albuterol	2 puffs as needed	2 puffs every 4 hours§	2 to 4 puffs every 20 minutes for 3 doses\|\| then 2 to 4 puffs every 4 hours	2 puffs as needed
Controller: (1) Inhaled low-dose corticosteroid† Beclomethasone 42 µg or	1 to 4 puffs 2 times per day	1 to 4 puffs 2 times per day	1 to 4 puffs 2 times per day	0
(2) Nonsteroid‡ Nedocromil (Tilade)	0	0	0	2 puffs 2 to 3 times per day#
Corticosteroid tablet or syrup	0	0	Begin with 1 to 2 mg per kg per day¶ Notify doctor	0

NOTE: Footnotes are for clinicians only.
*----Daily or increasing use indicates need for more long-term controller (anti-inflammatory) therapy.
†--Equivalent drugs: fluticasone 44 (Flovent), 1 to 2 puffs, 2 times per day; flunisolide 250 (Aerobid), 1 puff, 2 times per day; budesonide 200 (Rhinocort), inhalation once per day; or triamcinolone 100 (Azmacort), 2 to 4 puffs, 2 times per day.
‡--Nonsteroids include cromolyn (Intal) and nedocromil (Tilade). In young children, these may be tried before inhaled steroids. Antileukotriene agents may also be considered as an alternative: zafirlukast (Accolate), 20 mg 2 times per day, or zileuton (Zyflo), 600 mg, 4 times per day, for patients >=12 years of age; montelukast (Singulair), 5 mg once per day for patients 6 to 14 years of age, and 10 mg once per day for patients >=15 years age.
§--The need for beta₂ agonist for more than 24 to 48 hours indicates at least a moderate attack; consider short course of corticosteroid tablets or syrup.
||--If there is not a good response, patient should be instructed to seek emergency care immediately. If there is a good response, patient should remain in this column and notify doctor.
¶--Maximum steroid dose: 60 mg per day, 3- to 11-day course.
#--When free of symptoms for 4 to 6 months, may try discontinuing controller medicines.
**--If it is difficult to take short-acting beta₂ agonists before exercise, consider long-acting beta₂ agonist to protect against exercise-induced bronchospasm for up to 8 hours.

FIGURE 3. Sample long-term treatment plan for moderate-persistent asthma.

Name			Date	Spacer
Clinical condition or patient status	Baseline plan and when asthma is under control	At the first sign of a cold or mild attack	For rapidly worsening asthma (severe attack)	When there is no cough or wheeze for 2 months	For cough or wheeze with exercise
Peak flow (% personal best)	Baseline-- 60 to 80% Under control-- 80% or above	50 to 80%	Below 50%	Over 80% for 2 months	2 puffs 5 to 10 minutes before exercise**
Medication Reliever: Inhaled short-acting beta₂ agonist* Albuterol	2 puffs as needed	2 puffs every 4 hours§	2 to 4 puffs every 20 minutes for 3 doses\|\| then 2 to 4 puffs every 4 hours	2 puffs as needed
Controller: (1) Inhaled medium-dose corticosteroid† Beclomethasone 84 µg and (2) Antileukotriene‡	2 to 4 puffs 2 times per day	2 to 4 puffs 2 times per day	2 to 4 puffs 2 times per day	1 puff# 2 times per day
Corticosteroid tablet or syrup	0	0	Begin with 1 to 2 mg per kg per day¶ Notify doctor	0

NOTE: Footnotes are for clinicians only.
*--Daily or increasing use indicates the need for more long-term controller (anti-inflammatory) therapy.
†--Equivalent drugs: fluticasone 110 (Flovent), 1 to 2 puffs, 2 times per day; flunisolide 250 (Aerobid), 2 puffs, 2 times per day; budesonide 200 (Rhinocort), 1 inhalation, 2 times per day; or triamcinolone 100 (Azmacort), 4 to 6 puffs, 2 times per day. If nighttime symptoms not controlled, add long-acting inhaled beta₂ agonist 2 times per day.
‡--Antileukotriene agents may be used as additive therapy: zafirlukast (Accolate), 20 mg 2 times per day, or zileuton (Zyflo), 600 mg 4 times per day, for patients >=12 years of age; montelukast (Singulair), 5 mg once per day for patients 6 to 14 years of age, and 10 mg once per day for patients >=15 years of age.
§--The need for a beta₂ agonist for more than 24 to 48 hours indicates a moderate attack at the least; consider short course of corticosteroid tablets or syrup.
||--If there is not a good response, patient should be instructed to seek emergency care immediately. If there is a good response patient should continue in this column and notify doctor.
¶--Maximum steroid dosage: 60 mg per day, 3- to 11-day course.
#--When free of symptoms for 4 months, use low-dose inhaled corticosteroid.
**--If it is difficult to take short-acting beta₂ agonists before exercise, consider long-acting beta₂ agonist to protect against exercise-induced bronchospasm for up to 8 hours.

FIGURE 4. Sample long-term treatment plan for severe-persistent asthma.

Name		Date	Spacer
Clinical condition or patient status	Baseline plan and when asthma is under control	For rapidly worsening asthma (severe attack)	When there is no cough or wheeze for 2 months	For cough or wheeze with exercise
Peak flow (% personal best)	Baseline-- below 60% Under control-- 80% or above	Below 50%	Above 80% for 2 months	2 puffs 5 to 10 minutes before exercise
Medication Reliever: Inhaled short-acting beta₂ agonist* Albuterol	2 puffs as needed	2 to 4 puffs every 20 minutes for 3 doses\|\| then 2 to 4 puffs every 4 hours	2 puffs as needed
Controller: (1) Inhaled high-dose corticosteroid† Beclomethasone 84 µg and	4 to 5 puffs 2 times per day	4 to 5 puffs 2 times per day	2 to 4 puffs 2 times per day¶
(2) Long-acting beta₂ agonist and (3) Antileukotriene‡	2 puffs 2 times per day	2 puffs 2 times per day	2 puffs 2 times per day
Corticosteroid tablet or syrup	0.25 to 2 mg per kg per day§	2 mg per kg per day Notify doctor	0

NOTE: Footnotes are for clinicians only.
*--Daily or increasing use indicates need for more long-term controller (anti-inflammatory) therapy.
†--Equivalent drugs: fluticasone 110 (Flovent), 2 to 3 puffs, 2 times per day; flunisolide 250 (Aerobid), 2 to 3 puffs, 2 times per day; budesonide 200 (Rhinocort), 1 to 2 inhalations, 2 times per day; or triamcinolone 100 (Azmacort), >6 puffs, 2 times per day.
‡--Antileukotriene agents may be used as additive therapy: zafirlukast (Accolate), 20 mg 2 times per day, or zileuton (Zyflo), 600 mg 4 times per day, for patients >=12 years of age; montelukast (Singulair), 5 mg once per day for patients 6 to 14 years of age, and 10 mg once per day for patients >=15 years of age.
§--Maximum corticosteroid dosage: 60 mg per day. With improvement, gradually lower dose and if possible change to every other day schedule.
||--If there is not a good response, patient should be instructed to seek emergency care immediately. If there is a good response, patient should continue in this column and notify doctor.
¶--When free of symptoms for 4 to 6 months, reduce inhaled corticosteroids to medium dose.

Citation and Abstract

Am Fam Physician. 2000 Apr 15;61(8):2419-28, 2433-4. Developing and communicating a long-term treatment plan for asthma. Mellins RB, Evans D, Clark N, Zimmerman B, Wiesemann S.

Pediatric Pulmonary Division, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.

The treatment of asthma, according to current guidelines, requires complex treatment regimens that change as clinical conditions improve or deteriorate. We have developed a practical way to communicate long-term treatment plans in chart form in the primary care setting that is easy for patients to follow and use. The chart has been an important element in two interventions that have resulted in positive changes in health behavior and health outcomes in children with asthma. The plan provides recommendations for patients and families to make adjustments in medication based on changes in symptoms or peak expiratory air flow, or both, that are consistent with the Asthma Guidelines Expert Panel Report 2, 1997. The plan also indicates when the number and dosage of drugs should be increased or decreased and when emergency care should be sought, consistent with the Asthma Guidelines. By placing considerable control in the family's hands and by clearly delineating the conditions under which medicines can be reduced or discontinued, the physician provides incentives for families to adhere to the long-term treatment plan for asthma.

PMID: 10794583 [PubMed - indexed for MEDLINE]

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