How often should the progress of asthma patients be assessed? At what point is it safe to consider stopping a steroid metered-dose inhaler? — Kathleen M. St. Germain, PA-C, Springfield, Va.

Asthma is a chronic condition, and optimal treatment requires a quality relationship between practitioner and patient. The four steps of asthma severity are mild intermittent, mild persistent, moderate persistent, and severe persistent.

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The patient must be educated about the severity of his or her condition and the pharmacologic and nonpharmacologic treatment options. Studies have shown that patients who understand the disease and treatment plan suffer fewer exacerbations and complications.

Long-term control medications are recommended. Treatment options include oral corticosteroids, inhaled corticosteroids, cromolyn sodium (Intal) or nedocromil, long-acting ß2-agonists, leukotriene modifiers, and theophylline. Specific choice depends on the severity of the individual’s symptoms, his or her understanding of use and delivery methods, compliance, and a willingness to become active in disease management.

All patients should keep a log of their symptoms and need for rescue medication as well as use of long-term control medications. The key is to “treat up” the asthma scale, and consider stepping down once stabilized. For example, if someone diagnosed with mild intermittent asthma develops increasing symptoms that meet the criteria for moderate persistent asthma, treatment must be adjusted to include rescue medication (short-acting bronchodilator) and daily medication (inhaled corticosteroid and either a long-acting inhaled ß2-agonist, theophylline, or long-acting oral ß2-agonist).

Once the symptoms have been stabilized, the patient and the practitioner can decide to step down to treatment guidelines for mild persistent asthma, specifically rescue medication plus daily anti-inflammatory (inhaled corticosteroid, cromolyn or nedocromil, a leukotriene modifier). Eventual cessation of the inhaled corticosteroid would depend on patient response and stability. If a patient is symptom-free and not relying on rescue medication, you can attempt to wean from daily inhaled corticosteroids.

The most important aspects of this plan are the constant monitoring of symptoms, communication between the patient and the practitioner, and willingness to return to daily anti-inflammatory medication if the patient’s symptoms worsen. — Claire Babcock O’Connell, MPH, PA-C (176-2)

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