Omalizumab has a place in therapy for asthma disease management.

Abstract

Asthma is a complex disease because its presentation can vary considerably from patient to patient. The nature of asthma often requires physicians to use a multifaceted approach to ensure optimal outcomes (i.e., control of symptoms) and to prevent asthma exacerbations and increased health care utilization. Evidence-based disease management guidelines have been developed and published to aid in the diagnosis of asthma and to help guide treatment decisions. In 2007, the National Asthma Education and Prevention Program (NAEPP) released its updated guidelines for the management and treatment of asthma. 1 National guidelines such as these generally present the evidence currently available to support best practices for managing chronic diseases. In the January 2008 issue of JMCP, Urbano reviewed 7 changes to the NAEPP guidelines that were considered by a small expert panel to be the most important and clinically relevant messages in the updated document. 2 The bulk of these changes address diagnosis, successful comprehensive management, assessing disease severity, monitoring disease control, and managing asthma exacerbations. Some of the changes deal directly with medication use and choice. Because there is often a lag between the release of a new guideline and implementation in clinical practice, there is an opportunity to provide education and develop strategies that incorporate new recommendations into current programs. The management and treatment of asthma remain challenging for all health care stakeholders—patients, providers, and payers. Unlike other chronic diseases such as heart disease, which become increasingly prevalent with age, asthma affects patients across the age spectrum. Over the past 25 to 30 years, the prevalence of asthma has continued to grow at an alarming rate, with the greatest increase seen among children. 3,4 Current estimates cite the overall prevalence of asthma in the United States at approximately 22 million people, or about 7.7% of the population. 5 Despite growing recognition of asthma as a chronic disease and strides toward improving its treatment, the financial burden of this disease is enormous. The total direct and indirect costs associated with asthma are approximately $20 billion annually, 6 the greatest proportion of which is attributable to poorly controlled asthma. 7 According to The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study, a prospective, observational, multicenter, 3-year U.S. study of 4,756 patients with severe or difficult-totreat asthma, the highest percentage of health care utilization in the prior 3 months was linked to patients with severe asthma. 8 The mandate for improving the care of asthma is clear. However, the existence of guidelines does not always ensure improved patient care. In a 2-year retrospective study of claims data from more than 4 million United Healthcare enrollees nationwide, overall adherence to evidence-based practice guidelines was 59% for select chronic conditions, including coronary artery disease, congestive heart failure, hyperlipidemia, asthma, and diabetes. 9 For adults with persistent asthma, 79% of the commercially insured population filled a prescription for inhaled corticosteroid (ICS) therapy, whereas only 58% of Medicare enrollees filled an ICS prescription. 9 Adherence to national asthma guidelines among inner-city physicians is even poorer. In a survey of 202 primary care providers in East Harlem, New York, 62% reported adhering to the National Heart, Lung and Blood Institute (NHLBI) asthma guidelines for ICS use. 10 However, 34% reported adherence to the NHLBI guidelines recommendations for peak flow monitoring, 10% for referrals to allergy testing, and 9% for using an asthma action plan. It was also noted that greater provider self-efficacy was associated with greater adherence to peak flow monitoring, ICS use, and use of an asthma action plan. 10