Correspondence

Mild Asthma

N Engl J Med 2002; 346:1335-1336April 25, 2002

Article

To the Editor:

Naureckas and Solway (Oct. 25 issue)1 discuss the treatment of mild intermittent and mild persistent asthma but do not discuss the importance of indoor allergens. Allergens not only are triggers of symptoms, but some are also regarded as causal factors in the development of the disease.2,3 Because they continuously induce allergic inflammation of the airways, allergens may be more important as a cumulative cause of bronchial hyperreactivity than as triggers of acute attacks.4 Furthermore, longitudinal studies have shown an accelerated decline in the forced expiratory volume in one second in older adults who are exposed to certain allergens.5 In other diseases that are caused by exposure to foreign substances, such as hypersensitivity pneumonitis, avoidance of exposure to relevant antigens is the first line of treatment. In asthma, environmental control measures to reduce exposure to indoor allergens should be considered a primary antiinflammatory treatment.2 Such measures should help to prevent the development of chronic airflow limitation and, therefore, reduce the need for further pharmacologic treatment.

Arturo J. Bonnin, M.D.
Wright State University School of Medicine, Dayton, OH 45401
ajbonnin@aol.com

5 References

1. 1

   Naureckas ET, Solway J. Mild asthma. N Engl J Med 2001;345:1257-1262
   Full Text | Web of Science | Medline

2. 2

   Global initiative for asthma: global strategy for asthma management and prevention: NHLBI/WHO Workshop report. Bethesda, Md.: National Heart, Lung, and Blood Institute, January 1995. (NIH publication no. 95-3659.)
   

3. 3

   Platts-Mills TA, Thomas WR, Aalberse RC, Vervloet D, Chapman MD. Dust mite allergens and asthma: report of a second international workshop. J Allergy Clin Immunol 1992;89:1046-1060
   CrossRef | Web of Science | Medline

4. 4

   Platts-Mills TAE, Carter MC. Asthma and indoor exposure to allergens. N Engl J Med 1997;336:1382-1384
   Full Text | Web of Science | Medline

5. 5

   Weiss ST, O'Connor GT, DeMolles D, Platts-Mills T, Sparrow D. Indoor allergens and longitudinal FEV1 decline in older adults: the Normative Aging Study. J Allergy Clin Immunol 1998;101:720-725
   CrossRef | Web of Science | Medline

To the Editor:

Naureckas and Solway do not address the role of testing for allergens or precipitants. Effective management of mild asthma involves avoidance of allergens, and this often requires radioallergosorbent testing or careful skin testing.

Vincent A. Marinkovich, M.D.
801 Brewster Ave., Suite 220, Redwood City, CA 94063

To the Editor:

Naureckas and Solway provide definitions of mild intermittent and mild persistent asthma that are based on the frequency of clinical symptoms and objective measures of lung function. These definitions are derived from international guidelines.1-3 However, it is important to recognize that these definitions apply to untreated patients. After treatment has been established, and particularly after control medications are being taken regularly by the patient, the severity of the disease is defined not only by symptoms and lung-function values, but also by the amount of medication required to keep asthma under control — for example, low-dose inhaled corticosteroids for mild persistent asthma and short-acting inhaled β₂-agonists as needed or before exercise for mild intermittent asthma.1-3 This simple concept is included in the guidelines, but it is often overlooked.

Micaela Romagnoli, M.D.
Leonardo M. Fabbri, M.D.
University of Modena and Reggio Emilia, 41100 Modena, Italy
fabbri.leonardo@unimo.it

3 References

1. 1

   Expert Panel report 2: guidelines for the diagnosis and management of asthma. Bethesda, Md.: National Heart, Lung, and Blood Institute, 1997. (NIH publication no. 97-4051.)
   

2. 2

   Global initiative for asthma: global strategy for asthma management and prevention: NHLBI/WHO Workshop report. Bethesda, Md.: National Heart, Lung, and Blood Institute, January 1995. (NIH publication no. 95-3659.)
   

3. 3

   Boulet LP, Becker A, Berube D, Beveridge R, Ernst P. Canadian Asthma Consensus Report, 1999. CMAJ 1999;161:Suppl:S1-S61
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We agree with Drs. Bonnin and Marinkovich that the avoidance of environmental triggers is beneficial in patients with asthma of any severity. Indeed, the guidelines of the National Asthma Education and Prevention Program (NAEPP)1 recommend testing for individually relevant perennial allergens, but they also point out that the patient's history alone may be sufficient to suggest sensitivity to seasonal allergens. We note that the reduction of exposure to other exacerbating factors, such as inhaled irritants, is also worthwhile.

Drs. Romagnoli and Fabbri properly emphasize that the classification system outlined in the NAEPP guidelines1 is intended for the initial evaluation of asthma — implicitly, before the initiation of therapy. Successful treatment results in the diminution of symptoms and improvement in other objective measures and does not change the classification of the severity of asthma in an individual patient.

Edward T. Naureckas, M.D.
Julian Solway, M.D.
University of Chicago, Chicago, IL 60637
tnaureka@medicine.bsd.uchicago.edu

1 References

1. 1

   Expert Panel report 2: guidelines for the diagnosis and management of asthma. Bethesda, Md.: National Heart, Lung, and Blood Institute, 1997. (NIH publication no. 97-4051.)
   

Citing Articles (2)

Citing Articles

1. 1

   Klaus F Rabe, Mitsuru Adachi, Christopher K.W Lai, Joan B Soriano, Paul A Vermeire, Kevin B Weiss, Scott T Weiss. (2004) Worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys. Journal of Allergy and Clinical Immunology 114:1, 40-47
   CrossRef

2. 2

   Roy J. Soberman, Peter Christmas. (2003) The organization and consequences of eicosanoid signaling. Journal of Clinical Investigation 111:8, 1107-1113
   CrossRef