Annals of African Medicine
Home About AAM Editorial board Ahead of print Current Issue Archives Instructions Subscribe Contact us Search Login 


 
REVIEW ARTICLE
Year : 2007  |  Volume : 6  |  Issue : 1  |  Page : 1-6 Table of Contents     

Management of asthma in adults: Current trends and future directions


Department of Medicine, Usmanu Danfodiyo University, Sokoto, Nigeria

Date of Web Publication10-Oct-2009

Correspondence Address:
C H Njoku
Department of Medicine, College of Health Sciences, Usmanu Danfodiyo University, P. M. B. 2254, Sokoto
Nigeria
Login to access the Email id


DOI: 10.4103/1596-3519.55739

PMID: 18240483

Get Permissions

   Abstract 

Bronchial asthma has witnessed a significant increase in its prevalence in the past decade. Considerable morbidity and significant mortality has been associated with it and this has been matched by increased scientific research into new methods of therapy to supplement or replace the traditionally known treatment modalities. A search for old and new literature on asthma management in adults necessitated forage in the library for old works and an internet search into relevant websites to download several works on asthma from which those relevant to this article were selected. Evidences supporting current asthma therapies including some non-pharmacological measures of intervention and alternative approaches were highlighted. Some novel interventions that may be useful in the future management of asthma were discussed. Some novel therapeutic agents acting on specific components of the inflammatory pathways in asthma are emerging. The future management of asthma may involve the use of these newer agents in combination with more established therapies. For successful management of asthma, patient's education and involvement are essential.

   Abstract in French 

Ll'asthme bronchique a connu une augmentation significative à son fréquence au cours de la décennie passée. On l'avait associer avec une morbidité considérable et une mortalité significative et cellesci ont été égaler avec une recherche scientifique augmentée sur des nouvelles méthodes thérapeutiques pour supplementer ou remplacer les modalités du traitement connu traditionnellement.Une cherche pour l'ancienne ou la nouvelle littérature sur la gérance de l ;asthrue chez les adultes a nécessite un fourrage dans la bibliothéque pour des anciens travaux aussi qu'une cherche sur l'internet aux websites pertinent pour rétirer plusieurs travaux sur l'asthme. C'est à partir de ces travaux que ceux qui sont pertinent à cet article sont selectionés. Les preuves en faveur des thérapies actuelles de l'asthme y inclus quelques mesures pharmacologique d'intervention et des autres approches sont souliognées. Quelques interventions nouvelles qui peuvent être utile dans l'avenir pour la gérance de l'asthme sont aussi discutées. Quelques nouvelles agents thérapeutiques qui agir sur les composantes spécifiques des chemins inflamatoires en asthme s'émerge. Dans l'avenir la gérance de l'asthme peut entrainer l'emploie de ces nouveaux agents en association avec les thérapies les plus établir. Pour réussir à la gérance de l'asthme, l'education et la participation du malade est essential.

Keywords: Bronchial asthma, management, adults


How to cite this article:
Bello A K, Njoku C H. Management of asthma in adults: Current trends and future directions. Ann Afr Med 2007;6:1-6

How to cite this URL:
Bello A K, Njoku C H. Management of asthma in adults: Current trends and future directions. Ann Afr Med [serial online] 2007 [cited 2014 Sep 2];6:1-6. Available from: http://www.annalsafrmed.org/text.asp?2007/6/1/1/55739


   Introduction Top


The past decades have witnessed a spectacular increase in the prevalence of asthma globally, with associated significant use of healthcare resources. As far back as 1860, Henry Hyde Salter, a Physician at Charing Cross Hospital in London described asthma as paroxysmal dyspnoea of a peculiar character with intervals of healthy respiration in between attacks. [1],[2],[3] He drew attention to the musical rhonchi that characterised asthmatic bronchoconstriction, and identified its cellular basis, which was only fully elucidated after the development of eosin stain by Paul Ehrlich in 1875. [4] The pathological basis was further described by Huber and Koessler in 1922. [5] Similarly, another significant milestone is the characterisation of its trigger factors by Sir William Osler in the early part of the 19th century. [6]

Asthma is associated with variable airflow obstruction, airway hyper-responsiveness, and chronic airway inflammation. It can cause considerable morbidity and a significant mortality. It is defined as reversible airway obstruction associated with inflammation and bronchial hyper-responsiveness. [7] The airway hyper-responsiveness is induced by a variety of local stimuli involving biochemical pathways of histamine, leukotrienes and prostaglandins. Various risk factors are associated with the development of asthma. These include familial predisposition, maternal smoking, ethnicity, socio-economic status and gender (male sex). [7],[8]

National and international guidelines have developed a stepwise approach to management, with treatment increment until asthma control is achieved and stepped down once control has been maintained for several months. [7],[8] Currently available anti-inflammatory and bronchodilator drugs are very effective and a good asthma control can be achieved for most patients using these agents. A significant minority, however, will have more severe persistent asthma which is difficult to manage and which may require alternative approaches. New drugs which improve control and outcome, with minimal side effects, or improve compliance are therefore needed. Somenew classes of drugs, which may fill these roles, are currently under investigation. This review aims to discuss the evidence supportingcurrent asthma therapies including some non-pharmacological measures of intervention, and alternative approaches where appropriate, and finally discuss some novel interventions under development that may be useful in the future management of asthma.


   Lifestyle modification and other non-pharmacological strategies in the management of asthma Top


Changes in attitude, behaviour and lifestyle may play a significant role in the management of asthma. [9],[10]

Smoking

Cigarette smoking in adults with asthma is associated with an accelerated decline in lung function, increased symptoms severity and exacerbation of frequency of attacks in addition to impaired response to inhaled corticosteroids. [11] Although studies confined to populations of patients with asthma have not been done, smoking cessation clearly has a number of important health benefits which are likely to be particularly important to patients with pre-existing respiratory disease. [12] Appropriate counselling should therefore be given to all patients with asthma who smoke and pharmacological treatments such as nicotine replacement therapy may be relevant.

Patient involvement

Involving patients in their asthma management plans, particularly those that include written advice for patients to follow should symptoms and/or peak flow readings deteriorate, have been shown to reduce hospital admissions for asthma and are recommended in some current guidelines. [7],[8] How this can be applicable in our setting with low literacy rates remain to be determined.

Avoidance of allergen

The exposure of patients with atopic asthma to the allergens that they are sensitive to has been shown to increase asthmas ymptoms and airway hyper-responsiveness and to cause bronchoconstriction. Studies of allergen control measures in infancy have shown reductions in respiratory symptoms, but it remains to be determined if such measures will prevent the development of atopy and asthma in adulthood. [13]

Immunotherapy

Allergy specificity and reaction have been described in asthmatics, and its targeting in management may improve outcome. [14] Allergen specific immunotherapy, or desensitisation, involvesthe administration of specific allergen extracts via subcutaneousinjections of increasing concentration with the aim of inducingimmunological tolerance. The process may work by generatinginterleukin-10 producing regulatory T-cells. This has been found to be particularly useful in allergic rhinitis but has alsobeen shown to improve symptoms and airway responsiveness inpatients with allergic asthma. [15] Overall the benefits appearto be modest, but desensitisation therapy can be labour intensive, and is associated with life threatening anaphylaxis.

Pharmacological interventions

Most management guidelines have recommended graded interventions of therapy according to severity of symptoms and frequency of attacks. [7],[8]


   Mild asthma Top


Evidence-based management here revolves around whether the asthma is mild intermittent or persistent. Mild intermittent asthmatics are those in whom symptoms occur less than once a week and have nocturnal symptoms ≤ 2 per month. Their peak expiratory flow rate (PEF) is ≥ 80% of predicted value and shows < 20% variability. They are asymptomatic and have normal PEF between attacks. In mild intermittent asthma, the mainstay of therapy is still the use of Inhaled short acting ß2 -agonists which are shown to be effective in bronchodilation. [7],[8],[16] Their mechanism ofaction is thought to occur primarily by the relaxation of airwaysmooth muscle cells, but they also increase mucociliary clearance.They do not have any effective anti-inflammatory activity and should be used forsymptom relief when required. Their regular use provides no additional benefit andmay even be harmful. [16] The use of more than one canister of short acting ß2 -agonistsper month has been associated with poorly controlleddisease and should therefore alert the prescriber to the needfor increased regular anti-inflammatory treatment.

Mild persistent asthmatics are those in whom symptoms occur more than or equal to once a week but less than once a day. They have nocturnal symptoms more than twice a month while their PEF values are more than or equal to 80% of predicted value and show 20-30% variability. In this group corticosteroids are currently the most effective anti-inflammatoryagents for the treatment and inhaled corticosteroidsare currently recommended for all patients with persistent asthmawho require short acting ß2 -agonists more than onceper day or those with intermittent asthma who experience severeexacerbations. [7],[8] They exert their anti-inflammatory effects througha diverse range of mechanisms including the activation of theglucocorticoid receptors, leading to the regulation of transcriptionof target genes, and the direct inhibition of a range of inflammatorycells, particularly eosinophils. Studies have consistently shownthat treatment with regular inhaled corticosteroids resultsin significant improvements in airway inflammation in asthma.[17] There is also epidemiologicalevidence from cohort and case-control studies showing that regularlow dose inhaled corticosteroids reduce both hospital admissionsand asthma deaths. [18] A recent study of patients with mild, apparentlywell controlled asthma showed that the addition of regular lowdose inhaled corticosteroids resulted in significant reductionin asthma exacerbations compared with the control group. [19] These markedbenefits, coupled with the low incidence of side effects, haveled some to argue that inhaled corticosteroids should be givento all but the mildest patients. It is not yet fully known whetherlong term treatment with inhaled corticosteroids alters thenatural history of asthma, or protects against decline in lung function. Long term prospectivestudies of the effects of regular inhaled corticosteroids onthe decline in lung function in adults are needed to addressthis important issue.

In-addition, the cromones agents by inhalation, has been used as controller therapiesin mild persistent asthma. Though mechanism of action is notfully understood, they are believed to suppress IgE-mediatedinflammatory responses and may inhibit inflammatory cells. [20] However, theyappear to be rather less effective than low dose inhaled corticosteroids and their long term effects on airway inflammation are unknown.The use of these agents in adults has therefore largely beensuperseded by the introduction of low doses of inhaled steroidsfor the majority of patients with persistent asthma. [21]


   Moderate Persistent Asthma Top


This refers to patients who use ß2 agonist daily because of daily attacks and who have night time symptoms more than once a week. Their PEF values are more than 60% and less than 80% of predicted value and shows variability of more than 30%. Such patients may have been receiving treatment with lowdose inhaled corticosteroids and still have sufficient symptoms to justifya step up along the treatment ladder. There are an increasingnumber of treatment options for this group of patients. Long acting ß2 -agonists (e.g. salmeterol and formoterol)are currently generally recommended as the first choice forpatients who have symptoms that persist despite regular inhaledcorticosteroids. Salmeterol is a partial agonist of the ß2 -receptorswhile formoterol is a full agonist. Both appear to have similarclinical effects, but formoterol has a more rapid onset of action.Aswith short acting ß2 -agonists, these agents work primarilyvia the relaxation of airway smooth muscles, with additionaleffects on mast cells and vascular permeability, but withoutsignificant anti-inflammatory activity. This lack of anti-inflammatoryactivity precludes their use as first line agents in asthmaand current guidelines recommend that they are only prescribedalongside regular inhaled corticosteroids. [7],[8],[22] Long acting ß2 -agonists have been shown to improveday time and night time symptoms and reduce the need for rescue short acting ß2-agonists.In a randomised controlled trial of 852 patients treated withlow dose inhaled corticosteroids (the FACET study) the additionof formoterol to inhaled low or high dose budesonide improvedsymptoms and lung function and reduced the rate of acute exacerbations. [23] In-addition, the OPTIMA study in patients with milder disease suggested thatthe addition of formoterol resulted in greater reductions inexacerbation frequency than doubling the dose of inhaled corticosteroids. [24] One important concern with long acting ß2 -agonistsis that subjects recruited into many clinical trials are carefully selected and therefore notfully representative of the patients seen in everyday clinicalpractice.

The earlier approach to patients with persistent symptomsdespite low doses of inhaled corticosteroids was to increasethe corticosteroid dose, but the evidence for this is somewhatinconsistent. While some studies have demonstrated clear doserelated improvements in symptoms and lung function, [23],[25] others have not demonstrated clinically important benefits withmoderate or high doses. [26] Overall the beneficial effects ofincreasing the dose of inhaled corticosteroids appear to bemodest and may be largely outweighed by the increased risk ofside effects.

The next group of agents are the leukotrienereceptor antagonists which are capable of markedly inhibiting exerciseinduced bronchoconstrictionand the various responsesto inhaled allergen.[27],[28],[29] .Moreover, when added to as required short acting ß2-agonists,clinical trials have shown improvement in lung function. [30] Clinical trials have also shown evidenceof efficacy in patients taking high doses of inhaled steroids, and the introduction of montelukast has been shown to allowa reduction in the dose of inhaled corticosteroid without lossof asthma control. [31] The effectiveness of the addition of leukotrieneantagonists compared with increasing the dose of inhaled corticosteroidsin patients with persistent symptoms, however, has not yet beenfully addressed.

In-addition, high up the ladder is theophylline which has been in use for many years as a bronchodilator, but due to adverse effects, it hasoften been reserved for use in patients with more severe asthma.Recent interesthas been in the use of theophylline at lower doses where therisk of side effects is minimised. The combination of low doseinhaled corticosteroids and theophylline has been shown to resultin comparable asthma control as higher doses of inhaled corticosteroidsand may provide slightly greater improvements in lung function. [32] Following a meta-analysis, long acting ß2 -agonistsare shown to be superior to theophylline in patients taking lowdoses of inhaled corticosteroids and result in fewer side effects as well. [33] However, unlike long acting ß2 -agonists, theophyllinehas been shown to have anti-inflammatory activity andmay therefore be more beneficial in some patients.


   Severe persistent asthma Top


This refers to patients with limited physical activity due to continuous symptoms. Night time symptoms are frequent and their PEF values are less than or equal to 60% of predicted values with a variability of more than 30%. This group of patients have persistent symptoms despiteappropriate treatment for moderate persistent asthma. It is imperative in this group of patients to ensure that the persistent symptoms are due to asthma rather than other aggravatingfactors such as rhinitis or gastro-oesophageal reflux and toassess compliance with existing therapy. Once these issues havebeen resolved, current guidelines recommend a step-up in treatment,usually with high doses of inhaled corticosteroids in combinationwith long acting ß2 -agonists, leukotriene antagonists,theophylline, oral ß2 -agonists, or a combination ofthese agents.[7],[8] There have been no randomised controlled studiescomparing these different treatment options in this group ofpatients and therefore additional therapy should be institutedon a trial basis and discontinued if there is no objective evidenceof benefit. [34]

A further group of patients continue to have severe persistent asthma thatremains difficult to control despite the measures outlined above.In these circumstances treatment with oral corticosteroids,usually in the form of daily prednisolone, may be required tominimise symptoms and prevent severe asthma exacerbations. Whilecourses of oral corticosteroids are unquestionably a vital partof the management of acute exacerbations, careful considerationshould be made before they are administered on a long term basissince there is a high risk of significant adverse effects.When needed, the lowest dose which maintains asthmacontrol should be given. Prophylactic therapy for osteoporosisshould be considered and patients should be monitored for thedevelopment of hypertension, diabetes, cataracts, glaucoma,and adrenal suppression. Similarly, obesity, thinning and bruising of theskin, and myopathy are also important concerns. Other corticosteroid sparing agents that includemethotrexate, gold, and cyclosporine can be used in some instances. Although there is someevidence that these agents have steroid-sparing effects in asthmaeach has its own safety concerns and their use should belimited to specialist units. [35],[36]

There is also need for individualised treatment plans, required for different settings due to differences in circumstances regarding clinical presentation, and even in terms of personnel and resources. For instance, the severity of symptoms in asthma differs in pattern across the globe in epidemiology, risk profile and manifestations. [37] Relevant guidelines have evolved to suit different settings even in some developing countries as South Africa. [39]


   Future therapies Top


This involves the use of such agents as Anti-IgE monoclonal antibody. The hypersensitivity type 1 immunoglobulin, IgE has a significant role in the development of allergic diseasesin atopic subjects, and particularly asthma. [14] Its suppression is therefore a potentialtarget in the management of atopic asthma. A monoclonal anti-IgEantibody, omalizumab, which blocks the interaction of IgE withmast cells and basophils, has been developed. This agent given as subcutaneous injection at doses titratedto serum IgE levels, resulted in improved symptom control in a series of patients with resultantfewer exacerbations, and even a greater reduction in inhaled corticosteroiddoses with no apparent adverse effects. [40] This is an important future treatment of patientswith atopic asthma.

The development of monoclonal antibodies to interleukin-5 has been widely acknowledged. This is based on the principle that the eosinophils are a characteristic inflammatory response cells in asthma. The inhibition of the cytokine interleukin-5, responsible for the maturation and release of this group of cells in the bone marrow represents another potentialtreatment. It has been shownthat the humanised anti-interleukin-5 monoclonal antibody SB-240563was able to reduce the sputum eosinophilia after allergen challengewhen given intravenously, though without effect on the early orlate fall in FEV1 , or on airway responsiveness. [41]

More recently, the role of human recombinant interleukin-12 and interleukin-4 receptor antagonists in the armamentarium of management of asthma are being investigated.Interleukin-12 is a macrophage-derived cytokine that can suppress eosinophilicinflammation by modulating T-lymphocyte responses. In several studies it has been shown to suppress eosinophilic inflammationwith no associated improvements in airwayhyper-responsiveness. [42] It awaits further characterisation and development.

Interleukin-4 is another key cytokine in the development ofairway inflammation that has been targeted in the search fornovel asthma therapies by the use of its antagonists. Some initial reports have shown that this drug may reduce the deterioration in symptoms and the reduced lung functionthat follows after withdrawal of inhaled corticosteroids. [43]


   Conclusion Top


Despite the recent advancement in understanding of the pathophysiology and targets for therapeutic interventions in asthma, the use of inhaled corticosteroids is still the cornerstone of treatment in chronic asthma. Steroids are effective in improvingeosinophilic airway inflammation, lung function and also controlasthma symptoms in most patients. But some patients will still require additionaltherapy. There is a range of effective additionaltreatments available. It is vital to target treatmentsto patients who are most likely to respond through identification of individual treatment goals and careful assessment of likelyunderlying pathophysiology. In patients with more severe asthma,close monitoring of airway inflammation is required for optimalmanagement.

Currently, some novel therapeutic agents acting on specific componentsof the inflammatory pathways in asthma are emerging as discussed. The futuremanagement of asthma may well involve the useof these newer agents in combination with more established therapies, after their further development and establishment of efficacy. In another but equally important dimension, patient education and involvement is an essential component of successful asthma management. [44] Current management approaches require patients and families to effectively carry on with complex pharmacologic regimens, institute environmental control strategies, detect and self-treat most asthma exacerbations, and communicate appropriately with health care providers. Doctors should train patients to gain the motivation, skill, and confidence to control their asthma. Research shows that asthma education can be cost-effective and can reduce morbidity for both adults and children, especially among the high-risk patients, with appropriate lifestyle intervention. [44],[45]



 
   References Top

1.Salter HH. On asthma: its pathology and treatment. Churchill, London, 1860  Back to cited text no. 1      
2.Salter HH. An analysis of a hundred and fifty unpublished cases of asthma No.1. The Influence of sex and age in determining the liability to asthma. Lancet 1866; ii: 90-91  Back to cited text no. 2      
3.Salter HH. Lectures on dyspnoea Lecture 3.Lancet 1865;ii:475-8.  Back to cited text no. 3      
4.Hirsch J, Hirsch BI. Paul Ehrlich and the discovery of eosinophils. In: Mahmoud AAF, Austen KF (eds). The eosinophil in health and disease. Grune and Stratton, New York, 1980:3-23  Back to cited text no. 4      
5.Hubert HL, Koessler KK. The pathology of bronchial asthma. Arch Intern Med 1922; 30:689  Back to cited text no. 5      
6.Osler W. Bronchial asthma. In: Principles and practice of medicine. Appleton, New York, 1892:497-501  Back to cited text no. 6      
7.British Thoracic Society. Scottish intercollegiate guidelines network. British guidelines on asthma management. Thorax 2003;58 (suppl 1): 11– 94  Back to cited text no. 7      
8.Global initiative for asthma. Global strategy for asthma management and prevention. National Heart, Lung and Blood Institute, 199: publication No. 95– 3659   Back to cited text no. 8      
9.Erhabor GE, Aghanwa HS, Ndububa D. Patients attitude towards asthma in Ile-ife. Niger J Med 2003;12:206-210  Back to cited text no. 9      
10.Jones A, Pill R, Adams S. Qualitative study of views of health professionals and patients on guided self management plans for asthma. BMJ 2000; 321:1507– 510  Back to cited text no. 10      
11.Siroux V, Pin I, Oryszczyn MP, et al. Relationships of active smoking to asthma and asthma severity in the EGEA study. Epidemiological study on the genetics and environment of asthma. Eur Resp J 2000;15:470– 477  Back to cited text no. 11      
12.Ulrik CS, Lange P. Cigarette smoking and asthma. Monaldi Arch Chest Dis 2001;56:349– 353  Back to cited text no. 12      
13.Custovic A, Simpson BM, Simpson A, et al. Effect of environmental manipulation in pregnancy and early life on respiratory symptoms and atopy during first year of life: a randomised trial. Lancet 2001;358:188– 193  Back to cited text no. 13      
14.Onyemelukwe GC, Shakib F, Saeed TK, et al. RAST-Specific IgE in Nigerian asthmatic patients. Ann Allergy 1986;56:167-170  Back to cited text no. 14      
15.Abramson MJ, Puy RM, Weiner JM. Allergen immunotherapy for asthma. Cochrane Database of Systematic Reviews 2000(2):CD001186  Back to cited text no. 15      
16.Walters EH, Walters J. Inhaled short acting beta2-agonist use in asthma: regular vs as needed treatment. Cochrane Database of Systematic Reviews 2000(4):CD001285  Back to cited text no. 16      
17.Djukanovic R, Wilson JW, Britten KM, et al. Effect of an inhaled corticosteroid on airway inflammation and symptoms in asthma. Am Rev Resp Dis 1992;145:669– 674  Back to cited text no. 17      
18.Donahue JG, Weiss ST, Livingston JM, et al. Inhaled steroids and the risk of hospitalization for asthma. JAMA 1997;277:887– 891  Back to cited text no. 18      
19.Suissa S, Ernst P, Benayoun S, et al. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med 2000;343:332– 326  Back to cited text no. 19      
20.Diaz P, Galleguillos FR, Gonzalez MC, et al. Bronchoalveolar lavage in asthma: the effect of disodium cromoglycate (cromolyn) on leukocyte counts, immunoglobulins, and complement. J Allergy Clin Immunol 1984; 74:41– 8.  Back to cited text no. 20      
21.Edwards AM. Sodium cromoglycate (Intal) as an anti-inflammatory agent for the treatment of chronic asthma. Clin Exp Allergy 1994;24:612– 623  Back to cited text no. 21      
22.Lazarus SC, Boushey HA, Fahy JV, et al. Long-acting beta2-agonist monotherapy vs. continued therapy with inhaled corticosteroids in patients with persistent asthma: a randomized controlled trial. JAMA 2001;285:2583– 2593  Back to cited text no. 22      
23.Kesten S, Chapman KR, Broder I, et al. A three-month comparison of twice daily inhaled formoterol versus four times daily inhale albuterol in the management of stable asthma. Am Rev Resp Dis 1991;144(3 pt 1):622– 625  Back to cited text no. 23      
24.O'Byrne PM, Barnes PJ, Rodriguez-Roisin R, et al. Low dose inhaled budesonide and formoterol in mild persistent asthma: the OPTIMA randomized trial. Am J Resp Crit Care Med 2001;164(8 pt 1):1392– 1397  Back to cited text no. 24      
25.Greening AP, Ind PW, Northfield M, et al. Added salmeterol versus higher-dose corticosteroid in asthma patients with symptoms on existing inhaled corticosteroid. Allen and Hanburys Limited UK Study Group. Lancet 1994;344:219– 224  Back to cited text no. 25      
26.Adams NP, Bestall JB, Jones PW. Inhaled beclomethasone versus placebo for chronic asthma. Cochrane Database of Systematic Reviews 2000(4):CD002738  Back to cited text no. 26      
27.Finnerty JP, Wood-Baker R, Thomson H, et al. Role of leukotrienes in exercise-induced asthma: inhibitory effect of ICI 204219, a potent leukotriene D4 receptor antagonist. Am Rev Resp Dis 1992;145:746– 749  Back to cited text no. 27      
28.Ige OM, Onadeko BO. An open study to evaluate the safety and efficacy of Zafirlukast in patients with mild to moderate asthma in Ibadan, Nigeria. West Afr J Med 2001;20:220-226  Back to cited text no. 28      
29.Chukwu C, Okpapi J, Ige MO, Obodo JO. Efficacy and safety of Zafirlukast in the management of mild to moderate asthma. West Afr J Med 2000;19:111-119  Back to cited text no. 29      
30.Spector SL, Smith LJ, Glass M. Effects of 6 weeks of therapy with oral doses of ICI 204,219, a leukotriene D4 receptor antagonist, in subjects with bronchial asthma. ACCOLATE asthma trialists group. Am J Resp Crit Care Med 1994;150:618– 623  Back to cited text no. 30      
31.Pizzichini E, Leff JA, Reiss TF, et al. Montelukast reduces airway eosinophilic inflammation in asthma: a randomized, controlled trial. Eur Resp J 1999;14:12– 18  Back to cited text no. 31      
32.Evans DJ, Taylor DA, Zetterstrom O, et al. A comparison of low-dose inhaled budesonide plus theophylline and high-dose inhaled budesonide for moderate asthma. N Engl J Med 1997;337:1412– 1418  Back to cited text no. 32      
33.Wilson AJ, Gibson PG, Coughlan J. Long acting beta-agonists versus theophylline for maintenance treatment of asthma. Cochrane Database of Systematic Reviews 2000(2):CD001281  Back to cited text no. 33      
34.Mahajan P, Okamoto LJ, Schaberg A, et al. Impact of fluticasone propionate powder on health-related quality of life in patients with moderate asthma. J Asthma 1997;34:227– 234  Back to cited text no. 34      
35.Aaron SD, Dales RE, Pham B. Management of steroid-dependent asthma with methotrexate: a meta-analysis of randomized clinical trials. Resp Med 1998;92:1059– 1065  Back to cited text no. 35      
36.Lock SH, Kay AB, Barnes NC. Double-blind, placebo-controlled study of cyclosporin A as a corticosteroid-sparing agent in corticosteroid-dependent asthma. Am J Resp Crit Care Med 1996;153:509– 514  Back to cited text no. 36      
37.Falade AG, Olawuyi F, Osinusi K, Onadeko BO. Prevalence and severity of symptoms of asthma, allergic rhino-conjunctivitis and atopic eczema in secondary school children in Ibadan, Nigeria. East Afr Med J 1998 ;75:695-698  Back to cited text no. 37      
38.Kayantao D, Toloba Y, Kamissoko M, et al. Epidemiological, clinical and progressive aspects of asthma observed at Bamako, Mali. Sante 2001;11:101-103  Back to cited text no. 38      
39.Lalloo UG, Bateman ED, Feldman C, et al. Guideline for the management of chronic asthma in adults--2000 update. South African pulmonology society adult asthma working group. S Afr Med J 2000;90(5 Pt 2):540-541, 544-552  Back to cited text no. 39      
40.Soler M, Matz J, Townley R, et al. The anti-IgE antibody omalizumab reduces exacerbations and steroid requirement in allergic asthmatics. Eur Resp J 2001;18:254– 261  Back to cited text no. 40      
41.Leckie MJ, ten Brinke A, Khan J, et al. Effects of an interleukin-5 blocking monoclonal antibody on eosinophils, airway hyper-responsiveness, and the late asthmatic response. Lancet 2000;356:2144– 2148  Back to cited text no. 41      
42.Bryan SA, O'connor BJ, Matti S, et al. Effects of recombinant human interleukin-12 on eosinophils, airway hyper-responsiveness, and the late asthmatic response. Lancet 2000;356:2149– 21453  Back to cited text no. 42      
43.Borish LC, Nelson HS, Corren J, et al. Efficacy of soluble IL-4 receptor for the treatment of adults with asthma. J Allergy Clin Immunol 2001;107:963– 970  Back to cited text no. 43      
44.Clark NM, Evans D, Zimmerman BJ, et al. Patient and family management of asthma: theory-based techniques for the clinician. J Asthma 1994; 31:427-435  Back to cited text no. 44      
45.Parker SR, Mellins RB, Sogn DD. NHLBI workshop summary. Asthma education: a national strategy. Am Rev Resp Dis 1989; 140:848-853  Back to cited text no. 45      




 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
    Introduction
    Lifestyle modifi...
    Mild asthma
    Moderate Persist...
    Severe persisten...
    Future therapies
    Conclusion
    References

 Article Access Statistics
    Viewed2706    
    Printed118    
    Emailed6    
    PDF Downloaded107    
    Comments [Add]    

Recommend this journal