Asthma management guidelines: updates, advances, and new options.
ABSTRACT Asthma still poses a substantial and unacceptable health and economic burden. The National Asthma Education and Prevention Program (NAEPP) guidelines for the management of asthma continue to evolve based on emerging clinical data, improving the understanding of asthma and approaches to its management.
To examine the clinical implications of current NAEPP guidelines for the diagnosis and treatment of asthma and the potential impact of the proposed 2007 guidelines update on asthma management. To examine the role of managed care organizations in fostering evidence-based asthma management.
Current NAEPP guidelines recognize symptom control as the chief therapeutic target in the management of asthma. The proposed update to NAEPP guidelines places greater emphasis on symptom control by expanding its definition to not only include measures of impairment but also the risk for deteriorating pulmonary function, asthma exacerbations, and controller medication side effects. Although inhaled corticosteroids remain central to achieving long-term asthma control in both current and proposed guidelines, the latter offers greater treatment flexibility and recognizes combination therapy as a preferred choice for achieving control in many patients with moderate persistent asthma. Managed care organizations, primarily using disease management programs, provide impetus for the widespread adoption of evidence-based asthma treatment guidelines.
Widespread adoption of evidence-based asthma management programs offers the opportunity for achieving and maintaining asthma control.
- SourceAvailable from: ncbi.nlm.nih.gov[show abstract] [hide abstract]
ABSTRACT: Angiopoietin (Ang)1 and Ang2 are ligands for Tie2 tyrosine kinase receptor (Tie2). Elevated levels of Ang1 and Ang2 in induced sputum of patients with asthma have been reported, with a positive correlation of Ang2 levels with the severity of airway occlusion. Although studies have shown Tie2-mediated regulation of nonvascular cells in some pathological conditions, current knowledge on Tie2 signaling in asthma is limited to the vasculature. We examined the expression pattern of Ang1, Ang2, vascular endothelial growth factor (VEGF), and Tie2 and their correlation with the degree of airway remodeling in the lung of ovalbumin (OVA)-sensitized and OVA-challenged mice with airway hyperresponsiveness. Lung tissues were isolated from Balb/c mice after OVA sensitization and challenge. Hematoxylin and eosin, periodic acid-Schiff, and trichrome staining were used to show the lung pathology. The expression of Ang1, Ang2, VEGF, and Tie2 was examined using immunofluorescence, Western blot, ELISA, and real-time PCR. In the lung of normal mice, Tie2 expression was detected only in the blood vessels. However, in the lung of OVA-sensitized and OVA-challenged mice, Tie2 was abundantly expressed in airway epithelial cells and in a subset of macrophages in addition to constitutive expression in pulmonary vessels. The increase in Tie2 expression correlated with the severity of airway remodeling. Macrophages and airway epithelial cells express Ang2 and VEGF only in allergic models. Ang1 was constitutively expressed, with a decrease in mRNA level in allergic models. In conclusion, increased expression of Tie2 and Ang2 in allergic airway epithelium and alveolar macrophages correlates with the severity of airway remodeling.American Journal of Respiratory Cell and Molecular Biology 05/2010; 44(3):384-93. · 4.15 Impact Factor
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ABSTRACT: Asthma is a complex inflammatory condition often associated with bronchial hyper reactivity and atopy. Genetic and environmental factors are implicated in the etiopathogenesis of asthma. Regulated upon Activation Normal T- cell Expressed and Secreted (RANTES) is a CC chemokine responsible for the recruitment of inflammatory cells, suggesting a possible role for this chemokine in asthma. Both -403A and -28G alleles of the RANTES promoter region were found to be associated with asthma/atopy in some but not all studies. The purpose of this study was to investigate the genetic influence of -403A and -28G alleles of the RANTES promoter region on the development of asthma in Lebanon. This case control study was conducted at Makassed Hospital, Beirut on 40 asthmatic patients and 38 healthy controls. RANTES gene polymorphisms -403G/A and -28C/G alleles were genotyped using PCR-RFLP. No significant differences in allele or genotype frequencies for the RANTES gene polymorphisms between asthmatic patients and controls were found. The difference of the -403 GA genotype frequency between patients and controls was not statisti-cally significant; (OR=0.8, 95% CI=0.2-2.3, P=0.8). Similarly, the difference of the A-allele frequencies between patients and con-trols was not significant (OR=0.824, CI=0.3-2.2, P=0.7). Our data show that RANTES gene promoter polymorphisms are not associated with asthma susceptibility in the Lebanese population.Annals of thoracic medicine. 01/2012; 7(1):16-20.
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ABSTRACT: Asthma is a chronic lung disease that affects more than 23 million people in the United States, including 7 million children. Asthma is a difficult to manage chronic condition associated with disparities in health outcomes, poor medical compliance, and high healthcare costs. The research network coordinating this project includes hospitals, urgent care centers, and outpatient clinics within Carolinas Healthcare System that share a common electronic medical record and billing system allowing for rapid collection of clinical and demographic data. This study investigates the impact of three interventions on clinical outcomes for patients with asthma. Interventions are: an integrated approach to care that incorporates asthma management based on the chronic care model; a shared decision making intervention for asthma patients in underserved or disadvantaged populations; and a school based care approach that examines the efficacy of school-based programs to impact asthma outcomes including effectiveness of linkages between schools and the healthcare providers. This study will include 95 Practices, 171 schools, and over 30,000 asthmatic patients. Five groups (A-E) will be evaluated to determine the effectiveness of three interventions. Group A is the usual care control group without electronic medical record (EMR). Group B practices are a second control group that has an EMR with decision support, asthma action plans, and population reports at baseline. A time delay design during year one converts practices in Group B to group C after receiving the integrated approach to care intervention. Four practices within Group C will receive the shared decision making intervention (and become group D). Group E will receive a school based care intervention through case management within the schools. A centralized database will be created with the goal of facilitating comparative effectiveness research on asthma outcomes specifically for this study. Patient and community level analysis will include results from patient surveys, focus groups, and asthma patient density mapping. Community variables such as income and housing density will be mapped for comparison. Outcomes to be measured are reduced hospitalizations and emergency department visits; improved adherence to medication; improved quality of life; reduced school absenteeism; improved self-efficacy and improved school performance. Identifying new mechanisms that improve the delivery of asthma care is an important step towards advancing patient outcomes, avoiding preventable Emergency Department visits and hospitalizations, while simultaneously reducing overall healthcare costs.BMC Health Services Research 08/2011; 11:188. · 1.77 Impact Factor
Asthma Management Guidelines:
Updates, Advances, and New Options
Robert P. Navarro, PharmD
Gary K. Rice, RPh, MS, MBA
Kenneth L. Schaecher, MD, FACP
Vol. 13, No. 6, S-d
Continuing Education Activity
Robert P . Navarro, PharmD, is an independent consultant, who con-
sults with the pharmaceutical and health care industries on managed
pharmacy and pharmaceutical marketing issues through his company,
NavarroPharma, LLC, Raleigh, North, Carolina. He earned his
bachelor of science and doctor of pharmacy degrees at the University
of Minnesota College of Pharmacy and has practiced in acute care,
community pharmacy, long-term care, and managed care.
He began his career in managed care in 1983, when he wrote the
first drug formulary and began rebate contracting for United-
Healthcare. While a pharmacy director at UHC, Navarro was involved
in the creation of the pharmacy benefit manager (PBM) Diversified
Pharmaceutical Services. While in Minnesota, he also served as
pharmacy director of Physicians Health Plan (now Medica). As an
associate vice president with Health Net in California, Navarro
developed and managed the pharmacy program. He was vice presi-
dent, Pharmacy & Therapeutics, at the PBM Express Scripts, Inc.,
before continuing his consulting practice.
Navarro was a cofounder and first president of the Academy of
Managed Care Pharmacy. He is chief editor of the textbook Managed
Care Pharmacy Practice, which is currently in revision. He also
coauthored the “Prescription Drug Benefits in Managed Care” chapter
in the Essentials of Managed Health Care, 5th Edition textbook as
well as the chapter “Evolution of the management of US health
care: managing cost to care management” in the ASHP Handbook of
Institutional Pharmacy Practice, 4th Edition. Navarro serves on the
editorial review committees of the Journal of Managed Care Pharmacy,
Core Evidence, Managed Care Interface, and Managed Care Quarterly.
Gary K. Rice, RPh, MS, MBA, is vice president, Pharmaceutical
Services, Kelsey-Seybold Clinic, Houston, Texas, where he directs
11 retail pharmacies, distribution of in-clinic pharmaceuticals, Infusion
Center services, Hematology/ Oncology Clinic, Ambulatory Surgery
Center Pharmacy, a regional pharmacy network for KelseyCare,
Centralized Prescription Refill Request Center, and a Drug Information
Center. He developed and implemented a comprehensive multifaceted
marketing plan targeted at both consumers and clinical staff that
succeeds in promoting the services and programs of the pharmacies.
Rice collaborates with the University of Houston College of Pharmacy,
where faculty is committed to the clinic to promote and implement
clinical and staff development programs within the 23 clinics. Three
faculty members, two pharmacy residents, and pharmacy students
support the programs.
Rice is also an adjunct professor at Houston Community College,
where he teaches pharmacology to pharmacy technician students. He
owns and operates General Medical Consulting & Training, an
organization that creates individualized, full-service solutions for the
complex operational, sales, and marketing challenges faced by its
clients. Additional positions he has held in the Houston area include
F A C U L T Y
Frederic R. Curtiss, PhD, RPh, CEBS
(830) 935-4319, email@example.com
Tamara C. Faggen, (703) 323-0170
Diane P. Britton
Peer Review Administrator
Jennifer A. Booker, (703) 317-0725
Elisabeth M. Squire, (703) 823-3159
August Supplement Editor
Sean D. Sullivan, PhD
Peter Palmer, (856) 795-5777, ext. 13
Judith A. Cahill, CEBS
Academy of Managed Care Pharmacy
This supplement to the Journal of Managed Care
Pharmacy (ISSN 1083–4087) is a publication of
the Academy of Managed Care Pharmacy,
100 North Pitt St., Suite 400, Alexandria, VA 22314;
(703) 683-8416; (703) 683-8417 (fax).
Copyright© 2007, Academy of Managed Care Pharmacy.
All rights reserved. No part of this publication may be
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POSTMASTER: Send address changes to
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primary care regional sales manager for McKesson General Medical
and general manager of NMC Homecare. At HMSS, Inc., Rice
assumed several positions of increasing responsibility, including
branch management field trainer, operations facilities manager,
general manager of the Comprehensive Care Center, and director of
operations and business development. As director, he initiated and
developed operations for 7 ambulatory infusion centers and several
multimillion dollar management services agreements with physician
Rice earned a bachelor of science degree in pharmacy from the
Massachusetts College of Pharmacy and Allied Health Sciences in
Boston. He received a master of science degree in pharmacy from the
University of Houston and completed a pharmacy residency program
accredited by the American Society of Health-System Pharmacists at
the Veterans Administration Medical Center in Houston. He has
authored numerous articles and publications pertaining to both
clinical and managerial topics.
Kenneth L. Schaecher, MD, FACP, is medical director of utiliza-
tion management, SelectHealth, Salt Lake City, Utah. He has direct
responsibilities in the oversight and direction of physician review
services as part of the utilization management and customer serv-
ice/appeals processes for the health plan. Additional responsibilities
include oversight and direction for the new technologies assessment
process and as a clinical resource to the coding, clinical auditing,
and pharmacy services department. He also maintains an active
independent internal medicine practice, seeing patients 12 hours per
week. This provides unique insight into issues that arise from both
the payer and provider perspective and allows for decision making
that can be a win-win proposition for all parties.
He is currently an active participant in a wide array of academic/
community involvement activities, including serving as an adjunct
associate professor of medicine at the University of Utah School of
Medicine, member of the Utah Medical Association and a delegate to
its annual convention, member of the American College of Physicians,
and president-elect of the Salt Lake County Medical Society. His
previous experience includes serving as chief of staff of a local com-
munity hospital, president of the largest independent multispecialty
clinic in the Salt Lake Valley, medical director of an independent
medical services organization, chairman of the utilization management
(UM) review committee for a local physician hospital organization,
and member of Intermountain Healthcare Urban Central Region UM
Schaecher received his bachelor of science degree in biology at
South Dakota State University and medical degree from the
University of South Dakota Medical School. He completed his
internal medicine residency at the University of Utah. He is a current
member of Phi Kappa Phi.
Standards for Supplements to the
Journal of Managed Care Pharmacy
Supplements to the Journal of Managed Care Pharmacy
areas of clinical practice, health care quality improvement,
or efficient administration and delivery of health benefits.
The following standards are applied to all JMCP supple-
ments to assure quality and assist readers in evaluating
potential bias and determining alternate explanations for
findings and results.
1. Disclose the principal sources of funding in a manner
that permits easy recognition by the reader.
2. Disclose the existence of all potential conflicts of interest
among supplement contributors, including financial or
3. Describe all drugs by generic name unless the use of the
brand name is necessary to reduce the opportunity for
confusion among readers.
4. Strive to report subjects of current interest to managed
care pharmacists and other managed care professionals.
5. Seek and publish content that does not duplicate
content in the Journal of Managed Care Pharmacy.
6. Subject all supplements to expert peer review.
Table of Contents
Asthma Management Guidelines:
Updates, Advances, and New Options
This supplement was funded by an educational grant from AstraZeneca Pharmaceuticals. This supplement is based on
the proceedings of an independent symposium held April 11, 2007, in San Diego, California. The symposium was
supported by an educational grant from AstraZeneca Pharmaceuticals.
*A total of 0.15 CEU (1.5 contact hours) will be awarded for successful completion of this continuing education activity
(ACPE Universal Program No. 404-000-07-005-H01). For faculty disclosures, please see page S11. For accreditation
information, please see page S12.
The articles published in this supplement represent the opinions of the authors and do not reflect the official policy or views of the
Academy of Managed Care Pharmacy, the authors’ institutions, or AstraZeneca Pharmaceutical unless so specified. The
authors have disclosed if any unlabeled use of products is mentioned in their articles. Before prescribing any medicine, clinicians
should consult primary references and full prescribing information.
Pharmacists, physicians, and other managed health care providers involved in asthma management
Upon completion of this activity, participants will be able to
1. define the burden imposed by uncontrolled asthma,
2. describe the National Asthma Education and Prevention Program (NAEPP) definition of asthma severity and issues that
surround the diagnosis of asthma,
3. summarize the NAEPP treatment algorithm for asthma management and the place of asthma control as a treatment goal,
4. define asthma control and describe office-based measures for evaluating asthma control,
5. describe how the proposed 2007 NAEPP asthma guidelines will alter the definition of asthma and the treatment algorithm
for the management of asthma, and
6. describe the role of managed care organizations in fostering evidence-based asthma management.
Asthma Management Guidelines: Updates, Advances, and New Options
Robert P. Navarro, PharmD; Kenneth L. Schaecher, MD, FACP; and Gary K. Rice, RPh, MS, MBA
S12 Continuing Education*:
CE Submission Instructions and Posttest Worksheet
www.amcp.orgVol. 13, No. 6, S-dAugust 2007
Supplement to Journal of Managed Care PharmacyS3
increased for more than 2 decades, before plateauing or slightly
declining in 2000.1From 1979 to 1999, the asthma-associated
death rates per 100,000 people almost doubled from 0.9 to 1.7,
before declining slightly to 1.5 in 2002. The most recent estimates
revealed that, in the United States, almost 20 million people
were diagnosed with asthma in 2003, including approximately
spikes in children between the ages of 5 and 17 years, increasing
during adulthood in females (50% higher than males), and in
blacks (28% higher than whites). Uncontrolled asthma still
engenders nearly 500,000 hospitalizations and more than 4,000
deaths annually.1Disconcertingly, almost 40% of the asthma-
related hospitalizations occur in children under the age of 15
years. In addition, the direct and indirect costs associated with
asthma treatment now total about $16 billion annually, with the
costs associated with uncontrolled asthma about twice that for
Because uncontrolled asthma continues to be a prevalent and
sometimes debilitating and potentially life-threatening disorder,
optimal asthma management aimed at maintaining consistent
control remains a paramount treatment goal. The National Asthma
Education and Prevention Program (NAEPP) asthma guidelines
focus on symptom control as a central feature of optimal manage-
ment; the implementation of the most recent guidelines (2002)
and the proposed 2007 updates, when finalized, will offer managed
health care organizations an opportunity to optimize the treatment
of asthma for their enrollees.
In April 2007, a symposium was held in San Diego,
California, to examine the implications of current and proposed
NAEPP asthma treatment guidelines for improving asthma out-
comes. The symposium’s expert participants provided valuable
data and perspectives on the potential role of NAEPP proposed
guidelines in asthma diagnosis and treatment as well as the role
of managed care organizations in fostering their use among
health care providers. The faculty included Robert P. Navarro,
PharmD, president, NavarroPharma, LLC, cofounder of the
Academy of Managed Care Pharmacy; Gary K. Rice, RPh, MS,
MBA, vice president, Pharmaceutical Services, Kelsey-Seybold
Clinic, Houston, Texas; and Kenneth L. Schaecher, MD, medical
director, SelectHealth, Salt Lake City, Utah. This manuscript is
based on the content of that symposium and includes current
published clinical findings and expert opinions relevant to best
practices in asthma management.
ncontrolled asthma continues to pose a substantial
health care and financial burden. In the United States,
asthma prevalence, hospitalizations, and mortality
Asthma Management Guidelines:
Updates,Advances, and New Options
Robert P . Navarro, PharmD; Kenneth L. Schaecher, MD, FACP;
and Gary K. Rice, RPh, MS, MBA
BACKGROUND: Asthma still poses a substantial and unacceptable health and
economic burden. The National Asthma Education and Prevention Program
(NAEPP) guidelines for the management of asthma continue to evolve based
on emerging clinical data, improving the understanding of asthma and
approaches to its management.
OBJECTIVE:To examine the clinical implications of current NAEPP guidelines
for the diagnosis and treatment of asthma and the potential impact of the
proposed 2007 guidelines update on asthma management. To examine the
role of managed care organizations in fostering evidence-based asthma
SUMMARY: Current NAEPP guidelines recognize symptom control as the chief
therapeutic target in the management of asthma. The proposed update to
NAEPP guidelines places greater emphasis on symptom control by expanding
its definition to not only include measures of impairment but also the risk for
deteriorating pulmonary function, asthma exacerbations, and controller med-
ication side effects. Although inhaled corticosteroids remain central to achiev-
ing long-term asthma control in both current and proposed guidelines, the
latter offers greater treatment flexibility and recognizes combination therapy
as a preferred choice for achieving control in many patients with moderate
persistent asthma. Managed care organizations, primarily using disease man-
agement programs, provide impetus for the widespread adoption of evidence-
based asthma treatment guidelines.
CONCLUSION:Widespread adoption of evidence-based asthma management
programs offers the opportunity for achieving and maintaining asthma control.
KEYWORDS:Asthma, Managed care, Guidelines,Asthma control, Management
J Manag Care Pharm. 2007;13(6)(suppl S-d):S3-S11
Copyright© 2007,Academy of Managed Care Pharmacy.All rights reserved.
ROBERT P . NAVARRO, PharmD, is an independent consultant and presi-
dent, NavarroPharma, LLC, Raleigh, North, Carolina; KENNETH L.
SCHAECHER, MD, FACP , is medical director of utilization management,
SelectHealth, Salt Lake City, Utah; GARY K. RICE, RPh, MS, MBA, is
vice president, Pharmaceutical Services, Kelsey-Seybold Clinic, Houston,
AUTHOR CORRESPONDENCE: Robert P. Navarro, PharmD,
President, NavarroPharma, 13120 Ashford Park Dr., Raleigh, NC 27613.
Tel: (919) 645-9486; Fax: (919) 882-8782; E-mail: robert.p.navarro@