First new guidelines in more than a decade for managing asthma during pregnancy

The National Asthma Education and Prevention Program (NAEPP) is issuing the first new guidelines in more than a decade for managing asthma during pregnancy. The report reflects new medications that have emerged and updates treatment recommendations for pregnant women with asthma based on a systematic review of data on the safety of asthma medications during pregnancy. An executive summary ("Quick Reference") of the guidelines is published in the January issue of the Journal of Allergy & Clinical Immunology.

Poorly controlled asthma can lead to serious medical problems for pregnant women and their fetuses. The guidelines emphasize that controlling asthma during pregnancy is important for the health and well-being of the mother as well as for the healthy development of the fetus. A stepwise approach to asthma care similar to that used in the NAEPP general asthma treatment guidelines for children and nonpregnant adults is recommended. Under this approach, medication is stepped up in intensity if needed, and stepped down when possible, depending on asthma severity. Because asthma severity changes during pregnancy for most women, the guidelines also recommend that clinicians who provide obstetric care monitor asthma severity during prenatal visits of their patients who have asthma.

"The guidelines review the evidence on asthma medications used by pregnant patients," said Barbara Alving, M.D., acting director of the National Heart, Lung, and Blood Institute (NHLBI), which administers the NAEPP. "The evidence is reassuring, and suggests that it is safer to take medications than to have asthma exacerbations. The guidelines should be a useful tool for physicians to develop optimal asthma management plans for pregnant women."

"Simply put, when a pregnant patient has trouble breathing, her fetus also has trouble getting the oxygen it needs," added William W. Busse, M.D., professor of medicine at the University of Wisconsin Medical School, and chair of the NAEPP multidisciplinary expert panel that developed the guidelines. "There are many ways we can help pregnant women control their asthma, and it is imperative that providers and their patients work together to do so."

Asthma affects over 20 million Americans and is one of the most common potentially serious medical conditions to complicate pregnancy. Maternal asthma is associated with increased risk of infant death, preeclampsia (a serious condition marked by high blood pressure, which can cause seizures in the mother or fetus), premature birth, and low-birth weight. These risks are linked to asthma severity – more severe asthma increases risk, while better controlled asthma is tied to decreased risks.

Asthma worsens in approximately 30 percent of women who have mild asthma at the beginning of their pregnancy, according to a recent study by the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network and cofunded by NHLBI. The study also found that, conversely, asthma improved in 23 percent of the women who initially had moderate or severe asthma.

"We cannot predict who will worsen during pregnancy, so the new guidelines recommend that pregnant patients with persistent asthma have their asthma checked at least monthly by a healthcare provider," explained Mitchell Dombrowski, M.D., chief of obstetrics and gynecology for St. John Hospital in Detroit, and a member of the NAEPP expert panel. "Clinicians who provide obstetric care should be part of the patient's asthma management team, working with the patient and her asthma care provider to adjust her medications if needed to keep her asthma under control and to lower the risk of complications from asthma for her and her baby."

Key recommendations from the guidelines regarding medications include:

• Albuterol, a short-acting inhaled beta2-agonist, should be used as a quick-relief medication to treat asthma symptoms. Pregnant women with asthma should have this medication available at all times.

• Women who have symptoms at least two days a week or two nights a month have persistent asthma and need daily medication for long-term care of their asthma and to prevent exacerbations. Inhaled corticosteroids are the preferred medication to control the underlying inflammation in pregnant women with persistent asthma. The guidelines note that there are more data on the safety of budesonide use during pregnancy than on other inhaled corticosteroids; however, there are no data indicating that other inhaled corticosteroids are unsafe during pregnancy, and other inhaled corticosteroids may be continued if they effectively control a patient's asthma. Alternative daily medications are leukotriene receptor antagonists, cromolyn, or theophylline.

• For patients whose persistent asthma is not well controlled on low doses of inhaled corticosteroids alone, the guidelines recommend either increasing the dose of inhaled corticosteroid or adding another medication -- a long-acting beta agonist. The expert panel concluded that data are insufficient to indicate a preference of one option over the other.
• Oral corticosteroids may be required for the treatment of severe asthma. The guidelines note that there are conflicting data regarding the safety of oral corticiosteroids during pregnancy; however, severe, uncontrolled asthma poses a definite risk to the mother and fetus; and use of oral corticosteroids may be warranted.

"Several studies have shown that taking inhaled corticosteroids improves lung function during pregnancy and reduces asthma exacerbations--and other large, prospective studies found no relation between taking inhaled corticosteroids and congenital abnormalities or other adverse pregnancy outcomes," said Michael Schatz, M.D., M.S., chief of the Department of Allergy for Kaiser Permanente San Diego Medical Center. Schatz is also a member of the NAEPP expert panel on asthma during pregnancy and author of an editorial accompanying the guidelines report.

The guidelines highlight other important aspects of asthma management during pregnancy, such as identifying and limiting exposure to asthma triggers. Similarly, women with other conditions that can worsen asthma, such as allergic rhinitis, sinusitis, and gastroesophageal reflux, should have those conditions treated as well. Such conditions often become more troublesome during pregnancy.

"As important as medications are for controlling asthma, a pregnant woman can reduce how much medication is needed by identifying and avoiding the factors that make her asthma worse, such as tobacco smoke or allergens like dust mites," added Dr. Schatz.

The NAEPP was established in March 1989 to reduce asthma-related illness and death and to enhance the quality of life of people with asthma. Today, 40 organizations, including major medical associations, voluntary health organizations, and numerous federal agencies, comprise the NAEPP Coordinating Committee. The NAEPP also coordinates federal asthma-related activities, as designated by Congress through the Children's Health Act of 2000. NAEPP convenes expert panels as needed to ensure that the latest scientific evidence is translated into clinical recommendations to help clinicians provide the best possible asthma care.

http://www.nhlbi.nih.gov/