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Treatment of asthma during pregnancy
Guest editorial
Treatment of asthma during pregnancy The guiding principle behind the management of asthma during pregnancy can be summed by a direct quotation from the recent National Asthma Education and Prevention Program panel report: “inadequate control of asthma is a greater risk to the fetus than asthma medications are.”1 This is consistent within all asthma consensus guidelines.2,3 Nevertheless, asthma continues to be undertreated during pregnancy. Asthma symptoms may increase, decrease, or remain the same with relatively equal frequencies during pregnancy.4,5 This may relate in part to changes in asthma severity and in part to changes in asthma control (the two often being confused6) or both. Explanations for the variable behavior of asthma in pregnancy are not clear and are likely multifactorial. This could include a direct effect of pregnancy on asthma in either direction; an indirect effect of pregnancy, for example, via interactions with rhinitis or pregnancy; the inherent basic variable nature of the disease related to variable allergen exposure or respiratory tract infection; or combinations thereof. It is likely that there may be wide variations in medication use during pregnancy, ranging from the appropriate approach of rigorous controller therapy to lack of controller therapy due to either fear of medication use during pregnancy or noncompliance. The risks of poorly controlled asthma during pregnancy and the safety of asthma medications have been adequately reviewed1,7 and will not be repeated in depth. There is little question that suboptimal asthma control presents significant risk to the outcome of pregnancy.7,8 By contrast, asthma medications, particularly those administered by the inhaled route, have become established as safe during pregnancy.7,9 These medications include inhaled corticosteroids, inhaled conventional-acting 2-agonists, and by extension almost certainly inhaled long-acting 2-agonists. Although the largest amount of data exist for budesonide and albuterol (also known as salbutamol), other inhaled agents in both classes used at comparatively potent doses are likely equally safe. It has been reported that severe asthma is more likely to worsen (ie, be associated with asthma morbidity) during pregnancy.10 Since in that study severity was defined by symptoms and reduced expiratory flow rates as well as medication use, one could argue that the severity scale used in that study was, at least in part, an index of poor control.6 Therefore, it might be equally appropriate to suggest poorly controlled asthma is associated with greater asthma-related morbidity during pregnancy. Furthermore, patients whose severity or control changed had corresponding changes in risk of asthma morbidity.10 These data among others identify the need to recognize and intensively treat poorly controlled
VOLUME 95, SEPTEMBER, 2005
and/or severe asthma during pregnancy (as well as at other times). Inhaled corticosteroids are the most important and effective controller medications and the first-line recommended therapy.1–3 The study by Schatz and Leibman in this issue of the Annals11 provides more data on asthma controller use in pregnancy. These investigators use a large managed health care database to retrospectively examine inhaled corticosteroid use and asthma visits in patients with a pregnancy claim. They show that inhaled corticosteroids were used by a minority (16%) of pregnant asthmatic patients and that inhaled corticosteroids were associated with reduction in office and emergency department visits for asthma, whereas those not using inhaled corticosteroids had an increase in both office and emergency department visits for asthma. Despite the limitations of this type of data, several conclusions appear likely. Most importantly, asthma appears to be undertreated in these young women, and this undertreatment does not improve, perhaps even worsens, during pregnancy. This undertreatment appears to be associated, as anticipated, with increased asthma morbidity, which has the potential to adversely affect not only the mother but also the fetus. It is possible that these results, concerning as they are, may be better than the results that might occur in the population as a whole, since a large proportion may be less well insured or have lower access to health care. These data are welcome and add to the important need to educate physicians and patients alike that good asthma control during pregnancy has benefits that markedly outweigh any theoretical risks of inhaled corticosteroids. ACKNOWLEDGMENTS I thank Jacquie Bramley for assisting in the preparation of the manuscript. D. W. COCKCROFT, MD, FRCP(C) Department of Medicine Royal University Hospital Saskatoon, Canada REFERENCES 1. Busse WW, National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program Asthma and Pregnancy Working Group. NAEPP expert panel report: managing asthma during pregnancy: recommendations for pharmacologic treatment-2004 update. J Allergy Clin Immunol. 2005;115: 34 – 46. 2. Boulet LP, Becker A, Berube D, et al. Canadian asthma consensus report, 1999. CMAJ. 1999;161:S1–S61.
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3. GINA Workshop Report: Global Strategy for Asthma Management and Prevention. Updated April 2002. Scientific information and recommendations for asthma programs. NIH publication 02–3659). Available at: www.ginasthma.com. 4. Gluck JC, Gluck P. The effects of pregnancy on asthma: a prospective study. Ann Allergy. 1976;37:164 –168. 5. Stenius-Aarniala B, Piirila P, Teramo K. Asthma and pregnancy: a prospective study of 198 pregnancies. Thorax. 1988;43:12–18. 6. Cockcroft DW, Swystun VA. Asthma control versus asthma severity. J Allergy Clin Immunol. 1996;98:1016 –1018. 7. Namazy JA, Schatz M. Pregnancy and asthma: recent developments. Curr Opin Pulm Med. 2005;11:56 – 60.
8. Demissie K, Breckenridge MB, Rhoads GG. Infant and maternal outcomes in the pregnancies of asthmatic women. Am J Respir Crit Care Med. 1998;158:1091–1095. 9. Norjavaara E, de Verdier MG. Normal pregnancy outcomes in a population-based study including 2,968 pregnant women exposed to budesonide. J Allergy Clin Immunol. 2003;111: 736 –742. 10. Schatz M, Dombrowski MP, Wise R, et al. Asthma morbidity during pregnancy can be predicted by severity classification. J Allergy Clin Immunol. 2003;112:283–288. 11. Schatz M, Leibman C. Inhaled corticosteroid utilization and outcomes in pregnancy. Ann Allergy Asthma Immunol. 2005; 95:234 –238.
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ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
Treatment of asthma during pregnancy The guiding principle behind the management of asthma during pregnancy can be summed by a direct quotation from the recent National Asthma Education and Prevention Program panel report: “inadequate control of asthma is a greater risk to the fetus than asthma medications are.”1 This is consistent within all asthma consensus guidelines.2,3 Nevertheless, asthma continues to be undertreated during pregnancy. Asthma symptoms may increase, decrease, or remain the same with relatively equal frequencies during pregnancy.4,5 This may relate in part to changes in asthma severity and in part to changes in asthma control (the two often being confused6) or both. Explanations for the variable behavior of asthma in pregnancy are not clear and are likely multifactorial. This could include a direct effect of pregnancy on asthma in either direction; an indirect effect of pregnancy, for example, via interactions with rhinitis or pregnancy; the inherent basic variable nature of the disease related to variable allergen exposure or respiratory tract infection; or combinations thereof. It is likely that there may be wide variations in medication use during pregnancy, ranging from the appropriate approach of rigorous controller therapy to lack of controller therapy due to either fear of medication use during pregnancy or noncompliance. The risks of poorly controlled asthma during pregnancy and the safety of asthma medications have been adequately reviewed1,7 and will not be repeated in depth. There is little question that suboptimal asthma control presents significant risk to the outcome of pregnancy.7,8 By contrast, asthma medications, particularly those administered by the inhaled route, have become established as safe during pregnancy.7,9 These medications include inhaled corticosteroids, inhaled conventional-acting 2-agonists, and by extension almost certainly inhaled long-acting 2-agonists. Although the largest amount of data exist for budesonide and albuterol (also known as salbutamol), other inhaled agents in both classes used at comparatively potent doses are likely equally safe. It has been reported that severe asthma is more likely to worsen (ie, be associated with asthma morbidity) during pregnancy.10 Since in that study severity was defined by symptoms and reduced expiratory flow rates as well as medication use, one could argue that the severity scale used in that study was, at least in part, an index of poor control.6 Therefore, it might be equally appropriate to suggest poorly controlled asthma is associated with greater asthma-related morbidity during pregnancy. Furthermore, patients whose severity or control changed had corresponding changes in risk of asthma morbidity.10 These data among others identify the need to recognize and intensively treat poorly controlled
VOLUME 95, SEPTEMBER, 2005
and/or severe asthma during pregnancy (as well as at other times). Inhaled corticosteroids are the most important and effective controller medications and the first-line recommended therapy.1–3 The study by Schatz and Leibman in this issue of the Annals11 provides more data on asthma controller use in pregnancy. These investigators use a large managed health care database to retrospectively examine inhaled corticosteroid use and asthma visits in patients with a pregnancy claim. They show that inhaled corticosteroids were used by a minority (16%) of pregnant asthmatic patients and that inhaled corticosteroids were associated with reduction in office and emergency department visits for asthma, whereas those not using inhaled corticosteroids had an increase in both office and emergency department visits for asthma. Despite the limitations of this type of data, several conclusions appear likely. Most importantly, asthma appears to be undertreated in these young women, and this undertreatment does not improve, perhaps even worsens, during pregnancy. This undertreatment appears to be associated, as anticipated, with increased asthma morbidity, which has the potential to adversely affect not only the mother but also the fetus. It is possible that these results, concerning as they are, may be better than the results that might occur in the population as a whole, since a large proportion may be less well insured or have lower access to health care. These data are welcome and add to the important need to educate physicians and patients alike that good asthma control during pregnancy has benefits that markedly outweigh any theoretical risks of inhaled corticosteroids. ACKNOWLEDGMENTS I thank Jacquie Bramley for assisting in the preparation of the manuscript. D. W. COCKCROFT, MD, FRCP(C) Department of Medicine Royal University Hospital Saskatoon, Canada REFERENCES 1. Busse WW, National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program Asthma and Pregnancy Working Group. NAEPP expert panel report: managing asthma during pregnancy: recommendations for pharmacologic treatment-2004 update. J Allergy Clin Immunol. 2005;115: 34 – 46. 2. Boulet LP, Becker A, Berube D, et al. Canadian asthma consensus report, 1999. CMAJ. 1999;161:S1–S61.
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3. GINA Workshop Report: Global Strategy for Asthma Management and Prevention. Updated April 2002. Scientific information and recommendations for asthma programs. NIH publication 02–3659). Available at: www.ginasthma.com. 4. Gluck JC, Gluck P. The effects of pregnancy on asthma: a prospective study. Ann Allergy. 1976;37:164 –168. 5. Stenius-Aarniala B, Piirila P, Teramo K. Asthma and pregnancy: a prospective study of 198 pregnancies. Thorax. 1988;43:12–18. 6. Cockcroft DW, Swystun VA. Asthma control versus asthma severity. J Allergy Clin Immunol. 1996;98:1016 –1018. 7. Namazy JA, Schatz M. Pregnancy and asthma: recent developments. Curr Opin Pulm Med. 2005;11:56 – 60.
8. Demissie K, Breckenridge MB, Rhoads GG. Infant and maternal outcomes in the pregnancies of asthmatic women. Am J Respir Crit Care Med. 1998;158:1091–1095. 9. Norjavaara E, de Verdier MG. Normal pregnancy outcomes in a population-based study including 2,968 pregnant women exposed to budesonide. J Allergy Clin Immunol. 2003;111: 736 –742. 10. Schatz M, Dombrowski MP, Wise R, et al. Asthma morbidity during pregnancy can be predicted by severity classification. J Allergy Clin Immunol. 2003;112:283–288. 11. Schatz M, Leibman C. Inhaled corticosteroid utilization and outcomes in pregnancy. Ann Allergy Asthma Immunol. 2005; 95:234 –238.
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ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY