Krankheitskontrolle als Therapieprinzip beim Asthma bronchiale

 

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Zusammenfassung

Die Klassifikation auf der Grundlage der Krankheitskontrolle ermöglicht einen auf den Patienten zugeschnittenen Zugang zur Asthmatherapie, der flexibel genug sein dürfte, sich den Änderungen der Krankheitsaktivität im Verlauf anzupassen. Nach den aktuellen Empfehlungen richtet sich die Behandlung des Asthmas nicht mehr nach dem Schweregrad, sondern vielmehr nach der jeweiligen Asthmakontrolle. Dabei wird nicht mehr in Schweregraden, sondern in therapeutischen Kategorien gedacht. Damit nähern sich die Empfehlungen dem praktischen Umgang mit Asthmapatienten an und definieren mit dieser Vorgabe gleichzeitig auch ein Therapieziel. Das Ziel der Asthmabehandlung ist das Erreichen und die Aufrechterhaltung der klinischen Kontrolle („Kontrollstufe”), was bei der Mehrzahl der Patienten mithilfe nicht-medikamentöser und pharmakologischer Maßnahmen im Rahmen einer Partnerschaft zwischen Patient, Familie und behandelndem Arzt möglich ist. Gelingt die Kontrolle der Erkrankung nach Einleitung der Therapie nicht und erreicht der Patient mit den Maßnahmen keine oder nur eine partielle Kontrolle, sollte die Therapie intensiviert (Eskalation) werden. Kann dagegen eine Kontrolle der Erkrankung hergestellt werden, lässt sich die Medikation zurücknehmen, bis die minimal für die Kontrolle erforderliche Therapie gefunden ist. Die aktuellen Empfehlungen werden der Dynamik des Asthmas besser gerecht als die Empfehlungen auf der Basis von Schweregradeinteilungen und berücksichtigen die individuellen Unterschiede zwischen Asthmatikern sowohl im Hinblick auf die Schwere, die Variabilität als auch die Behandlung der Erkrankung.

Abstract

GINA together with many other national guidelines for the clinical management of asthma recommend a disease severity assessment in order to determine the quantity and frequency of medication. This classification scheme groups patients into one of four categories (intermittent, mild-persistent, moderate-persistent, and severe-persistent). However, it is important to recognise that asthma severity includes both severity of the underlying disease and responsiveness to treatment. In addition, severity is not an unvarying feature in any individual asthma patient and disease severity may change over months or years. Thus, for ongoing asthma management, classification using the level of control may be more relevant and useful in clinical practice. The new version of the GINA guidelines 2006 recognises these limitations of severity assessment and classifies the condition according to the level of control as “controlled”, “partly controlled”, and “uncontrolled” asthma on the basis of daytime symptoms, restrictions of physical activity, nocturnal symptoms/awakening, need for reliever/rescue medication, lung function (PEF or FEV1) and the frequency of exacerbations. In addition, the patient is assigned to one of five treatment “steps”. Each step represents treatment options that are alternatives for controlling asthma. Moreover, steps 1 to 5 provide options of increasing efficacy. In order to maintain asthma control regular monitoring and adjustment is essential. In cases where asthma is not or only partially controlled with the current treatment regimen, step-up treatment is recommended whereas disease control allows a gradual stepping-down to the lowest possible dose of medication necessary to maintain control. This novel asthma management approach based on disease control, may facilitate acceptance and use of asthma guidelines in clinical practice.

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Prof. Dr. med. Dr. rer. nat. Claus Kroegel

Pneumologie und Allergologie/Immunologie, Medizinische Klinik I, Friedrich-Schiller-Universität

Erlanger Allee 101

7740 Jena

Email: claus.kroegel@med.uni-jena.de