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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EAsthma exacerbations during pregnancy declined 50% in patients who were managed by a clinical algorithm that was guided by exhaled nitric oxide. This article discusses the results of the Managing Asthma in Pregnancy [MAP] trial.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EPulmonary Clinical Trials\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EAsthma\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPregnancy\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAsthma exacerbations during pregnancy declined 50% in patients who were managed by a clinical algorithm that was guided by exhaled nitric oxide. Peter Gibson, MD, University of Newcastle, New South Wales, Australia, reported the results of the Managing Asthma in Pregnancy (MAP) trial.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe time to first exacerbation was significantly prolonged in patients who were managed by the fraction of exhaled nitric oxide (F\u003Csub\u003EE\u003C\/sub\u003ENO) algorithm, associated with a hazard ratio of 0.565, compared with the control group. The proportion of patients who had at least one exacerbation was about 40% lower in the F\u003Csub\u003EE\u003C\/sub\u003ENO group.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EUnplanned or unscheduled clinic visits and use of oral corticosteroids also were significantly reduced by adherence to the F\u003Csub\u003EE\u003C\/sub\u003ENO algorithm. More patients in the experimental arm received inhaled corticosteroids and long-acting beta agonists; however, inhaled corticosteroid dose requirements were significantly lower.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EAsthma is the most common chronic illness in pregnancy, occurring in about 12% of cases. Asthma exacerbations are common during pregnancy and associated with significant maternal and fetal morbidity. Given the concern over medication use during pregnancy, a method to optimize the dosing of inhaled corticosteroids would be helpful in clinical management.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003ETreatment that is based on sputum eosinophil count has been shown to reduce asthma exacerbations, and F\u003Csub\u003EE\u003C\/sub\u003ENO is a marker of airway eosinophilia and inflammation [Petsky H. \u003Cem\u003ECochrane Rev\u003C\/em\u003E 2008]. However, studies of F\u003Csub\u003EE\u003C\/sub\u003ENO-guided management have yielded equivocal results, said Prof. Gibson. Continuing the evaluation of F\u003Csub\u003EE\u003C\/sub\u003ENO-guided asthma management, investigators designed a randomized trial to assess the value of an algorithm in pregnancy. They enrolled asthmatic women between gestational weeks 12 and 20.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EAll patients on maintenance inhaled corticosteroids were switched to an equivalent dose of budesonide, and patients with unstable disease status began treatment with budesonide. Randomization occurred at the second clinic visit. Thereafter, patients in the F\u003Csub\u003EE\u003C\/sub\u003ENO and control groups underwent the same evaluation at each clinic visit: F\u003Csub\u003EE\u003C\/sub\u003ENO, spirometry, asthma control by Asthma Control Questionnaire (ACQ), and optimization of asthma self-management.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EPatients in the control group were managed according to clinical guidelines. The remaining patients were managed by use of a validated algorithm, comprising F\u003Csub\u003EE\u003C\/sub\u003ENO and ACQ [Gibson PG. \u003Cem\u003EClin Exp Allergy\u003C\/em\u003E 2009]. The algorithm was used to adjust the budesonide dose in response to changes in F\u003Csub\u003EE\u003C\/sub\u003ENO, and a long-acting beta agonist (LABA) was used for symptom management in the absence of elevated F\u003Csub\u003EE\u003C\/sub\u003ENO.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EThe algorithm comprises five steps:\u003C\/p\u003E\u003Col class=\u0022list-ord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n            \u003Cp id=\u0022p-10\u0022\u003EF\u003Csub\u003EE\u003C\/sub\u003ENO \u0026gt;29 parts-per-billion (ppb): Increase inhaled corticosteroid dose by one step\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n            \u003Cp id=\u0022p-11\u0022\u003EF\u003Csub\u003EE\u003C\/sub\u003ENO 16\u201329 ppb, ACQ \u22641.5: No change\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n            \u003Cp id=\u0022p-12\u0022\u003EF\u003Csub\u003EE\u003C\/sub\u003ENO 16\u201329 ppb, ACQ \u0026gt;1.5: Increase LABA dose by one step\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n            \u003Cp id=\u0022p-13\u0022\u003EF\u003Csub\u003EE\u003C\/sub\u003ENO \u0026lt;16 ppb, ACQ \u0026gt;1.5: Decrease inhaled steroid dose by one step, increase LABA dose by one step\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n            \u003Cp id=\u0022p-14\u0022\u003EF\u003Csub\u003EE\u003C\/sub\u003ENO \u0026lt;16, ACQ \u22641.5: Reduce inhaled steroid dose by one step\u003C\/p\u003E\n         \u003C\/li\u003E\u003C\/ol\u003E\u003Cp id=\u0022p-15\u0022\u003EThe study involved 220 patients, 203 of whom completed the trial. The two groups were similar with respect to baseline characteristics, including FEV\u003Csub\u003E1\u003C\/sub\u003E and use of inhaled corticosteroids. The primary outcome was the sum of moderate and severe asthma exacerbations during pregnancy. Exacerbations consisted of unscheduled visits to a doctor, visits to an emergency department, hospital admission, and oral steroid use for asthma control.\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EWhen the trial ended, the F\u003Csub\u003EE\u003C\/sub\u003ENO group had an incidence rate ratio of 0.499 versus the control group (p=0.001). In the control group, 40% of patients had at least one asthma exacerbation during pregnancy, compared with 25% in the F\u003Csub\u003EE\u003C\/sub\u003ENO group (p=0.011). The number-needed-to-treat was 6, meaning that for every 6 pregnant women with asthma who were managed by this algorithm, then 1 had an asthma exacerbation that was prevented.\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EAnalysis of the individual types of exacerbations showed no difference in hospital admission or visits to an emergency department or labor ward. Patients in the control group had a significantly higher rate of unplanned or unscheduled clinic visits (p=0.002), and significantly more patients required oral steroids as compared with the FENO group (p=0.04). The algorithm was associated with a significantly lower daily dose requirement of inhaled corticosteroids (p=0.043).\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003E\u201cAsthma exacerbations during pregnancy can be significantly reduced by the use of a validated F\u003Csub\u003EE\u003C\/sub\u003ENO-based treatment algorithm,\u201d said Prof. Gibson. \u201cFuture work should investigate the application of this algorithm in routine antenatal care and other settings.\u201d\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/11\/4\/9.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzn2pe\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}