Treating Asthma and Comorbid Allergic Rhinitis in Pregnancy
Treating Asthma and Comorbid Allergic Rhinitis in Pregnancy
Women with severe or uncontrolled asthma are at higher risk for pregnancy complications and adverse fetal outcomes than women with well-controlled asthma. Recent evidence-based guidelines have concluded that it is safer for pregnant women with asthma to be treated pharmacologically than to continue to have asthma symptoms and exacerbations. According to the Asthma and Pregnancy Working Group (APWG) of the National Asthma Education and Prevention Program, optimal treatment of asthma during pregnancy includes treatment of comorbid allergic rhinitis (AR), which can trigger or aggravate asthma symptoms. In general, treatment of both asthma and AR during pregnancy should follow the same stepwise approach that is used in the general population. This article presents the specific recommendations from the most recent APWG report and from other systematic reviews about which asthma and allergic rhinitis drugs should be preferred during pregnancy. Of the corticosteroids, budesonide has the most data and is listed as Pregnancy Category B (no evidence of risk in humans). Other inhaled and intranasal corticosteroids have less data and are listed as Pregnancy Category C but may be continued during pregnancy if the patient's asthma was well controlled with the medication before pregnancy. Family physicians should help their patients control allergic rhinitis and asthma during pregnancy, encouraging adherence to needed medications.
Asthma is potentially the most common chronic medical condition to complicate pregnancy. It was estimated that 3.7% to 8.4% of pregnant women in the United States were affected by the disease between 1997 and 2001. Evidence-based guidelines from two national professional societies, the British Thoracic Society and the APWG of the National Asthma Education and Prevention Program (NAEPP), state that pregnant women with asthma should receive optimal treatment. APWG further specifies that the goals of treatment are to maintain asthma control for the health and quality of life of the mother, as well as for normal fetal development. Both groups have concluded from systematic reviews of the literature that asthma treatment is a much safer option for pregnant women than nontreatment of continuing asthma symptoms.
According to APWG, optimal treatment of asthma includes treatment of comorbid AR. Up to 80% of adults with asthma also have AR, and 20% to 50% of patients with AR have coexisting asthma. Due to the increased occurrence of nasal symptoms in pregnancy, AR may be overlooked. Previously recognized AR should continue to be treated and the evaluation of new onset rhinitis should include consideration of AR.
Consensus is building that asthma and AR are a single airway disease. Prospective data from multiple studies show that AR is an independent risk factor for adult-onset asthma. In fact, in a recent study, monotherapy with intranasal beclomethasone was as effective as inhaled beclomethasone.
A secondary analysis of the Kaiser-Permanente Prospective Study of Asthma During Pregnancy indicated that improvement or worsening of nasal symptoms was associated with improvement or worsening of asthma, respectively. The researchers concluded that the course of AR during pregnancy may help to predict the asthma course, and that aggressive treatment of worsening AR in pregnant women may improve asthma control. This review presents the latest conclusions of evidence-based reports and other relevant data to guide clinicians in caring for pregnant patients with asthma and comorbid AR.
Abstract and Introduction
Abstract
Women with severe or uncontrolled asthma are at higher risk for pregnancy complications and adverse fetal outcomes than women with well-controlled asthma. Recent evidence-based guidelines have concluded that it is safer for pregnant women with asthma to be treated pharmacologically than to continue to have asthma symptoms and exacerbations. According to the Asthma and Pregnancy Working Group (APWG) of the National Asthma Education and Prevention Program, optimal treatment of asthma during pregnancy includes treatment of comorbid allergic rhinitis (AR), which can trigger or aggravate asthma symptoms. In general, treatment of both asthma and AR during pregnancy should follow the same stepwise approach that is used in the general population. This article presents the specific recommendations from the most recent APWG report and from other systematic reviews about which asthma and allergic rhinitis drugs should be preferred during pregnancy. Of the corticosteroids, budesonide has the most data and is listed as Pregnancy Category B (no evidence of risk in humans). Other inhaled and intranasal corticosteroids have less data and are listed as Pregnancy Category C but may be continued during pregnancy if the patient's asthma was well controlled with the medication before pregnancy. Family physicians should help their patients control allergic rhinitis and asthma during pregnancy, encouraging adherence to needed medications.
Introduction
Asthma is potentially the most common chronic medical condition to complicate pregnancy. It was estimated that 3.7% to 8.4% of pregnant women in the United States were affected by the disease between 1997 and 2001. Evidence-based guidelines from two national professional societies, the British Thoracic Society and the APWG of the National Asthma Education and Prevention Program (NAEPP), state that pregnant women with asthma should receive optimal treatment. APWG further specifies that the goals of treatment are to maintain asthma control for the health and quality of life of the mother, as well as for normal fetal development. Both groups have concluded from systematic reviews of the literature that asthma treatment is a much safer option for pregnant women than nontreatment of continuing asthma symptoms.
According to APWG, optimal treatment of asthma includes treatment of comorbid AR. Up to 80% of adults with asthma also have AR, and 20% to 50% of patients with AR have coexisting asthma. Due to the increased occurrence of nasal symptoms in pregnancy, AR may be overlooked. Previously recognized AR should continue to be treated and the evaluation of new onset rhinitis should include consideration of AR.
Consensus is building that asthma and AR are a single airway disease. Prospective data from multiple studies show that AR is an independent risk factor for adult-onset asthma. In fact, in a recent study, monotherapy with intranasal beclomethasone was as effective as inhaled beclomethasone.
A secondary analysis of the Kaiser-Permanente Prospective Study of Asthma During Pregnancy indicated that improvement or worsening of nasal symptoms was associated with improvement or worsening of asthma, respectively. The researchers concluded that the course of AR during pregnancy may help to predict the asthma course, and that aggressive treatment of worsening AR in pregnant women may improve asthma control. This review presents the latest conclusions of evidence-based reports and other relevant data to guide clinicians in caring for pregnant patients with asthma and comorbid AR.
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