In 1991, in response to observed increasing asthma mortality in the 1970s and 1980s, especially among inner-city African-Americans, the National Asthma Education and Prevention Program (NAEPP) introduced Guidelines for Asthma treatments.1 A group of experts were invited to Virginia from all regions of the country to hear the guidelines and disseminate the suggestions to local physicians through lectures using specific content material. Although physician knowledge was documented to be more consistent with the guidelines over the next five years, patient management changed little, with the use of beta agonists remaining the major therapy administered to private and public sector moderate and severe asthmatics.

Two more updates have been published based on more recent reviews of scientific literature and subsequent expert opinions.2,3 Numerous subsequent studies have demonstrated that guidelines tend to be poorly followed by physicians.4-6 This is not specific for asthmatics.7 Even when guidelines are introduced with a program of education that is specifically developed using adult learning theory, the effect on physician behavior is not impressive8,9 and requires incremental steps.10 One problem with asthma guidelines is that, although they make sense, they are not often backed by large randomized clinical trials (RCTs) with solid proof of effectiveness. This is especially true in real-life circumstances such as doctors- offices.11 For example, use of daily peak flow meters, flow meters as part of an action plan, action plans per se, long acting beta agonist as controllers, very high inhaled corticosteroid dosing with more severe clinical asthma, and frequent office visits are just a few recommendations that are of questionable added efficacy.3,12-14 These guideline recommendations, which often appear to the practicing clinician as added effort without personal observation of major gain, have created credibility gaps and barriers with practicing physicians.

Another problem with guidelines has been their stated final goals - -near normal- pulmonary function and activity for all asthma patients. This may be unrealistic. In fact, some had suggested that asthma control as defined by the NAEPP is unrealistic for a large majority of patients.15 A recent study has examined the question of whether or not asthma-guidelines-defined control could be achieved in a one-year randomized, double blind parallel group study of over 3,000 patients in cohort of previously uncontrolled patients. The study attempted to achieve a measure of control defined as total and/or well controlled. Treatment was stepped up until total control was achieved or 500 micrograms bid of inhaled fluticasine plus salmeterol was administered.Across all strata, most patients ended up on the highest doses of medication.Total control was achieved in less than half of the patients, and well controlled status as strictly defined by the authors as a reflection of the NAEEP guidelines was less than 50% and 63%, respectively. These levels of control were better than on the same patients- prior regimens before the study. Although the majority of patients received good control, 40% of severe asthmatics did not, even at high dose combination therapy over 52 weeks.These were well motivated patients managed in a study environment that is unlikely to be simulated in standard practice.