Aim to keep your patient on the lowest effective dose of inhaled corticosteroid that will prevent symptoms. Inhaled corticosteroids are often used in inappropriate doses. If your patient's asthma is well controlled you should step down treatment (reduce the dose by 25-50% every three months). Only 5-10% of people with asthma will need high dose corticosteroids.
Equally, concordance with use of regular inhaled corticosteroids is poor, and many patients are undertreated.
Use the three morbidity index questions recommended by the Royal College of Physicians to assess symptoms of asthma in the past week or month:
- “Have you had your usual asthma symptoms during the day, such as cough, wheeze, chest tightness, or breathlessness?”
- “Have you had any difficulty sleeping because of your symptoms, including cough?”
- “Has your asthma interfered with your usual activities (such as housework, work, or school)?”
Measuring PEFR is a useful tool for making a diagnosis, and assessing how well a patient's asthma is controlled. It is essential in objectively assessing the severity of an acute attack, when it should be compared with the patient's best achieved peak flow. Ideally, all adults should have their best peak flow measured every five years to compensate for decreasing lung function with age. Children who are still growing should be assessed more frequently—for example, as part of an annual asthma review.
Include the following information in a patient's action plan: details of asthma drugs including names, doses, and side effects; advice about when to take further action (for example, based on the pattern of their symptoms or peak flow measurements); what to do if symptoms get worse; when to return to usual doses; and when to seek urgent medical help.
Increasing the dose of inhaled corticosteroid during an exacerbation is an essential component of successful asthma action plans. One study showed that increasing the dose fivefold was effective.9
Rhinitis is a common comorbidity. Ask patients with asthma about nasal symptoms, and ask patients with rhinitis about wheeze.
Consider keeping a register of high risk patients with asthma. These include those who have been admitted to hospital with asthma in the past year, those with “brittle” asthma (condition tends to deteriorate rapidly during an exacerbation with little warning), and those who have ever been admitted to an intensive care unit with asthma.
It is marginally cheaper to prescribe combined corticosteroid and long acting β2 agonist inhalers rather than prescribing them individually, and this prevents the potential danger of non-compliance with the inhaled steroid. However, it prevents the flexibility of adjusting the dose of the drugs independently