|Home | About | Journals | Submit | Contact Us | Français|
The prevalence of active asthma in the United Kingdom is 5.8% according to data from the quality and outcomes framework of the new general medical services contract (which allocates 45 points for caring for patients with asthma). There are still about 1500 deaths a year from asthma in the UK, many of which may be preventable, and asthma affects about eight million people in the UK at some stage in their lives.
Asthma is a variable condition. You can make the diagnosis by noting a history of variable symptoms, confirmed by variability of peak flow (or spirometry):
Building on a previously published trial,1 this study randomised 194 adults with asthma in the south west of England to telephone review or surgery review over 12 months.2 Patients in the telephone group were contacted every six months and asked the Royal College of Physicians' three morbidity index questions plus two other questions about hospital admissions and treatment in intensive care. An action plan was agreed for those considered to be at low risk. A surgery appointment was arranged if the patient answered “yes” to any of the questions.
Control of asthma was similar in both groups, with a mean cost of £210 per patient per year in the telephone group compared with £334 in the clinic group.
Bottom line—Telephone reviews may be as effective as face to face reviews and are cost effective, so it is surprising that telephone review is not permitted under the quality and outcomes framework. The rationale is that inhaler technique cannot be checked over the telephone.
In this study 225 adults with mild asthma who did not smoke were randomised to one of three treatment arms—regular budesonide, regular oral zafirlukast (20 mg twice daily), or intermittent use of inhaled budesonide.3 Primary outcome was peak flow measured in the morning.
Patients in all three groups had similar increases in morning peak flow (of about 7.8%) and similar rates of exacerbations, though those taking intermittent treatment experienced more symptoms and markers of bronchial inflammation. Patients using intermittent treatment took budesonide for an average of only 0.5 weeks a year.
Bottom line—This is an exploratory study, which needs to be confirmed, but it raises the possibility that some patients with mild persistent asthma could be treated with short, intermittent courses of inhaled steroids
This study, of 7219 patients with asthma in the UK, found that 76% reported symptoms of rhinitis (blocked or runny nose, itchy eyes, and sneezing).4 Of this 76%, half said that their rhinitis made their asthma worse, 58% reported seasonal rhinitis whereas the others reported constant symptoms, and only 54% were being prescribed a nasal corticosteroid.
Bottom line—There is growing evidence of the importance of the overlap between rhinitis and asthma. You should ask all patients with asthma if they have symptoms of rhinitis.
This trial found that salmeterol may increase the risk of severe and life threatening exacerbations of asthma, especially in African-American patients, and in those who are not prescribed concomitant inhaled corticosteroids.5 6 Whether this risk is due to genetic factors, or patient behaviours leading to poor outcomes is not known
Bottom line—Long acting β agonists are effective in reducing asthma symptoms, but clinicians should prescribe, and patients be counselled to take, concomitant inhaled corticosteroids.
This review looked at all randomised controlled trials that included children older than 2 years who were given inhaled β2 agonists for chronic cough (that is, cough lasting more than three weeks).7 Salbutamol showed no benefit over placebo.
Bottom line—Salbutamol may not be useful for children with chronic cough.
See box for management advice based on these guidelines.8 Important points are
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:
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
You should refer your patient if you are unsure of the diagnosis, especially in infants, or if you suspect that asthma may be related to your patient's working conditions (occupational asthma).
It is also reasonable to refer if asthma control is not achieved by stepping up treatment to step 4 (adults and children) or step 3 (children under 5 years) see Summary of the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) guidance:
It is difficult to be certain whether a wheezy toddler has asthma, but you should consider following a structured diagnostic process:
Empowering people to adjust their dose of inhaled corticosteroid in response to symptoms or peak flows is an effective part of action plans.11 In the real world, where patients reduce or even stop their inhaled corticosteroids between exacerbations, it is appropriate to remind patients to reinstate prophylactic treatment when their asthma control deteriorates. For patients with low maintenance doses of inhaled corticosteroids, the dose should be increased substantially if control worsens. Patients with more severe asthma who are already regularly taking high doses of inhaled corticosteroids may be better advised to start oral corticosteroids.
Before increasing treatment, assess the clinical situation, checking diagnosis, inhaler technique, concordance with treatment, possible environmental triggers and concomitant rhinitis.
The BTS-SIGN guidelines recommend long acting β agonists as the first choice for additional therapy for adults and older children. This statement does not, however, take into account the complexity of tailoring treatment to individual circumstances.
Many people with asthma are not receiving their prescribed treatment because of poor concordance with regular treatment and poor inhaler technique. You should try to discuss concordance in a non-judgmental way and check that patients know how to use their inhaler correctly before you change their treatment. (The Asthma UK website (www.asthma.org.uk) has an interactive demonstration of inhaler technique.)
Do not underestimate seasonal asthma. There is a strong link between asthma and hay fever, and deaths from asthma in young adults peak during the pollen season.12 You should advise these patients to ask for help early when their symptoms worsen, and tell them about the link between asthma and rhinitis.
There is often confusion between chest infections and acute asthma. Acute asthma is commonly triggered by viral infections or allergens. You should not routinely prescribe antibiotics.
Delaying treatment is the most common preventable factor in asthma related deaths. This is often because the doctor or patient underestimates severity. You should use and record objective measures of severity such as peak flow measurements.
Do not prescribe long acting β agonists for patients with asthma without also prescribing inhaled corticosteroids.
Competing interests: None declared.