Dr Andy Whittamore explains why the updated BTS/SIGN asthma guideline is important for improving practice and patient outcomes

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Read this article to learn more about:

  • the importance of personalised asthma action plans
  • risk factors for poor asthma control and life-threatening attacks
  • audit suggestions for good practice.

Key points

GP commissioning messages

There has been a lot of coverage of asthma recently, with an oral medication for moderate to severe asthma on the horizon,1 talk of how smart inhalers and technology can help transform care,2 and evidence suggesting that optimum levels of vitamin D may reduce exacerbation rates.3

There is also a multitude of new inhalers on the market with new molecules and novel devices available, providing greater choice for clinicians and patients but without any new types of treatments for the patients that we see in primary care.

There are some exciting options for our more severely affected patients, with several monoclonal antibodies having good evidence for improving outcomes in allergic asthma starting to become available in specialist clinics.4

These glimmers of light distract us from some stark realities. The respiratory community is still reeling from the National Review of Asthma Deaths (NRAD), published in 2014.5 This review highlighted that there were potentially avoidable factors related to patients and their families in nearly two-thirds (65%) of asthma deaths between February 2012 and January 2013, including inadequate information, education and advice on managing asthma. Seventy-seven per cent of the people who died did not have a personalised asthma action plan (PAAP), even though people with a PAAP are four times less likely to be hospitalised.

Since the publication of NRAD, we have seen an increase in the number of asthma deaths.6 The ADMIT study showed that over the last 40 years, inhaler use has not improved.7

The 2016 update to the BTS/SIGN British guideline on the management of asthma8 provides increased relevance to some key features of asthma management and good medical practice, as detailed below.

Carry out a detailed history and diagnostic process

Studies repeatedly highlight the over- and under-diagnosis of asthma.9 The authors of the BTS/SIGN guideline recommend the use of the read code 'Suspected asthma' until a diagnosis is reached, and to accurately record the basis of any diagnosis so that other clinicians can understand the rationale of any asthma diagnosis.8

The BTS/SIGN guideline encourages clinicians to systematically consider the history before starting treatment to prove the hypothesis of an asthma diagnosis; it describes a protocol for people with a high probability of asthma, based on the history, moving straight into a 'monitored initiation of therapy' with inhaled corticosteroid (ICS) therapy. The importance of good history taking is again emphasised for reviewing people with asthma—using closed rather than open questions to identify symptoms, reliever use, and adherence to medication.

Audit suggestion: review the notes of 10 children and/or 10 adults with asthma to see if diagnostic reasoning is clear.

Identify regular symptoms and reliever over-reliance

Symptoms and reliever use are the best markers of poor asthma control in primary care. They should also be considered as risk factors for life-threatening asthma attacks. Short-acting beta2 agonists (SABAs) relieve asthma symptoms but do not treat the underlying inflammation.

The occurrence of symptoms and/or use of SABA more than three times per week is regarded as poor disease control, as is any degree of night-time symptoms.8 Anyone with poor disease control should be assessed and their management optimised. The BTS/SIGN guideline recommends reviewing anyone prescribed more than one SABA inhaler per month (or 12 SABA inhalers per year).

Clinicians in general practice and community pharmacies need to do more to educate patients about disease control and reliance upon SABA medication, and look to create systems that identify unsafe over-use of reliever medication.

Audit suggestion: how many patients have been prescribed more than 12 SABA inhalers in the last year?

Asthma is an inflammatory condition

The bedrock of asthma treatment is anti-inflammatory medication, usually prescribed in the form of ICS medication. The importance of treating the inflammation that causes asthma symptoms is highlighted early on in the diagnostic process, which includes a monitored initiation of ICS treatment.8

Poor adherence to ICS medication is outlined as a key factor in poor asthma control and should be identified and addressed before increasing medication.

Inhaled corticosteroid medications have been categorised within the guideline as very low, low, medium, and high dose for ease of comparison and safety.

Whenever assessing poor control of asthma symptoms, check the diagnosis, triggers, and adherence. Treating concomitant allergies and gastric reflux, identifying and avoiding allergens where possible, and eliminating exposure to tobacco smoke are all important aspects of asthma management.

Audit suggestion: how many patients are on a SABA but no ICS?

The right drugs in the right device

It is important that the inhaled medication is prescribed in a device and formulation that suits the patient. We must take time to observe whether the patient can take the medication correctly. Given the number of different devices available,the BTS/SIGN guideline suggests we should not prescribe inhalers generically.8

The guideline gives added clarity to the stepwise increases in therapy, with the next step after low-dose ICS being the addition of a long-acting beta2 agonist (LABA).

It is also important to refer to a specialist if maintenance with high-dose ICS, multiple additional therapies, or oral steroids are being considered.8

Audit suggestion 1: how many patients are on high-dose ICS or regular oral steroids?
Audit suggestion 2: how many inhalers are prescribed generically?

Self-care and exacerbations matter

It is essential that we give patients the tools to manage their own condition, which will fluctuate. The BTS/SIGN guideline update highlights the importance of a written PAAP in doing this. Two PAAPs—for adults and children—and associated resources can be downloaded at Asthma UK, as well as health advice for patients. Asthma UK also has a helpline for healthcare practitioners and patients with asthma (0300 222 5800).

An exacerbation is a key opportunity to review the diagnosis, triggers, treatment, and adherence in order to prevent the next exacerbation and gain control of symptoms. Patients are at high risk of death in the first month after discharge from hospital.

Following discharge, patients with asthma should be followed up in primary care within 2 working days to ensure improvement and optimise management.8

Audit suggestion 1: what proportion of patients have a documented PAAP?
Audit suggestion 2: how many patients were reviewed within 2 working days after an admission in the last year?

Conclusion

Attention to good history taking and diagnostic rigour, monitoring SABA overuse to identify and manage untreated inflammation, and aiding adherence to anti-inflammatory therapy by giving the patient the self-management support and an appropriate inhaler can make a big difference to the safety, outcome, and quality of life for people with asthma.

Key points

  • Deaths from asthma in the UK continue to rise. Many deaths have been associated with:
    • clinicians' failure to follow guidelines
    • over-reliance on reliever medication
    • patients not receiving personalised asthma action plans
  • Asthma diagnosis requires careful and considered history taking, and a monitored initiation of therapy supported by objective measurements
  • All patients should be given a personalised asthma action plan
  • Regular symptoms and the over-use of relievers (SABAs) are riskfactors for life-threatening asthma attacks:
    • people with poor disease control should be assessed and their management optimised
  • Poor adherence to ICS medication should be identified and addressed before medication is increased
  • Inhaled medication should be prescribed in a device and formulation that suits the patient. Generic devices should be avoided
  • Refer the patient to a specialist if maintenance with high-dose ICS, multiple additional therapies, or oral steroids are being considered
  • Patients should be reviewed in primary care within 2 working days of leaving hospital after an exacerbation:
    • there is a high risk of death in the first month after discharge from hospital.

SABAs=short-acting beta2 agonists; ICS=inhaled corticosteroid

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GP commissioning messages

written by Dr Andy Whittamore

  • Commissioners should aim to:
    • increase access to tests like FeNO and skin-prick testing for primary care
    • target safety programmes around inhaler monitoring to reduce admissions and prevent untreated inflammation and deaths
    • consider quality improvement programmes around accurate diagnosis, asthma symptom control, and ICS adherence/SABA over-reliance
    • consider how clinical competencies can impact on accurate diagnosis of respiratory disease in light of new plans for a register of accredited professionals performing spirometry.10

FeNO=fractional exhaled nitric oxide; ICS=inhaled corticosteroid; SABA=short-acting beta2 agonists

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References

  1. Gonem S, Berair R, Singapuri A et al. Fevipiprant, a prostaglandin D2 receptor 2 antagonist, in patients with persistent eosinophilic asthma: a single-centre, randomised, double-blind, parallel group, placebo-controlled trial. Lancet Respir Med 2016; 4 (9): 699–707.
  2. Asthma UK. Connected asthma: how technology will transform care. Asthma UK, 2016. Available at: www.asthma.org.uk/connectedasthma
  3. Martineau A, Cates C, Urashima M et al. Vitamin D for the management of asthma. Cochrane Database Syst Rev 2016; 9. DOI: 10.1002/14651858.CD011511.pub2
  4. NICE. Omalizumab for treating severe persistent allergic asthma. NICE Technology Appraisal 278. NICE, 2013. Available at:www.nice.org.uk/ta278
  5. Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) confidential enquiry report. London: RCP, 2014. Available at: www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
  6. Office for National Statistics. Death registrations in England and Wales, summary tables: 2015. ONS, 2015. Available at: www.ons.gov.uk/releases/deathregistrationsinenglandandwalessummarytables2015 (accessed 26 September 2016).
  7. Sanchis J, Gich I, Pedersen S. Systematic review of errors in inhaler use: has patient technique improved over time? Chest 2016; 150 (2): 394–406.
  8. British Thoracic Society and Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Updated 2016. Available at: sign.ac.uk/pdf/ SIGN153.pdf and www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016
  9. Bush A, Fleming L. Is asthma overdiagnosed? Arch Dis Child 2016; 101: 688–689
  10. Asthma UK, British Lung Foundation, British Thoracic Society et al. Improving the quality of diagnostic spirometry in adults: the National Register of certified professionals and operators. September, 2016. Available at: www.pcc-cic.org.uk/sites/default/files/articles/attachments/improving_the_quality_of_diagnostic_spirometry_in_adults_the_national_register_of_certified_professionals_and_operators.pdfG