Dr Steve Holmes (left) and Jane Scullion discuss the updated guidance from BTS/SIGN on monitoring and pharmacological therapy for asthma, and its management in adolescents
Asthma is the most common symptomatic long-term condition and has a known prevalence of 5.9%.1 The management of people with asthma is a significant part of primary care, paediatrics, emergency medicine, and respiratory clinical practice.
So how well are we managing asthma? Do we still need to address any issues in asthma? Unfortunately, the answer is that we have a considerable way to go before being able to say we are providing good care.
Asthma UK suggests that 75% of asthma admissions could be avoided with better symptom control;2 prevention of inappropriate hospital admissions would be an appropriate area to explore in commissioning particularly with respect to the quality, innovation, productivity, and prevention challenge.3 Although the UK mortality rate for asthma is reasonable compared to that of other countries, it is not as low as the rate achieved by Finland.4
Moreover, people with asthma also experience more severe symptoms than suspected. The GOAL (Gaining Optimal Asthma controL) study found that 80% of people obtain control with regular use of therapy under clinician review.5 However, most of the studies investigating patient symptoms appear to show two key features:6
- Many people have symptoms from their asthma
- Many patients have accepted these symptoms and when informed what good control of their asthma would be like, indicate that they have poor control.
For example, a review of 2803 patients with asthma found that 46% had symptoms during the day and 30% at night. Additionally, 50% of the individuals concerned did not realise that they had poor control.7 Even in people with the most severe asthma, who are seen in tertiary asthma clinics, concordance with recommended medication remains an issue, with more than one-third of patients using less than half the expected amount of prescribed inhaler medication.7
The British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) published the latest update to the British guideline on the management of asthma in May 2011.8 It provides a useful review of new evidence and knowledge to inform clinical practice, but it is for primary care, as skilled clinicians, to address the gap in patient expectations and outcomes through good communication. The guideline is termed a ‘living guideline’ and several of the chapters (but not all) are reviewed each year. The review of the guideline in 2011 concentrated on three areas:
- Monitoring and control
- Pharmacological management
- Adolescents with asthma.
Monitoring and control
The BTS/SIGN guideline found little evidence that biomarkers such as peak flow improve asthma control as even in trials, adherence to regular monitoring is poor.8 For the majority of people with asthma, symptom-based monitoring is satisfactory.8 The recommendations also suggest that monitoring at least annually is good practice and use of a validated symptom tool (e.g. the Royal College of Physicians’ three questions used in the quality and outcomes framework9) or validated questionnaire does improve the likelihood of a healthcare professional identifying clinical issues.8
Although not linked to the literature, the guideline includes a good practice point that advises using open (e.g. ‘How is your asthma affecting you?’) as well as closed questions (e.g. ‘Do you use your inhaler every day?’).8 Primary care has ready access to prescription dates through practice records, which can be used routinely to assess the use of both reliever and preventer medications. However, it is important to remember that although patients may collect a prescription from the practice, they may:
- not always take it to the chemist
- stockpile the inhaler device at home
- acquire their inhalers for, or from other family members.
As we become increasingly conscious of the cost of inhalers and their use, we should always remember that an unused inhaler sitting in the cupboard under the stairs is a waste of a limited NHS resource!
One of the key ways to encourage concordance and patient understanding is the provision of self-management plans (asthma action plans), which if developed with the patient and in association with regular clinical review and patient education, have proven benefit in improving patient outcomes. The possession and use of a self-management plan/personalised asthma action plan is one of the new recommendations for primary care in the monitoring of children with asthma.8 An example action plan is available to download (click here).
An action plan can be used to help people to understand their medication and condition better. An important aspect of action plans is that they are tailored to the individual patient. There are many action plans available including ones from Asthma UK. Some practices are producing plans as part of a computerised template; however this format is still very much in its infancy.
The BTS/SIGN guideline on asthma contains a revised pharmacological section. It includes consideration of starting doses for inhaled corticosteroids (ICS) in both children and adults and at step 3 recommends the use of combination inhalers in light of concerns over the use of long-acting ?2 agonists (LABA) without ICS.
It is still anticipated that the majority of adult patients will be commenced on preventer therapy at a dose of 400 ?g daily beclometasone dipropionate (BDP-hydrofluoroalkane) (see Figure 1, below) and 200 ?g daily for children. The BTS/SIGN guideline includes a table that highlights the comparative doses of ICS relative to BDP (see Table 1).8
The guideline supports Medicines and Healthcare products Regulatory Agency advice to always prescribe LABA with ICS10 and recognises that in clinical practice a combination inhaler may aid compliance and ensure that the LABA is not taken without the ICS.8 This is because of strong evidence supporting the use of ICS in reducing death rates, and improving symptoms for people with asthma.8 No major concerns over the safety profile of ICS at normal doses have been expressed.
Monitoring and review
A significant new recommendation in the updated BTS/SIGN guideline on asthma (good practice point) suggests that growth (height and weight centiles) should be monitored annually in all children on ICS and oral corticosteroids.8 This appears appropriate as the risk of growth failure with oral corticosteroids is well accepted. The risks of normal-dose ICS have not been proven, however, and under treatment and poor control of asthma is also thought to restrict growth in children.8 There have been no changes in the recommendations on carrying out a careful clinical review (including evaluation of symptoms and concordance) before stepping up therapy if asthma is uncontrolled and consideration of stepping down if their condition is controlled.8
|Figure 1: Summary of stepwise management of asthma in adults8|
LABA=long-acting ?2 agonist; SR=sustained release
|Table 1: Equivalent doses of inhaled steroids relative to beclometasone dipropionate and current licensed age indications8|
|UK licence covers|
|Steroid||Equivalent dose (?g)||>12 years||5–12 years||<5 years|
|Beclometasone dipropionate CFC||400||No longer available|
|Clickhaler||?||Aged over 6 years||?|
|Asmabec Clickhaler||?||Aged over 6 years||?|
|Dry powder (Becodisks)||?||?||?|
|Pulvinal||?||Aged over 6 years||?|
|Fostair||200||Aged over 18 years||?||?|
|Metered-dose inhaler||?||?||Aged over 2 years|
|Easyhaler||?||Aged over 6 years||?|
|Novolizer||?||Aged over 6 years||?|
|Symbicort||?||Aged over 6 years||?|
|Symbicort (regular and as required dosing)||Aged over 18 years||?||?|
|Metered-dose inhaler (HFA)||200||?||?||Aged over 4 years|
|Accuhaler||?||?||Aged over 4 years|
|Seretide HFA||?||?||Aged over 4 years|
|Seretide (Accuhaler)||?||?||Aged over 4 years|
|*When changing over to Qvar from BDP-CFC, if (a) control is good on BDP-CFC change to half the dose of Qvar; (b) control is not good on BDP-CFC change to Qvar at the same daily dose. Ciclesonide is a new inhaled steroid. Evidence from clinical trials suggests that it has less systemic activity and fewer local oropharyngeal side-effects than conventional inhaled steroids. The clinical benefit of this is not clear as the exact efficacy to safety ratio compared to other inhaled steroids has not been fully established. Non-CFC beclometasone is available in more than one preparation, and the potency relative to CFC beclometasone is not consistent between these. CFC=chlorofluorocarbon; HFA=hydrofluoroalkane British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. A national clinical guideline. SIGN 101. Edinburgh: SIGN, 2011. Reproduced with kind permission. Available at: brit-thoracic.org.uk and sign.ac.uk|
Asthma in adolescents
Asthma in adolescents is a completely new section in the BTS/SIGN guideline and is a welcome addition as many healthcare professionals find clinical management of this age group particularly challenging. The guideline indicates that there is considerable underdiagnosis in this patient group.8
Independent risk factors associated with under diagnosis of asthma in adolescents include:8,11
- female gender
- smoker (both current smoker and passive exposure)
- low socioeconomic status
- family problems
- low physical activity
- raised body mass index
The transition from child to adult is clearly challenging for many patients with asthma and the healthcare professionals responsible for their management. The Guideline Development Group considered acceptance of the independence of the adolescent to be important, along with careful career and work guidance. Adolescents should be given the opportunity to talk to their nurse/doctor alone to discuss asthma management.8
The BTS/SIGN recommendations also noted that care should be taken with choice of inhaler devices. Despite proven benefit, many adolescents may not like using a pressured meter dose inhaler and spacer because of their inconvenience.8,12,13 Providing more advice and options for inhalers are suggested to be an important factor in improving adherence.8
The updated recommendations in the BTS/SIGN asthma guideline are focused specifically on:
- improving monitoring and control
- new evidence in pharmacological management
- managing this condition in adolescents.
There is good evidence that our current admission levels and degree of control for people with asthma is well below the standards we would hope to achieve. The guideline provides the best summary of the evidence we have on asthma care and is updated regularly. The challenge, however, is not only to be familiar with the guideline but to be able to apply the recommendations when we see our patients, combining the advice with high-quality communication, and shared decision making to improve the quality of life and outcomes for our patients and their families.
- Most cases of asthma can be adequately managed in primary care
- Commissioners should check their local rates for emergency asthma admissions and identify if there are any significant local variations between practices
- The QOF does incentivise good asthma care but the threshold for full payments for annual reviews (Asthma 6) is 70% meaning that many patients with asthma can be missed from review
- There is wide variation in prices between inhaler types and devices and local formularies could be developed to identify ´best-value´ products, which are easy for patients to use effectively
- Respiratory outpatient costs for:a
- adults = £232 (new), £109 (follow up)
- children = £254 (new), £168 (follow up)
- Asthma emergency admission (without complications or intubation):a
- adults = £857 (DZ15F)
- children = £645 (PA12Z).
- The NHS Information Centre, Prescribing and Primary Care Services. Quality and outcomes framework achievement data 2009/2010. The Health and Social Care Information Centre, 2010. Available at: www.ic.nhs.uk/statistics-and-data-collections/supporting-information/audits-and-performance/the-quality-and-outcomes-framework/qof-2009-10/bulletin
- Asthma UK. The asthma divide: inequalities in emergency care for people with asthma in England. Asthma UK, 2007.
- Department of Health. The NHS quality, innovation, productivity, and prevention challenge: an introduction for clinicians. London: DH, 2010. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113806
- Haahtela T, Tuomisto L, Pietinalho A et al. A 10 year asthma programme in Finland: major change for the better. Thorax 2006; 61 (8): 663–670.
- Bateman E, Boushey H, Bousquet J et al. Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study. Am J Respir Crit Care Med 2004; 170 (8): 836–844.
- Rabe K, Vermeire P, Soriano J, Maier W. Clinical management of asthma in 1999: the Asthma Insights and Reality in Europe (AIRE) study. Eur Respir J; 2000; 16 (5): 802–807.
- Gamble J, Stevenson M, McClean E, Heaney L. The prevalence of nonadherence in difficult asthma. Am J Respir Crit Care Med 2009; 180 (9): 817–822.
- British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 101. Edinburgh: SIGN, 2011. Available at: www.sign.ac.uk/guidelines/fulltext/101/index.html or www.brit-thoracic.org.uk/Clinical-Information/Asthma/Asthma-Guidelines.aspx
- Pearson M, Bucknall C, editors. Managing clinical outcome in asthma: a patient-focused approach. London: RCP, 1999.
- Medicines and Healthcare products Regulatory Agency website. Long-acting β2-agonists: reminder for use in children and adults. www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON093845
- Yeatts K, Davis K, Sotir M et al. Who gets diagnosed with asthma? Frequent wheeze among adolescents with and without a diagnosis of asthma. Pediatrics 2003; 111 (5 Pt 1): 1046–1054.
- Brennan V, Osman L, Graham H et al. True device compliance: the need to consider both competence and contrivance. Respir Med 2005; 99 (1): 97–102.
- Edgecombe K, Latter S, Peters S, Roberts G. Health experiences of adolescents with uncontrolled severe asthma. Arch Dis Child 2010; 95 (12): 985–991. G