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Asthma care U-turn as GPs told to step up steroid dose

GPs have been told to reverse their approach to asthma management and cut dramatically the initial dose of inhaled steroid they prescribe, in an overhaul of the national

asthma guidelines.

Experts from the British Thoracic Society last week made a dramatic U-turn on previous advice that GPs should prescribe a high initial dose of steroids and step it down once control is achieved.

Under the new step-up

approach, the evidence-based guidelines recommend patients start on a dosage appropriate to the severity of the asthma ­ as low as 200µg/day.

The new guidelines also recommended GPs consider giving other treatments such as long-acting ?-2 agonists, leukotriene receptor antagonists or theophyllines, before increasing the steroid dose.

Dr David Bellamy, a GP in Bournemouth and a member of the group that revised the BTS guidelines, said there was a tendency to increase the steroid dose without considering other options.

He said: 'In the past after initial treatment with steroids there was more of a push to up the dose to between 800 and 1,500.

'We now believe upping the dose beyond 800µg/day can cause an increase in side-

effects without any real good therapeutic response.'

The new guidelines, published last week in Thorax, encourage GPs to offer self-management plans to help patients take control of their condition. All practices should have a register of asthma patients, who should be regularly reviewed by a trained asthma nurse.

East Kilbride GP Dr John Haughney, chair of the guidelines diagnosis and natural history review group, said GPs had a poor record in providing asthma self-management plans to patients.

He said: 'There is currently a poor take-up rate because they are time-consuming to put together. These guidelines remind clinicians of how useful they are.'

The guidelines, which were produced jointly by the BTS and the Scottish Intercollegiate Guidelines Network, also said breast-feeding by asthmatic mothers could have a preventive effect on wheezing in early life.

New BTS/SIGN national asthma guidelines

l Set up register of all asthmatic patients

l Increase use of self-management plans

l Encourage smoking cessation strategies and breast-feeding in asthmatic mothers

l Confirm diagnosis with peak flow measurements

Step 1 Inhaled short-acting ?-2 agonist as required.

Step 2 Add inhaled steroid 200-800µg/day in adults and 200-400µg/day

in children (or other preventer drug if inhaled steroid cannot

be used).

Step 3 Add inhaled long-acting ?-2 agonist in adults and school children. Increase steroid dose if control is still inadequate and consider a trial of another add-on therapy such as a leukotriene receptor antagonist (LTRA) or a theophylline. In under-fives, consider adding an LTRA or refer to a respiratory paediatrician.

Step 4 Consider increasing inhaled steroid dose up to 2000µg/day in adults and 800µg/day in school children. Adding a LTRA/theophylline/?-2 agonist tablet in adults may confer some benefit.

Step 5 Add daily steroid tablet in lowest dose and maintain inhaled steroids of 2000µg/day in adults and 800µg/day in school children. Consider treatments to minimise use of steroid tablets and refer patient for specialist care.

Source: Thorax (February)

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