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As major revisions to asthma guidance and QOF negotiations loom, Dr Kevin Gruffydd Jones looks forward to five key issues that will need to be addressed

As major revisions to asthma guidance and QOF negotiations loom, Dr Kevin Gruffydd Jones looks forward to five key issues that will need to be addressed

When the British Thoracic Society and the Scottish Intercollegiate Guidelines Network revise their guidance, and GP negotiators and NHS employers sit down to negotiate the QOF, clinical developments in asthma mean that some change is inevitable. Exactly what the changes are remains uncertain for now, but these are the five burning questions that need to be addressed.

1 Review of patients with asthma

Many QOF targets reward process, such as recording that a procedure like lung function reversibility in making a diagnosis of asthma has been carried out. There is a move to give increased prominence to measures of outcome (in this case a measure of asthma control) using the Royal College of Physicians' ‘three questions'.

In the last week/month

• Have you had difficulty sleeping because of your asthma symptoms (including cough)?

• Have you had your usual asthma symptoms during the day – cough, wheeze, chest tightness or breathlessness? (Asking about use of reliever medication may help to quantify this.)

• Has your asthma interfered with your usual activities, for example housework, work or school?

Many patients do not attend for asthma review. The QOF unsatisfactorily acknow-ledges this by allowing maximum payment if 70% of patients attend for review. However, many patients with high asthma morbidity are among the non-attenders. Telephone review of patients with asthma, using the RCP three questions identify those who need to be seen in person, has been shown to increase the number of patients who can be reviewed, with no reduction in asthma control and at less overall cost to the practice. An innovative method of carrying out asthma review using mobile phone technology is currently being researched.

In practice

• Use the RCP three questions as part of regular asthma review

• Consider use of the telephone to improve review rate (not at present recognised under QOF)

2 Asthma and rhinitis

There is a strong link between the presence of asthma symptoms and symptoms of allergic rhinitis. Up to 80% of patients with asthma report symptoms of allergic rhinitis and up to 50% with allergic rhinitis exhibit symptoms of asthma. Children with allergic rhinitis are three times more likely to develop asthma than children without allergic rhinitis. Unsurprisingly the pathological mechanisms underlying the pathogenesis of atopic (allergic) asthma and allergic rhinitis – an IgE mediated response – are similar.

There is also evidence from retrospective analysis of the UK General Practice Database that asthmatic children with co-existent allergic rhinitis are more likely to be hospitalised for asthma than those without rhinitis.

These observations have led to the concept of the ‘one airway hypothesis', where treatment of the upper airway affects the lower airway and vice versa. So what does the evidence show us?

Unfortunately while intranasal steroids and oral antihistamines undoubtedly have positive effects on treating allergic rhinitis, the effects of these therapies on asthma symptoms is less convincing.

The oral leukotriene antagonist (LTRA) montelukast has been shown to improve allergic rhinitis symptoms and asthma symptoms, but there is little evidence from prospective randomised controlled trials comparing the use of LTRAs with alternative treatment strategies for patients with co-existing rhinitis and asthma.

In practice

• Ask about symptoms of allergic rhinitis in patients with asthma

• Consider treatment of the upper and lower airway , but bear in mind the cumulative load of using intranasal and intrapulmonary inhaled steroids. Steroids such as mometasone and ciclesonide, with fewer systemic side-effects, may be more useful in this context.

3 Asthma action plans

A Cochrane review of written asthma action plans in 2002 showed that their use leads to an improvement in symptoms and reduction in hospital admissions for asthma. However, there is still low use (4% to 24% of patients with plans depending on the survey) of such plans in practice. While the evidence for their use is strongest in patients suffering exacerbations of asthma, all patients will need advice about what to do when their asthma starts to go out of control. Standardised asthma action plans are available from Asthma UK (, but it is important to tailor the simplicity (or complexity) of the plan to the individual patient.

The essential ingredients of the action plan are as follows.

• The patient should be asked to write down what it's like to be well and what the usual medication and dosage should be. A simple definition of ‘being well' is to use answers to the RCP questions – no night-time symptoms , no daytime symptoms, no restrictions in activities.

• The patient should be able to recognise when they are becoming unwell and note adjustments in dosage. Again it is useful to tell them to use the RCP questions as a guide and adjust medication if they get night or daytime symptoms or their asthma starts to restrict activities.

• They need to recognise when they should call for help and how to do this.This may include advice that if they are using their reliever more than every two hours or have difficulty talking in sentences then they should call (or ask someone else to call) a given telephone number or urgent ambulance help.

In practice

• Ensure all patients with asthma have a personalised action plan

4 Single maintenance and reliever therapy (SMART)

A major development in asthma treatment is the use of one inhaler, in the form of a combination of formoterol and budesonide for the relief of asthma symptoms as well as regular preventive therapy. Patients no longer have to use separate short-acting ß-2 agonist relievers.

This approach is licensed for adults (18 and over)with moderate persistent asthma (roughtly equivalent to Step 3 of the BTS/SIGN Asthma Guidelines)

The theory behind this approach is that for most people with moderate persistent asthma. Their condition can be well controlled by a relatively low maintenance dose of a combination of 200µg budesonide and 6µg formoterol twice daily. When a patient's asthma symptoms worsen, up to an extra 10 puffs per day of the combination can be given to suppress the worsening inflammation and prevent a severe attack. In addition the formoterol element of the combination starts to work within two to three minutes as a bronchodilator (the same as salbutamol) and therefore provides rapid relief of symptoms.

There is now evidence from clinical trials on over 14,000 patients that this approach reduces the number of severe asthma exacerbations compared with traditional fixed-dose maintenance with the combination of an inhaled steroid and long-acting ß2-agonist therapy and short-acting ß2-agonist relief therapy.

Fears have been expressed that this approach will lead to an overuse of combination therapy, but the evidence shows that on average patients use just over half an extra inhalation per day.

The advantages of this approach are that, in addition to reducing the number of exacerbations of asthma the simplified approach of using just one inhaler for treating asthma will improve compliance.

A further development of the SMART approach is a recent study1, published in the New England Journal of Medicine, showing that ,in patients with mild intermittent asthma (Step 2 in BTS/SIGN Guidelines) intermittent high-dose combination beclometasone and salbutamol therapy given only at times of worsening asthma control, produced better outcome measures than using a low dose of the combination or inhaled steroid on a regular basis. This approach needs further investigation before it can be recommended in practice.

In practice

• Consider using SMART with budesonide/formoterol combination in adults at step 3 of the BTS/SIGN Guidelines.

5 Inhaled steroids

The discontinuation of CFC-containing beclometasone as Becotide has put increased pressure on prescribers to use CFC-free preparations when prescribing beclometasone as a metered-dose inhaler. There are currently two available CFC-free preparations, which should be prescribed by brand. Clenil Modulite is licensed for adults and children and has dose-equivalence with CFC-containing beclometasone metered dose inhalers. QVAR is licensed for adults with asthma and is active at half the dose of CFC-containing preparations (200µg CFC-containing beclometasone is equivalent to 100µg QVAR.)

Newer inhaled steroids have recently been developed that can be given once a day and have fewer systemic side-effects. Mometasone is licensed for adults in a dry-powder inhaler but is relatively expensive . Ciclesonide is an inhaled prodrug, activated in the lungs and rapidly metabolised in the blood, minimising local and systemic side-effects. It is licensed for use as a metered dose inhaler in adults and children 12 and over.

Omalizumab is a novel Anti IgE agent licensed for use in patients with severe asthma associated with high IgE levels (severe atopic asthma). It has been shown to improve symptoms and reduce exacerbations in suitable patients. It is expensive and should only be prescribed in secondary care.

In practice

• When switching from CFC-containing to CFC-free preparations of beclometasone prescribe by brand name to prevent dose-confusion.

• Consider ciclesonide or mometasone for patients with side-effects or concerns about side-effects of inhaled steroids.

• Consider referral of patients with severe atopic asthma (uncontrolled by high-dose inhaled steroids and add-on therapy and with high IgE levels) for treatment with omalizumab.

Kevin Gruffydd-Jones is a GP in Box, Wiltshire, and education lead for the General Practice Airways Group

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