How we take ear temperature is in urgent need of a rethink
Dr Mark Levy discusses new advice and ways to persuade patients that the benefits outweigh the risks
It has been estimated that more than half a million extra patients with mild asthma ought to be taking inhaled steroids following changes to the BTS/SIGN asthma guidelines.
The new guidelines include data from published literature up to March 2003 and provide a list of indications for starting inhaled steroids earlier in those patients who are on reliever medication.
The biggest challenge facing GPs in implementing the changed guidance is 'steroid phobia' among patients, particularly if their disease is mild.
Evidence for recommending earlier introduction of inhaled steroids in mild persistent asthma (respiratory symptoms at least once a week) is based on two studies which investigated early introduction of inhaled steroids in people with mild asthma.
Study one: Pauwels et al2. This involved 7,241 patients, aged five to 66, in 32 countries, randomly allocated to regular budesonide or placebo for three years. Budesonide both reduced the chance of having an asthma attack and prolonged the time to the first severe asthma attack/related event.
In addition, patients on budesonide had significantly more symptom-free days during the whole study period than did those on placebo.
Study two: O'Byrne PM et al3. This study lasted one year, during which 1,970 patients over the age of 12 were randomised to treatment with budesonide (two strengths), placebo and addition of formoterol. In patients not treated previously with steroid inhalers, low-dose inhaled budesonide alone reduced severe exacerbations and improved asthma control.
This study also provided evidence for the recommendation in the guidelines that it is preferable to add a long-acting ß2 agonist (like salmeterol or formoterol) rather than increase the dose of inhaled steroid above 400µg or 800µg daily in children or adults respectively.
To tackle 'steroid phobia' in patients with mild asthma we should make every effort to inform them that inhaled steroids:
lreduce the underlying inflammation of asthma
lif used within the recommended dose ranges, seldom cause significant adverse effects.
The data from the studies in this article may help to persuade them that earlier treatment with preventive medication may help prevent attacks and consequent hospitalisation. Furthermore, these newly updated guidelines reassuringly state there is little evidence that inhaled steroid doses below 800µg per day cause any short-term detrimental effects apart from the local side-effects of dysphonia and oral candidiasis.
Health professionals and patients are often worried about the possibility of long-term effects on bone density. The guidelines recommend that clinicians try to prescribe less than 400µg or 800µg per day of beclometasone (or equivalent). In addition they recommend (as before) that health professionals titrate the dose of inhaled steroid to the lowest point at which effective control of asthma is maintained.
The evidence for these recommendations is based on a recent systematic review4 in adults with asthma or mild COPD, on the effect of inhaled steroid versus placebo on markers of bone function and metabolism.
These studies reported no effect on bone density at doses below 1,000µg of beclometasone per day, though the authors did recommend further long-term prospective research.
Should we be targeting those with more severe asthma?
The old argument persists: should we focus on patients at the more severe end of the asthma spectrum or those with mild disease? In my
opinion we should improve our care for both these groups.
Patients who have severe attacks are not necessarily those with more severe, overt disease. Nor are there any clear predictors indicating who is likely to have an attack. However, we have evidence indicating considerable potential benefit for well-treated mild patients.
How do we identify patients in need of more treatment?
When reviewing patients in order to earn points under the new quality framework, it may be helpful to include some questions to establish the effect of asthma on the patient's quality of life. The guidelines suggest the use of the three Royal College of Physicians questions5 together with the relevant Read codes (see below).
These questions may assist clinicians in determining who needs more medication as well as assisting in persuading patients of this need.
By using the Read codes and recording the number of days where asthma limits the patient's activities, valuable audit data becomes available to the practice.
Mark Levy is a GP in Harrow, Middlesex , editor of the General Practice Airways Group and a member of the BTS/SIGN asthma guideline development group
Who needs steroids
Consider inhaled steroids for patients with any of the following
1 An exacerbation of asthma in the last two years, ie:
•Treatment with nebuliser or high-dose bronchodilator
•Out-of-hours visit or attendance for asthma
•A&E attendance for asthma
•Hospital admission for asthma
2 Use of inhaled ß2 agonist bronchodilators three times a week or more
3 Evidence of morbidity or reduced quality of life due to asthma, ie:
•Symptomatic three times a week or more
•Waking one night a week because of asthma
How much do they need?
Start at an appropriate dose for the severity of asthma and titrate down to the lowest effective dose
Adults 400µg beclometasone* per day
Children 200µg beclometasone* per day
* or half this dose in the case of fluticasone or mometasone
Other messages from the new guidelines
l Mometasone, a new inhaled steroid included in this guideline, is placed at equivalent to twice the dose of beclometasone, as is the case with fluticasone
l Long-acting inhaled ß2 agonists should not be used as monotherapy without inhaled steroids
l Check compliance, inhaler technique and eliminate trigger factors before adding on new therapy
l Try adding other therapy before increasing the dose of inhaled steroids above 400µg and 800µg per day for children and adults respectively –
•Long-acting ß2 agonists
•Leukotriene receptor antagonists
•Slow-release ß2 agonist tablets
•Short-acting anticholinergic inhalers (ipratropium)
•Sodium cromoglycate (nedocromil)
l Prescribe long-acting bisphosphonates for patients on long-term oral steroid therapy (www.nos.org.uk)
l Monitor growth in children with asthma
l Provide written self-management plans for all patients with asthma
1 BTS/SIGN. British guidelines on the management of asthma.
Thorax 58[Suppl 1], 1-94. 2003. www.sign.ac.uk/guidelines/fulltext/63/index.html
2 Pauwels RA et al. Early intervention with budesonide in mild persistent asthma: a randomised, double-blind trial. The Lancet 361,
3 O'Byrne PM et al. Low-Dose Inhaled Budesonide and Formoterol in Mild Persistent Asthma. The OPTIMA Randomised Trial. American Journal of Respiratory and Critical Care Medicine 164, 1392-1397. 15-10-2001
4 Jones A. Inhaled steroids and markers of bone metabolism for asthma and chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews Issue 1, 2001.
5 Measuring Clinical Outcome in Asthma: A patient-focused approach. Pearson MG, Bucknall CE, editors. 7-1-1999. Royal College of Physicians, Clinical Effectiveness and Evaluation Unit.