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respiratory medicine

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Dr Dermot Ryan outlines five papers that have caught his eye

How many patients with asthma also have rhinitis?

The paper: Walker S, Sheikh A. Self-reported rhinitis is a significant problem for patients with asthma. Primary Care Respiratory Journal 2005 14,83-7

Method: This study was carried out in 239 practices in the UK from which 10,000 patients with asthma were identified and asked to complete a questionnaire. Some 7,129 patients responded.

Results: 76 per cent of respondents reported symptoms of rhinitis (blocked or runny nose, sneezing, itchy eyes/ears/palate) in the absence of a cold. Of these 50 per cent reported that their rhinitis made their asthma worse, 58 per cent reported seasonal rhinitis with the others reporting perennial symptoms.

Some 2 per cent were taking a non-sedating antihistamine and 13 per cent a sedating antihistamine, 54 per cent were taking a nasal spray and 16 per cent reported receiving their treatment from a pharmacist.

Conclusion: Rhinitis has been demonstrated to have a significant effect on asthma control leading to poorer control and more frequent and severe exacerbations. This study demonstrates that the size of the problem has been underestimated. Previously it has been shown that topical nasal steroids appears to improve bronchial hyper-reactivity and yet in this study only 54 per cent of respondents were treated in this manner.

The authors' conclusions, in line with the ARIA guidelines, are that all patients with asthma should be questioned about rhinitis symptoms and that on identification, treatment is given.

What I am going to do now: Ask all asthma patients about rhinitis symptoms (nose running or blocking, itching or sneezing) and treat accordingly.

How well are GPs managing rhinitis?

The paper: Dermot Ryan et al. Management of allergic rhinitis in UK primary care: Baseline audit. PCRJ 2005.14,204-209. doi:10.1016/j.pcrj.2005.03.009

Method: This study looked at the performance of a group of GPs with a professed interest in the management of rhinitis in the UK. The criteria against which they were assessed were formulated from the then current international consensus guidelines for the management of rhinitis; 188 GPs from 70 practices across the UK were interviewed to assess their knowledge and views concerning allergic rhinitis.

Results: A disappointing 14 per cent satisfied all the criteria for identification of symptoms; only 25 per cent collected further information to support a clinical diagnosis whereas no one achieved all the criteria for examination and investigations. Only one interviewee satisfied the criteria for adequate treatment.

Conclusion: There does appear to be a lack of structure in the approach to diagnosis and management of this very common disease, which causes a lot of unrecognised suffering. One of the drawbacks of the study is that the criteria against which GPs were assessed were drawn from a guideline formulated by secondary and tertiary care practitioners so that some of the criteria were not pertinent to primary care.

What I am going to do now: As I too am a GP with a professed interest in the management of rhinitis I will be making sure I'm even more familiar with the guidelines which can be downloaded from

Should GPs prescribe as-needed steroids for mild persistent asthma?

The paper: Boushey HA et al. National Heart, Lung and Blood Institute's Asthma Clinical

Research Network. Daily versus as-needed

corticosteroids for mild persistent asthma. New England Journal of Medicine. 352(15):1519-28, 2005 Apr 14

Method: Patients with mild asthma (by American standards) were randomised to one of three parallel treatment groups: twice-daily oral placebo and inhalation of 200µg of budesonide, twice-daily oral zafirlukast (20mg) and inhalation of placebo, or twice-daily oral and inhaled placebo.

They were instructed to take a high dose of budesonide or oral steroids if they had a set of predefined symptoms. This was written down for them. The primary outcome measure was morning PEFR.

Results: The outcome was the same in all groups but secondary parameters improved in the group receiving once-daily budesonide. The similar outcomes meant that these highly symptomatic patients with asthma who were waking more than two nights per month; using short-acting ?2-

agonists more than twice per week and who had peak flow variability of 20-30 per cent would continue to be highly symptomatic if this plan were to be adopted.

Conclusion: It may be possible to treat mild persistent asthma with short, intermittent courses of inhaled or oral corticosteroids taken when symptoms worsen.

What I am going to do now. In short ­ nothing. In my opinion the conclusion reached is faulty because with appropriate treatment these patients should expect to become symptom free with no night wakings and

little or no need for rescue medication,

normalisation of lung function and no restriction on activities in keeping with the goals of national and international guidelines.

This trial was much reported in the GP press but the conclusions drawn are at best misleading and at worst dangerous. It is important to note that this research was carried out in the US where asthma care is inferior as evidenced by a steady year-on-year increase in asthma morbidity and mortality and characterised by an aversion to the use of inhaled steroids.

Further studies are required to determine whether this novel approach to treatment should be recommended.

Do mucolytics still benefit COPD patients after three years?

Paper: Decramer M et al. Effects of N-acetylcysteine on outcomes in chronic obstructive pulmonary

disease: A randomised placebo-controlled trial. Lancet 2005; 365:1552-60

Method: This multinational study carried out over three years in 10 different European countries compared the effects of adding

N-acetylcysteine (not licensed for use in the UK) 600mg daily versus placebo to existing treatment.

Results: Outcomes measured showed equivalence between NAC and placebo for exacerbation rates and annual decline in FEV1 and improvement in health status. Sub-group analysis did demonstrate a reduction in exacerbations in those patients who were not on inhaled steroids in the order of 33 per cent.

Conclusion: No advantage for patients after three years compared with placebo unless patients were not on inhaled steroids

What I am going to do now: Meta-analyses of the use of mucolytic agents have demonstrated a reduction in exacerbation in patients suffering from COPD, but most studies performed to date have been for periods of one year or less. There is little doubt that they are beneficial to many patients, but do they need to be on them long-term or should they only be prescribed seasonally? More work is needed to guide optimal utilisation of this class of drugs.

Should budesonide/ formoterol combination therapy be used as both maintenance and reliever medication?

The paper: O'Byrne PM et al. Budesonide/

formoterol combination therapy as both maintenance and reliever medication in asthma. American Journal of Respiratory & Critical Care Medicine. 171(2):129-36, 2005 Jan 15

Method: This was a very large (n=2760) year-long, double-blind, randomised, parallel, multicentre study in subjects aged four to 80 with FEV1 of 60-100 per cent demonstrating poor asthma control.

Patients were randomised to one of three arms: Budesonide/ formoterol 80/4.5 twice-daily with budeson-ide/formoterol 80/4.5 as reliever medication, budesonide/formoterol 80/4.5 twice-daily with terbutaline 400µg as needed for reliever medication, or budesonide 320µg bd with terbutaline 400µg as needed for reliever medication.

Children were given half these doses once daily.

Results: The primary outcome measure was severe exacerbations. There was approximately 47-50 per cent reduction in severe exacerbations requiring medical attention in the budesonide/formoterol 80/4.5 twice-

daily with budesonide/formoterol 80/4.5 as reliever medication group compared with the other two groups.

There was also a statistically and clinically significant reduction in this group in time to first exacerbation, interval between exacerbations (in those subjects who had more than one exacerbation).

In terms of secondary outcome measures all groups demonstrated a reduction in asthma symptom scores, inhaled rescue medication, reduced night awakenings and an increase in asthma symptom-free days.

This improvement was greater for budesonide/ formoterol 80/4.5 twice-daily with budesonide/formoterol 80/4.5 as reliever medication group compared with the other groups.

Conclusion: By using one inhaler only, ie budesonide/formoterol, a significant improvement in asthma control can be achieved.

What I am going to do now: The answer is to consider this evidence and see whether it fits in with a common-sense approach to the self-management of asthma. We already know that patients increase and decrease their medication in an unstructured fashion, does work like this help to legitimise this approach?

I s

Dermot Ryan is a GP in Loughborough and a member of the 2003 BTS SIGN asthma guidelines committee; he is part-time General Practice Airways Group clinical research fellow at the University of Aberdeen ­ he sits on the BASCI rhinitis guidelines committee and International Airways Rhinitis guidelines group

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