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Updated asthma guideline will improve outcomes

How should asthma be diagnosed?

What is the role of long-acting beta agonists?

How can difficult asthma be managed?

How should asthma be diagnosed?

What is the role of long-acting beta agonists?

How can difficult asthma be managed?

An estimated 1.1 million children and 4.1 million adults in the UK are currently receiving treatment for asthma, and eight million have been diagnosed with asthma at some stage in their lives. The estimated prevalence for asthma in children ranges from 12.5% to 15.5% in the UK and in adults in England it has been reported as 7.8%. In 2004, the Global Initiative on Asthma (GINA) reported that Scotland had the highest rate of self-reported wheezing in the previous 12 months among 13- to 14-year-olds in the world, at more than 30%, while the overall prevalence of asthma in Scotland was 18.4%.1

Across the UK, GPs see more than 20,000 new cases each week. In 2002 there were more than 4.1 million GP consultations for asthma and 6% of these patients had had emergency treatment in the previous month. Mortality remains significant, with 1,400 deaths annually in the UK. This equates to one death every seven hours.

The updated British Guideline on the Management of Asthma was recently published in Thorax.2 It was developed by the BTS and SIGN using a rigorous evidence-based methodology with input from practising healthcare professionals.

The guideline has been substantially revised since the last printed version in 2003 and has considered literature published up to March 2007.

Diagnosis

The diagnosis of asthma is clinical and there is still no gold standard definition. However, the presence of symptoms (more than one of wheeze, breathlessness, chest tightness and cough) and variable airflow obstruction are central to diagnosis.

The key is to take a careful history, measure lung function and review the probability of a diagnosis of asthma.

The guideline advises using spirometry, rather than peak flow, as the preferred measure of lung function. This is because spirometry allows clear identification of airflow obstruction and the results are less dependent on effort. It should now be the test of choice where available. However, some training is required to obtain reliable recordings and interpret the results.

It is important to remember that a normal FEV1 or peak flow obtained when the patient is not symptomatic does not exclude the diagnosis of asthma (see figure 1, attached).

Patients with a high probability of asthma, based on history and spirometry, should begin treatment.

If there is a good response the diagnosis is confirmed but if not further investigation or specialist referral may be necessary.

Patients with a low probability of asthma should be investigated and treated for other, more likely, conditions such as COPD and bronchiectasis in adults.

Patients with an intermediate probability of asthma require further investigation:

• Patients with airflow obstruction should have lung function (FEV1 or peak flow) assessed:

– Before and 20 minutes after 400µg inhaled salbutamol

or

– Six to eight weeks after starting an inhaled corticosteroid (beclometasone 200µg twice a day or equivalent)

or

– After a two-week course of oral prednisolone (30mg daily for 14 days)

• Patients who repeatedly have no evidence of airflow obstruction should be considered for tests of airway hyperresponsiveness and/or airway inflammation. The tests are sensitive, so normal results are strong evidence against a diagnosis of asthma.

41205387Tests of airway hyperresponsiveness have been used in research but are not widely available in clinical practice. However, this is likely to change, particularly with the introduction of a simple indirect challenge test using mannitol, see box 1, left.3

Airway inflammation can now be assessed non-invasively by measuring exhaled nitric oxide (FENO). A raised FENO concentration (>25ppb at 50ml/s) is seen in 70-80% of patients with untreated asthma. However, this is not specific to asthma and 30-40% of patients with a chronic cough or COPD will also have abnormal results. There is increasing evidence that such measures of airway inflammation are more closely linked to a positive response to inhaled corticosteroid therapy than other measures.4

This new guidance to confirm the diagnosis of asthma in patients with repeatedly normal lung function should lead to increasing availability of bronchial challenge testing and measurement of FENO in district general hospitals.

Management

The aim of asthma management should be good control, defined as:
• No daytime symptoms
• No night-time waking due to asthma
• No need for rescue medication
• No exacerbations
• No limitations on activity, including exercise
• Normal lung function (FEV1 and/or peak flow >80% predicted or best).

Figure 2, attached, summarises stepwise management in adults.

Step 2

The 2008 guideline recommends a lower threshold for starting inhaled steroids than previous versions.

Inhaled steroids should now be considered for patients:
• Who have had exacerbations of asthma in the past two years
• Using inhaled beta agonists at least three times a week
• Who are symptomatic at least three times a week
• Waking one night a week.

The suggested starting daily dose of inhaled steroid is 400µg beclometasone or equivalent for an adult and 200µg for a child.

Step 3

Add-on therapy with an inhaled long-acting beta agonist (LABA) has been shown to be the most effective option for adults and children aged 5-12 inadequately controlled at step 2.5

The MHRA has recently completed a full review of the risks and benefits of LABAs in the management of both asthma and COPD and concluded that an inhaled LABA should only be started in patients who are already receiving an inhaled steroid.

If asthma control remains suboptimal after the addition of an inhaled LABA, the LABA should be stopped and the dose of inhaled steroid increased to 800µg beclometasone or equivalent per day in adults and 400µg per day in children aged 5-12.

In practice, most patients at step 3 are prescribed a combination inhaler containing an inhaled steroid and a LABA. For adult patients at step 3 who are poorly controlled, recent studies have suggested that using a budesonide/ formoterol combination inhaler as rescue medication instead of a short-acting beta agonist, in addition to its regular use as a maintenance therapy, can be an effective treatment option. This management technique has not been investigated with other combination inhalers and while there is clear evidence in studies of improved control and reduced use of healthcare services with this technique, it is still unclear which patients will gain the most benefit. Before starting this form of management careful patient education is required.6,7

Difficult asthma

The 2008 guideline update includes a new section on difficult asthma, where asthma-like symptoms and exacerbations persist in a patient diagnosed with asthma despite the prescription of high-dose therapy.

These patients should be assessed systematically to confirm or refute the diagnosis and identify the mechanism of persisting symptoms. Poor compliance with maintenance therapy should always be considered and is often associated with psychological morbidity, such as depression.8

Case control studies have found that mould sensitisation can be associated with recurrent admissions and oral steroid use, and the guideline recommends allergen testing to moulds in these patients.

Difficult asthma makes considerable demands on healthcare services and it is hoped that the guideline will lead to the setting up of local clinics for difficult asthma and focus research in this problem area.

Action plans

There is now considerable evidence that personalised action plans, as part of self-management education, improve outcomes in patients with asthma. The evidence is particularly strong for those managed in secondary care with moderate to severe asthma and patients who have had recent exacerbations requiring admission.9

Inpatients should receive written personalised action plans as part of self-management education, given by a clinician with expertise in asthma management, before discharge from hospital. Plans should include:

• Written, personalised structured education
• Specific advice about recognising loss of asthma control, either through symptoms or peak flow recordings
• Actions, summarised as two or three points, to take if asthma deteriorates. This may include how to seek help in an emergency and commence an oral steroid, as appropriate to clinical severity.

Every asthma consultation is an opportunity to review and reinforce the patient's understanding and skills in self-management.

Concordance

Achieving concordance is likely to improve, although does not guarantee, compliance. Concordance signifies a negotiated agreement between the clinician and the patient; non-concordance that they cannot reach agreement, not merely the failure of the patient to follow the health professional's instructions.

Computerised repeat prescribing systems provide a good indication of adherence with prescribed asthma regimens.

The following tips may help improve concordance:

• Questions such as ‘if we could make one thing better for your asthma what would that be?' may help produce a more patient-centred agenda
• Make it clear you are listening to the patient's concerns and goals
• Reinforce practical information and negotiated treatment plans with written instructions
• Consider reminder strategies
• Record patients who miss appointments.

The updated guideline should continue to serve as a basis for the high quality management of both acute and chronic asthma and as a stimulus for research into areas of management for which there is little evidence. Sections will continue to be updated annually and new reviews on the management of acute asthma, inhaler devices and asthma in pregnancy will be included in 2009.

Copies of the guideline can be downloaded free of charge from the both the BTS and SIGN websites.
British Guideline on the Management of Asthma

Key points Figure 1: Presentation with suspected asthma in adults Figure 2: Summary of stepwise management in adults Author

Dr Graham Douglas
BSc FRCPE
consultant physician, Aberdeen Royal Infirmary and Co-chair, BTS/SIGN Asthma Guideline Development Group

Updated asthma guideline will improve outcomes tab1_asthma

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