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Casebook: Complex asthma presentations

Dr Andrew Whittamore discusses how to optimise control in challenging asthma presentations

Key points

  • Any patient requesting more than one reliever inhaler a month, or more than six in a year, should undergo a review for poor asthma control
  • The review may require objective testing to confirm asthma diagnosis and detailed history and examination to explore triggers or comorbidities that may need addressing
  • Specialist input may be required to distinguish between difficult and severe asthma and treat appropriately 
  • Select suitable patients carefully when switching inhalers to reduce the environmental impact of treatment
  • Emphasise the value of good disease control in limiting the environmental impact of an inhaler with a larger carbon footprint
  • Late-onset asthma requires careful investigation to rule out differential diagnoses and tailor treatment appropriately
  • MART can help improve asthma control and reduce environmental impact of treatment, but requires careful explanation and follow-up

Case 1   
You notice that one of your patients, a 45-year-old female with asthma, has received 12 salbutamol inhalers over the past year. As this is a sign of poor asthma control you arrange a call to assess her and ascertain whether she might have difficult or severe asthma.

What is ‘difficult asthma’ and what is ‘severe asthma’?
Asthma is considered poorly controlled if the patient is experiencing symptoms three or more times per week, or any night-time symptoms. 

Any patient requesting more than one reliever inhaler per month, or more than six reliever inhalers per year, should undergo assessment of their asthma. Remember that a person with well controlled asthma will require up to three doses of two puffs of their reliever inhaler per week. On that basis, a 200-actuation reliever inhaler will last 33 weeks – so they will need no more than two inhalers in a year. 

Every asthma attack or exacerbation is also a sign of poor disease control and should prompt an urgent assessment.

The term ‘difficult asthma’ describes confirmed asthma with persistent asthma-like symptoms and exacerbations despite prescription of high-dose asthma therapy.1 

Meanwhile ‘severe asthma’ describes confirmed asthma with any comorbidities addressed, which ‘requires treatment with high-dose inhaled steroids plus a second controller (or systemic steroids) to prevent it from becoming “uncontrolled” or which remains “uncontrolled” despite this therapy’.2 NICE provides guidance as to the treatments that are considered high dose.3

Poor asthma control has a significant impact on people’s lives, education and employment. The burden of oral steroids and high-dose inhaled steroids is significant for each patient.4

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Dr Andrew Whittamore is a GPSI in respiratory medicine in Hampshire and clinical lead at Asthma UK