Around 200,000 people in the UK have the severest form of asthma, and last month, data showed that deaths from the condition are at their highest for a decade. Additionally, Pulse reported that asthma-related GP appointments triple over the back-to-school period.
Not responding to standard medication, the most severe strand leaves patients prone to frequent exacerbations and A&E admissions. Often, the only hope for many is referral to secondary or tertiary care for assessment for biologic therapies, but new research from Asthma UK shows that only one in five people at risk of having severe asthma are being referred.
GP practices play a vital role in tackling this issue, but we are hamstrung by unclear guidance on when to refer patients with suspected severe asthma. There are no specific NICE guidelines on severe asthma, and the ones which do exist from them, NICE, the National Review of Asthma Deaths, the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) conflict on when patients should be referred*.
What is actually happening, according to the charity’s report ‘Living in limbo: the scale of unmet need in difficult and severe asthma’ is that four in five people with suspected difficult or severe asthma who should have been referred under BTS guidelines aren’t actually being referred**.
Tens of thousands of patients aren’t getting a diagnosis and may be dependent on long term high-dose oral steroids, which can lead to debilitating side effects, from weight gain to osteoporosis and diabetes.
Further to this, they could be missing out on lifechanging biologic treatments, such as monoclonal antibodies (mAbs), which have been proven to transform lives.
In July, NICE committed to work with BTS and SIGN to provide joint guidelines on asthma, including severe asthma. While this is promising, Asthma UK says it will also need to be efficiently implemented.
In the meantime, what can we GPs do to ensure severe asthma patients are getting the help they need from secondary care?
Firstly, we need to avoid being complacent about the benefits of secondary care for this group.
Until recently, referral to an asthma clinic would often have led to the same treatment we could provide – oral steroids – but there are now more tests and assessments available from multidisciplinary teams in secondary care that we in primary care can’t access, as well as treatments like mAbs.
To feel more confident about referring patients, we need to educate ourselves on what severe asthma is.
Signs that your patient might have severe asthma include: they have had more than two courses of oral steroids in the last year, or have persistent poor control of asthma symptoms with short-acting beta-agonists use three or more times per week, despite specialist level therapies.
You can also use your IT systems to identify patients who appear to be overusing their reliever medications, or who have been prescribed two or more courses of oral steroids in a year. Annual asthma reviews are another opportunity to identify patients with suspected severe asthma and refer them for specialist assessment.
Early referral of those with suspected severe asthma could reduce the burden on GP practices and prevent wasted medicines. If patients get a severe asthma diagnosis and access to better treatments, they will no longer need frequent unscheduled appointments, freeing up our time to see other patients.
It also means they may be able to reduce the burden of conventional asthma medicines, or no longer experience the severe side-effects associated with frequent or long-term oral steroids.
We need to see new guidelines, but let’s also work together to educate ourselves on severe asthma and make a real difference to the lives of patients with suspected severe asthma.
Dr Andy Whittamore is clinical lead at Asthma UK and a GP in Portsmouth
*BTS/SIGN says the patient should be referred if they have: high dose ICS use and/ or continuous or frequent oral steroid use, and/or symptoms of acute severe or life-threatening asthma and/or signs of occupational asthma, while the NRAD says patients should be referred if they have: more than 2 courses of oral or injected corticosteroids in the previous 12 months.
** Living in limbo, the scale of unmet need in difficult and severe asthma. New analysis found that 82% or 127,000, prescribed high dose inhaled corticosteroids were referred to secondary care. This data is via the Clinical Practice Research Datalink (CPRD), and looked at referral rates in England in 2016