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Asthma Management: The Goal Is Control

This report is based on medical evidence presented at sanctioned medical congress, from peer reviewed literature or opinion provided by a qualified healthcare practitioner. The consumption of the information contained within this report is intended for qualified Canadian healthcare practitioners only.

PRIORITY PRESS - Family Medicine Forum 2011

Montréal, Quebec / November 3-5, 2011

Chief Medical Editor: Dr. Léna Coïc, Montréal, Quebec

Despite great advances in therapy, asthma produces considerable morbidity and economic and social costs. Although mortality has been substantially reduced, about 80% of asthma-related deaths (of the approximately 300/year in Canada) are preventable. Most deaths are not the result of severe disease but of poorly controlled milder asthma, observed Dr. Anthony D’Urzo, Associate Professor, Department of Family and Clinical Medicine, University of Toronto, Ontario.

A first step in appropriate respiratory disease management is to ensure the correct diagnosis, stressed family physician Dr. Alan Kaplan, Clinical Lecturer, University of Toronto. Spirometry is an often neglected tool that can help differentiate asthma and chronic obstructive pulmonary disease (COPD), establish disability and guide management. In patients in whom spirometry is equivocal but asthma is still suspected, a methacholine challenge can be useful. In both asthma and COPD, earlier detection and initiation of management can help prevent lung function decline.

Poor Control Common

A “disconnect” exists between patients’ perceptions of asthma control and the clinical reality. This is problematic, Dr. D’Urzo indicated, “because we often rely on what our patients tell us with respect to control [and] it may not be a true reflection of what’s going on... We have to make certain that we probe patients in terms of understanding what the asthma control level actually is... Our patients may not be aware of what good or acceptable or reasonable control is.”

In the EUCAN AIM survey of 2400 Canadian and European patients (www.takingaimatasthma.ca), 93% of patients reported their asthma was well controlled. However, 39% had experienced a severe episode in the last 12 months; more than half (52%) had required medical attention; 45% had seen a doctor for worsening symptoms; 28% had required emergency or hospital care; and 5% had spent a night in the hospital due to asthma. Furthermore, significant numbers of patients reported asthma-related limitations in sleep (42%) or daily physical or social activities (48% and 37%, respectively); more than 20% had missed work or school. Another indicator of widespread poor control is that EUCAN AIM respondents used 6 rescue inhalers per year, on average. “That’s 1200 inhalations over the year... about 3 inhalations a day, far more than they should be using,” Dr. D’Urzo remarked.

Poor compliance, especially with maintenance medication, is a principal reason for poor control. “If patients are not taking their medications properly and regularly, it makes it very difficult if not impossible to achieve the level of control we want,” Dr. D’Urzo emphasized. About 1 in 3 patients does not fill a prescription for an inhaled corticosteroid (ICS) and about 1 in 5 fails to use the medication. Many do not want to take maintenance medication, especially when they feel well. They prefer and erroneously believe it is acceptable to use quick-relief medications when symptoms arise, even if they occur daily. Some patients cite the expense of extra medication as a reason for poor adherence. “In the end, discontinuation often leads to a decline in asthma control,” Dr. D’Urzo affirmed.

Even among patients who do use medication regularly, poor inhaler technique is very common, leading to not only poor control but also side effects, such as thrush due to posterior pharynx deposition, and increased drug costs due to wasted medication. Any patient with poor control should be asked to show how they use their inhaler, noted family physician Dr. Christopher Fotti, East St. Paul, Manitoba, who previously worked as a respiratory therapist. He added that physicians should be able to demonstrate inhaler techniques to their patients, given that asthma educators may not always be accessible.

Current Control and Future Risk

Patients lack awareness of the pathology underlying asthma, especially the continuous nature of inflammation and its long-term negative impact on lung function. It is appropriate to stress to patients that poor control and asthma exacerbations heighten the risk of future problems, Dr. D’Urzo remarked. On the other hand, treatment adherence can prevent deterioration of lung function. Patients should be reminded that lung remodelling related to inflammation can occur even in the absence of symptoms. “If their symptoms are under control at the present time, then it’s like an investment. They’re investing in reducing the risk of an exacerbation, the need for acute care, the need for oral steroids and permanent reduction in lung function, as well as mortality...You can talk to them about how inhaled steroids are potent anti-inflammatory medications and help them understand it’s like buying insurance.”

Options for Management

Current Canadian guidelines for asthma management (Can Respir J 2010;17:15-24) recommend ICS as first-line maintenance therapy. Patients who are concerned about consuming steroids can be reassured that the doses used in asthma therapies are low enough to be described as homeopathic, Dr. D’Urzo stated. Asthma therapy should be personalized for each patient, he added. “If they don’t buy into it, they are not going to use it.”

In adult patients and children over age 12 whose asthma is inadequately controlled with first-line ICS monotherapy, adding a long-acting bronchodilator (LABA) can lead to further improvement in asthma symptoms and lung function and reduce exacerbations. This step may be more effective and better tolerated than increasing the dose of ICS, Dr. D’Urzo commented. In addition, he noted, “the efficacy of the combination is superior to that of the components given individually.” Some data support starting asthma therapy with a combination inhaler rather than ICS alone, remarked Dr. Fotti; deciding whether to do so requires balancing the likelihood of better efficacy with increased costs and the potential for overtreatment or increased side effects.

Several single-inhaler products combining an ICS and a LABA are now available; they have similar efficacy, Dr. D’Urzo said. These include fluticasone/salmeterol in a dry powder or inhaled aerosol formulation and budesonide/formoterol in a dry powder formulation. The newest combination in the treatment of asthma in Canada is mometasone/formoterol. Mometasone is a potent steroid that is highly protein-bound and has low bioavailability, which reduces systemic exposure, Dr. D’Urzo observed.

Summary

Whether asthma is controlled is now considered more relevant than its severity, speakers agreed here. Complete absence of symptoms may not be achievable in all patients with asthma but good control is possible in the majority, Dr. D’Urzo emphasized. Meeting this goal requires regular assessment of symptoms and medications as well as ongoing and comprehensive patient education about the desirability and the characteristics of controlled asthma, Dr. Fotti stressed.

Providing a written plan for management of asthma or COPD helps patients monitor their disease, control their symptoms in various scenarios, and understand when to seek medical care. They have also been shown to lead to better overall treatment compliance, Dr. Kaplan indicated. However, only about 20% of patients currently receive a written action plan from their physicians. (Templates can be downloaded from several sites, including The Lung Association and the Canadian Thoracic Society: http://www.respiratoryguidelines.ca/sites/all/files/COPD-actionplan_1.pdf)

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