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The way forward in asthma management

Marilyn Eveleigh
BA PGCE RGN SCM RHV NP FWT FRSH
Nurse Adviser in Primary Care and Public Health
Independent Trainer

Since 1990, organised asthma care in general practice has mushroomed, partly fuelled by asthma guidelines, the Chronic Disease Management Programme and the organisational approach of specifically trained asthma nurses. In 1997, of 36,000 GPs in the UK, 25,645 signed up to provide asthma care under this programme.(1) Almost two-thirds of practice nurses have completed diploma-level asthma training and are increasingly delegated a significant responsibility for asthma care to the 3.25 million people with asthma in the UK.
This investment in care has occurred at a time of increasing asthma prevalence and has been associated with a welcome fall in asthma death rates of approximately 25%, along with some concomitant improvements in morbidity. However, the fall in the UK death rate lags substantially behind some countries in northern Europe, and current morbidity surveys show significant room for improvement.(2)

Self-management plans
Many people are living with poorly controlled asthma that seriously disrupts their everyday lives. Much of this suffering is unnecessary. With written self-management plans, users have fewer attacks and emergency admissions and an improved quality of life.(3) Written information indicates what treatment patients should take and when; how to spot whether symptoms are worsening; and what to do in an emergency.
Self-management plans benefit patients, healthcare professionals and the NHS, but they are not widely used at present in the UK, with less than 10% of patients having received them.(4) Where such plans are provided, the majority are verbal, despite the evidence that written plans are more effective.
There is a real need for healthcare professionals to ensure they offer self-management plans to their patients as an integral part of routine asthma care. Where clinicians have contact with asthma sufferers opportunistically, it may be pertinent to enquire whether the patient has a self-management plan and, if not, to encourage them to request one from their asthma specialist.

CFC-free inhalers
A major, and unavoidable, challenge is the change from chlorofluorocarbon (CFC) to hydrofluoroalkane (HFA) propellants in aerosol inhalers. Approximately 80% of asthma sufferers use metered-dose inhalers (MDIs), as do COPD (chronic obstructive pulmonary disease) patients, who mostly use them with large-volume spacers.
The transition to CFC-free inhalers has been substantially slower than originally envisaged due to lack of appropriate alternatives, and there has been no formal withdrawal date set for CFC-propelled MDIs as yet. Transition options for practices include brand or generic switches and wholesale or individual changeovers. While generic substitution may seem initially attractive, automatic transfer to CFC-free inhalers may cause potential problems due to the inhalers having differently shaped mouthpieces. This may cause patient confusion or problems fitting them to patients' spacer devices, with potential harm where spacers are used in acute exacerbations or for routine therapy.
Primary Care Groups/Trusts (PCG/Ts) should have a policy for transition that covers these issues and provides patient education to explain:

  • Why the new inhalers are needed.
  • That they may taste different.
  • That the treatment is safe and effective.
  • That the medication is equivalent.

Ideally, this should be done as part of an asthma consultation, where the new device is explained and the MDI technique and asthma control are re-evaluated.
Beclomethasone and other inhaled steroids have proven difficult to reformulate. As a result, different inhaled corticosteroids will be changed to HFA propellants at different times. One beclomethasone formulation currently licensed in the UK - beclomethasone dipropionate - has increased lung deposition and is licensed at half the standard beclomethasone dose. It is uncertain when others will be licensed.
This, therefore, leaves a range of options:

  • Make no changes unless policy dictates.
  • Switch patients to CFC-free beclomethasone dipropionate or suitable dry-powder inhalers.
  • Put new patients, or those needing a change in therapy, on a CFC-free preparation.

Practices should not miss the opportunity this changeover offers for a full patient asthma review.

Recent oral therapies
Montelukast and zafirlukast are leukotriene receptor antagonists (LTRAs), a new class of oral asthma therapy that works to block the effects of inflammatory mediators. Leukotrienes are released in response to an asthma trigger from mast cells and eosinophils causing the classic hyperreactive airway response, including prolonged bronchoconstriction, airway oedema, mucous hypersecretion, reduced mucociliary clearance, and increased bronchial hyperreactivity.
Updated National Asthma Guidelines are due and will include these therapies. Until then, it is important to be aware of the evidence for possible uses of LTRAs.
Montelukast and zafirlukast have shown improvements in asthma control over placebo and as add-ons to inhaled steroids when inhaled corticosteroids have provided inadequate control.(5)
LTRAs appear generally well tolerated with few contraindications to their use, but nurses need to be aware of potential drug interactions outlined in the Prescribing Information.
Currently, it seems best to use these drugs as add-ons to low- or high-dose inhaled steroids where control of persistent asthma symptoms has not been achieved. More studies are needed to determine relative clinical benefits and clinical indications.
Some patients may have symptoms that are particularly sensitive to LTRAs, while others may show little or no response. Evidence suggests that those with activity-induced symptoms, aspirin-sensitive asthma or associated allergic rhinitis may do well with LTRAs.

References

  1. DoH. Statistical bulletin. 1998.
  2. Price D, et al. Asthma J 1999;4:74-7.
  3. Gibson PG, et al. In: Cochrane Collaboration Library Issue 2. Oxford: Update Software; 1999.
  4. National Asthma Campaign. Needs of people with asthma (survey). 2000.
  5. Reiss TF, et al. Arch Intern Med 1998;158:1213-20.

Resources
National Asthma Campaign
T:020 7226 2260
Helpline: 0345 010103
W:www.asthma.org.uk

British Lung Foundation
T:020 7831 5831
W:www.lunguk.org

GPs in Asthma Group
T:01225 858880
W:www.gpiag-asthma.org/

National Heart, Lung and Blood Institute
W:www.nhlbisupport.com