A Clinical update in Asthma

A Clinical update in Asthma
Lee Dobson Torbay Hospital

Questions?

A brief history of asthma management
2007 SMART 2001 Symbicort 1996, 1997 Woolcock & Pauwels Landmark studies 1990 Serevent introduced Fostair 1994 Greening, Ind Landmark study 1999 Seretide launched 1997 Oxis 1980s Major developments in asthma management 1995 onwards GINA How are we doing? 1969 Ventolin introduced 1991 The β2 agonist debate 1993 Flixotide introduced Late 60s Bronchoscope 1972 Becotide introduced Respiratory medicine has seen many significant changes over the past five decades, including the introduction of several important medicines, devices and landmark studies. A&H/GSK has played a part in introducing several key respiratory medicines. In 1969, a short-acting beta agonist, Ventolin, was introduced. This gave patients the ability effectively to manage acute asthma attacks for the first time. In 1972, the low-dose inhaled corticosteroid Becotide gave patients with asthma and doctors the first effective preventative treatment option. Serevent was brought to the market in 1990 and Flixotide in 1993. In 1999, Seretide, the first combination long-acting beta-2-agonist (salmeterol) and inhaled corticosteroid (fluticasone propionate), was launched and is now the most widely prescribed combination inhaler. As well as the introduction of these medicines, there have been several landmark clinical studies, which have changed the way asthma is managed. For example, the study by Greening and Ind,1 which showed that adding in a long-acting beta-2-agonist was better than doubling the dose of inhaled corticosteroid, was an unexpected finding and changed the way asthma is managed. This was later confirmed by studies by Pauwels and Woolcock.2,3 So what does the future hold? In today’s presentation, I would like to put the GOAL (Gaining Optimal Asthma controL) study into context with these influences on asthma management and show you what the future of asthma management might look like. References 1. Greening AP, Ind PW, Northfield M, Shaw G. Lancet 1994; 344: 219–24. 2. Pauwels RA, Lofdahl CG, Postma DS et al. N Engl J Med 1997; 337: 140–511. 3. Woolcock A, Lundback B, Ringdal N, Jacques LA. Am J Respir Crit Care Med 1996; 153: 1481–8. 1956 3M launch The MDI 1965 Intal introduced Early 1950s MDI

Asthma Burden in Europe 2006
Not Well-Controlled asthma (% of treated patients) % Patients not Well Controlled In Europe today, most patients with asthma have disease that is not controlled and experience symptoms. The Global INitiative for Asthma (GINA) guidelines state that the aim of asthma management is to achieve and maintain asthma control. However, the 1999 Asthma Insights and Reality in Europe (AIRE) study showed that only 5% of adult asthmatic patients were controlled.1 The National Health & Wellness Survey (NHWS) was a population-based cross-sectional survey carried out in 2006 in France, Germany, Italy, Spain and the UK.2 A detailed questionnaire was administered to a sample of individuals drawn from an Internet Panel.2 The Asthma Control Test (ACT™) was used to assess the level of control: Total Control (TC, score 25), Well Controlled (WC, score 20–24) and Not Well-Controlled (NWC, score <20). The ACT has been validated previously and is recommended in the GINA 2007 and BTS/SIGN 2008 guidelines as a tool for assessing asthma control.3,4,5 NHWS results: 37,476 participants, 2337 (mean age 44 years) had been diagnosed with asthma by a physician: France (n=476), Germany (n=486), Italy (n=223), Spain (n=227) and the UK (n=915).2 Of the patients currently receiving treatment for asthma, most were NWC: overall 55%, UK 45%, Spain 45%, Italy 61%, Germany 72% and France 56%.2 For the overall population: NWC 55%, WC 38% and TC 7%.2 Conclusions: this survey suggests that the level of asthma control has improved since AIRE. However, most patients continue to have asthma that is uncontrolled.2 References 1. Rabe K et al. Eur Respir J 2000;16:802–807. 2. Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s. 3. Nathan R et al. J Allergy Clin Immunol 2004;113:59–65. 4. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention. Revised Edition 2007. 5. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma: A National Clinical Guideline. Revised Edition, 2008. NHWS: A population-based cross-sectional survey conducted in 2006 in 2337 patients diagnosed with asthma in France (n=476), Germany (n=486), Italy (n=223), Spain (n=227) and the UK (n=915) Not Well-Controlled defined as Asthma Control Test score ≤19 Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s

Number of people living with asthma in the UK today
Data includes 590,000 teenagers and 700,000 people over 651 Total 5.2 million1 Every 6 hours someone dies from asthma2 Women 2.9 million1 Key message: Asthma is an ongoing daily problem for millions of people in the UK. Every 6 hours someone dies from asthma.1 The UK has one of the highest rates of asthma of any country in the world.1 It is estimated that there are 5.2 million people with asthma in the UK, with approximately 60% of adults with asthma being female.1 There has been a rise of 400,000 in the number of adults with asthma in the UK since the last asthma audit in With over 1,400 deaths per annum, one person dies from asthma every 6 hours.2 References Where Do We Stand? Asthma in the UK Today. Published December Available at: [Accessed October 2006.] General Register Office collated in Office for National Statistics mortality statistics for England and Wales; General Register Office for Scotland; General Register Office for Northern Ireland collated by the Northern Ireland Statistics & Research Agency (2004). Men 2.3 million1 1. Where Do We Stand? Asthma in the UK Today. Published December Available at: [Accessed October 2006.]. 2. General Register Office collated in Office for National Statistics mortality statistics for England and Wales; General Register Office for Scotland; General Register Office for Northern Ireland collated by the Northern Ireland Statistics & Research Agency (2004). 5

Asthma deaths occur across disease severity
It is a myth that only severe asthma can prove fatal Asthma deaths occur across disease severity with deaths occurring in those patients whose asthma is considered mild-to-moderate Asthma severity (%) Number of deaths 25 50 75 100 Severe Moderately severe Mild Unknown 10% 16% 21% 53% Number of asthma deaths across disease severity 2001–2003 Key message: Asthma deaths occur across disease severity. Harrison et al studied all asthma deaths in the eastern region of the UK during the period 2001–2003. Findings showed only 53% of deaths occurred in patients whose asthma was considered severe. Patients with mild asthma accounted for 16% of asthma deaths, and those classed as having moderately-severe asthma 21%.1 In two thirds of all asthma deaths during this period, medical management failed to comply with national guidelines.1 Medical factors contributing to death included: inappropriate care, inadequate ICS prescribing, inadequate patient monitoring and follow-up.1 A study of asthma deaths of patients under 65 living in Wales found that whilst in half the deaths investigated chronic and severe asthma was the cause, over one third of patients who died from an acute attack had asthma that was considered mild-to-moderate.2 Poor compliance and lack of disease awareness by the patient was a factor in a number of deaths, so too was inadequate medical care, such as lack of patient follow-up.2 Preventable asthma deaths are still occurring in the UK.3 References Harrison B, Stephenson P, Mohan G, Nasser S. An ongoing confidential enquiry into asthma deaths in the eastern region of the UK, 2001–2003. Prim Care Respir J 2005; 14: 303–3. Burr ML, Davies, BH, Hoare A et al. A confidential inquiry into asthma deaths in Wales. Thorax 1999; 54; 985–9. Where Do We Stand? Asthma in the UK Today. Published December Available at: [Accessed October 2006.]. n=57 Harrison B et al. Prim Care Respir J 2005 Dec; 14: 303–13.

2007/8 QOF Prevalence of Asthma
Source: NHS Information Centre: The Quality Outcomes Framework (QOF),

QOF Prevalence of Asthma
TCT SD Source: NHS Information Centre: The Quality Outcomes Framework (QOF),

Source: NHS Information Centre: Hospital Episodes Statistics (HES)
Change in Asthma Hospital Admissions, Length of Stay and Bed Days in Torbay Care Trust (2005/06 to 2006/07) Asthma admissions increased by 30% 45 more hospital admissions Average length of stay decreased by 39% From 3.8 days to 2.3 days Asthma bed days decreased by 21% 122 fewer bed days Source: NHS Information Centre: Hospital Episodes Statistics (HES)

International/National Guidance

British Guideline on the Management of Asthma
British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN) Reference: British Thoracic Society, Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma - May Available from: Date accessed: August 2008.

Definition of asthma “A chronic inflammatory disorder of the airways … in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.” Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92

Diagnosis The diagnosis of asthma is a clinical one
There is no standardised definition, therefore, it is not possible to make clear evidence based recommendations on how to make a diagnosis Central to all definitions is the presence of symptoms and of variable airflow obstruction The section on diagnosis for both adults and children has been completely rewritten in the 2008 guideline. New text from the 2008 guideline is underlined in this slide. Central to all definitions is the presence of symptoms (more than one of wheeze, breathlessness, chest tightness, cough) and of variable airflow obstruction. Although there are many shared features in the diagnosis of asthma in children and in adults there are also important differences. 13

Diagnosis Base initial diagnosis on a careful assessment of symptoms and a measure of airflow obstruction Spirometry is the preferred initial test to assess the presence and severity of airflow obstruction (use PEF if spirometry not available) PEFR – spirometry unavailable occupational monitoring New text from the 2008 guideline is underlined in this slide. 14

Following clinical assessment in adults
This algorithm is new for the 2008 guideline. Following clinical assessment, establish the probability of an asthma diagnosis and proceed accordingly. 15

Features that increase the probability of asthma in adults
>1 of the following: wheeze, breathlessness, chest tightness, cough, particularly if: worse at night and early morning in response to exercise, allergen exposure and cold air after taking aspirin or beta blockers Personal/family history of asthma/atopy Widespread wheeze heard on auscultation of the chest Unexplained low FEV1 or PEF Unexplained peripheral blood eosinophilia New text from the 2008 guideline is underlined in this slide. 16

Features that lower the probability of asthma
Prominent dizziness, light-headedness, peripheral tingling Chronic productive cough in the absence of wheeze or breathlessness Repeatedly normal physical examination of chest when symptomatic Voice disturbance Symptoms with colds only Significant smoking history (>20 pack-years) Cardiac disease Normal PEF or spirometry when symptomatic New text from the 2008 guideline is underlined in this slide. 17

Following clinical assessment in adults
This algorithm is new for the 2008 guideline. Following clinical assessment, establish the probability of an asthma diagnosis and proceed accordingly. 18

Differential Diagnosis
Without airflow obstruction Chronic cough syndromes DBS Vocal Cord Dysfunction Rhinitis GORD Heart Failure Pulmonary Fibrosis With airflow obstruction COPD Bronchiectasis Inhaled Foreign Body Obliterative Bronchiolitis Large Airway Stenosis Lung Cancer Sarcoidosis

Pharmacological Therapy

Aims of pharmacological management
Start treatment at the step most appropriate to the initial severity of their asthma Aim is to achieve early control Step up or down with therapy Minimal therapy Before initiating new drug therapy: Compliance Inhaler technique Eliminate trigger factors New text from the 2008 guideline is underlined in this slide. In the 2007 guideline, control was defined as achieving the following with minimal side effects: minimal symptoms during day and night minimal need for reliever medication no exacerbations no limitation of physical activity normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best) The new definition of control appears to be in line with the Global Initiative For Asthma (GINA) guidelines.1 In clinical practice patients may have different goals and may wish to balance the aims of asthma management against the potential side effects or inconvenience of taking medication necessary to achieve perfect control. Reference: 1. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) Available from: Date accessed: August 2008.

Aim pharmacological management
Control of asthma, defined as: No daytime symptoms No night time awakening due to asthma No need for rescue medications No exacerbations No limitations on activity including exercise Normal lung function (FEV1 and/or PEF >80% predicted or best) with minimal side effects. New text from the 2008 guideline is underlined in this slide. In the 2007 guideline, control was defined as achieving the following with minimal side effects: minimal symptoms during day and night minimal need for reliever medication no exacerbations no limitation of physical activity normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best) The new definition of control appears to be in line with the Global Initiative For Asthma (GINA) guidelines.1 In clinical practice patients may have different goals and may wish to balance the aims of asthma management against the potential side effects or inconvenience of taking medication necessary to achieve perfect control. Reference: 1. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) Available from: Date accessed: August 2008.

Monitoring asthma in primary care
Factors that should be monitored and recorded: Symptomatic asthma control using RCP ‘3 questions’, Asthma Control Questionnaire or Asthma Control Test (ACT) Lung function (spirometry/PEF) Exacerbations Inhaler technique Compliance (prescription refill frequency) Bronchodilator reliance (prescription refill frequency) Possession of and use of self management plan/personal action plan New text from the 2008 guideline is underlined in this slide. Asthma is best monitored (in the primary care setting) by routine clinical review on at least an annual basis. Patients achieving control of symptoms with treatment have a low risk for exacerbations. A management strategy that controls eosinophilic airway inflammation or airway hyper-responsiveness results in better control of exacerbations than one which controls immediate clinical manifestations.

Component of action plan Practical Considerations
PAAPs Component of action plan Result Practical Considerations Symptom vs PEF trigger Standard written instruct Traffic Light Similar effect Consistently beneficial Not better than standard 2-3 action points 4 action points No better <80% - increase ICS <60% - oral steroids <40% - urgent advice PEF on %personal best PEF on % predicted Assess when stable, update every few years ICS and steroids Oral steroids only ICS Unable to evaluate >400 – steroids 200 – increase substant Restart medication

Inhaler devices

Step 1: Mild intermittent asthma
Prescribe inhaled short acting β2 agonist (SABA) as short term reliever therapy for all patients with symptomatic asthma Good asthma control is associated with little or no need for short-acting β2 agonist Using two or more canisters of β2 agonists per month or > puffs per day is a marker or poorly controlled asthma that puts individuals at risk of fatal or near-fatal asthma Patients with high usage of inhaled short-acting β2 agonists should have their asthma management reviewed New text from the 2008 guideline is underlined in this slide. Using short acting β2 agonists as required is at least as good as regular (four times daily) administration. Unless individual patients are shown to benefit from regular use of inhaled short-acting β2 agonists then as required use is recommended.

A stepwise approach The 2008 guideline has retained the stepwise approach advocated in the 2007 guideline with some minor updates. We will look more closely at the updates at each individual step. A stepwise approach aims to abolish symptoms as soon as possible and optimise peak flow by starting treatment at the level most likely to achieve this. Patients should start treatment at the step most appropriate to the initial severity of their asthma. The aim is to achieve early control and to maintain control by stepping up treatment as necessary and stepping down when control is good. Before initiating new drug therapy practitioners should check compliance with existing therapies, review inhaler technique and eliminate trigger factors.

Step 2: Regular preventer therapy
Inhaled steroids are the recommended preventer drugs for adults for achieving overall treatment goals Consider inhaled steroids if any of the following: Using inhaled β2 agonist three times a week or more Symptomatic three times a week or more Waking one night a week Exacerbation of asthma in the last two years (adults and 5-12 only) Step 2 remains unchanged from the 2007 guideline.

Adults: mcg/day BDP*(reasonable starting dose 400mcg per day for many adults) Start patients at a dose appropriate to the severity of the disease Titrate the dose to the lowest dose at which effective control of asthma is maintained Start patients at a dose of inhaled steroids appropriate to the severity of disease. In mild to moderate asthma, starting at very high doses of inhaled steroids and stepping down confers no benefit. Titrate the dose of inhaled steroid to the lowest dose at which effective control of asthma is maintained. Give inhaled steroids twice daily (except ciclesonide). Once a day inhaled steroids at the same total daily dose can be considered if good control is established. As current and previous smoking reduces the effect of inhaled steroids, higher doses may be needed in patients who are smokers or ex-smokers.

Steroid Equivalent dose (mcg) Beclomethasone CFC 400 Beclomethasone Clenil Qvar Fostair 200 Budesonide Symbicort Fluticasone Seretide Mometasone Ciclesonide

Step 3: Initial add-on therapy
A proportion of patients may not be adequately controlled at step 2 Check and Eliminate Adults and Children 5-12: First choice as add-on therapy is an inhaled long-acting β2 agonist (LABA), which should be considered before going above a dose of 400mcg BDP* and certainly before going above 800mcg New text from the 2008 guideline is underlined in this slide. No exact dose of inhaled steroid can be deemed the correct dose at which to add another therapy. The addition of other treatment options to inhaled steroids has been investigated at doses from mcg in adults and up to 400mcg in children. Many patients will benefit more from add-on therapy than from increasing inhaled steroids above doses as low as 200mcg/day. At doses of inhaled steroid above 800mcg/day side effects become more frequent. An absolute threshold for introduction of add-on therapy in all patients cannot be defined. Before initiating new drug therapy practitioners should check compliance with existing therapies, review inhaler technique and eliminate trigger factors.

Step 3: Initial add-on therapy
After introduction of LABA, assess control of asthma: Good response to LABA – continue LABA Benefit from LABA but control still inadequate – continue LABA and increase inhaled corticosteroid dose to 800 mcg/day (400 mcg/day in children) No response to LABA – stop LABA and increase inhaled corticosteroid to 800 mcg/day (400 mcg/day in children). If control still inadequate, institute trial of other therapies, e.g. leukotriene receptor antagonist or theophylline

Is “1” better than “2”? …why?
Can’t miss their ICS More convenient Increased compliance Pathophysiology? Different inhalers – different deposition Interaction occurs at single cell level Deposition varies from one inhalation to the next

Step 4: Persistent poor control
If control remains inadequate… At high doses of inhaled steroid via MDI, a spacer should be used. No controlled trials indicating which of these is the best option, although the potential for side effects is greater with theophyllines and β2 agonist tablets. If a trial of add-on therapy is ineffective, stop the drug (or in the case of increased dose of inhaled steroid, reduce to the original dose). Before proceeding to step 5, consider referring patients with inadequately controlled asthma, especially children, to specialist care.

Step 5: Continuous or frequent use of oral steroids
Still uncontrolled.. Monitor - Blood pressure Diabetes Hyperlipidaemia BMD The aim of treatment is to control the asthma using the lowest possible dose or, if possible, to stop long term steroid tablets completely. Inhaled steroids are the most effective drug for decreasing requirement for long term steroid tablets. Prednisolone is the most widely used steroid tablet for maintenance therapy in chronic asthma. There is no evidence that other formulations offer any advantage.

Step 5: Continuous or frequent use of oral steroids
Steroid sparing medication - Methotrexate - Ciclosporin - Oral Gold Colchicine IVIG Subcutaneous Terbutaline Anti- TNF The aim of treatment is to control the asthma using the lowest possible dose or, if possible, to stop long term steroid tablets completely. Inhaled steroids are the most effective drug for decreasing requirement for long term steroid tablets. Prednisolone is the most widely used steroid tablet for maintenance therapy in chronic asthma. There is no evidence that other formulations offer any advantage.

Stepping down Stepping down therapy once asthma is controlled is recommended Regular review of patients as treatment is stepped down is important Patients should be maintained at the lowest possible dose of inhaled steroid Reductions should be slow, decreasing dose by ~25-50% every three months When deciding which drug to step down first and at what rate, the severity of asthma, the side effects of the treatment, time on current dose, the beneficial effect achieved, and the patient’s preference should all be taken into account.

Case 1 Miss BL 1984 Admission Sep 2006
Exacerbation asthma, PEFR 200 l/min (normal 450) Recent LRTI 1 Admission to hospital this year, usual control adequate Known panic attacks – this different

Case 1 ? Regular meds – becotide
At university, smokes!..moderate alcohol! Acute management? Steroids, ICS, ventolin, RNS, OPD

Case 1 Clinic October 2006 Good recovery, still some SOBOE, started attending gym. Nocturnal symptoms – none Ventolin – three times per week. What to do?

Case 1 Lifestyle advice Compliance RNS - Management Plan, Education
Pre-dose with ventolin LABA - Combination inhaler

Do we understand what the patients want?

Living and Breathing Study
UK qualitative and quantitative study to evaluate patient understanding of their asthma and determine patient preferences regarding the delivery of asthma care and treatment. Patient preferences: Treatment as simple as possible Few inhalers Lowest dose of steroid to control symptoms Avoid hospitals when possible Minimise symptoms Haughney J et al ERS 2006

Do the patients know what they want?

Patients overestimate their asthma control
Self-reported level of control by Not Well-Controlled patients 40% of Not Well-Controlled patients consider themselves “Well” or “Completely Controlled” % Patients NOTE: THIS IS A BUILD SLIDE Patients overestimate their level of asthma control and are therefore likely to under-report symptoms to their doctor, making effective identification of poor control difficult. Of those patients NWC, the self-reported level of control was: “Completely Controlled” 6%, “Well Controlled” 34%, “Somewhat Controlled” 37%, “Poorly Controlled” 11% and “Not at all Controlled” 11%. These results are consistent with the findings of the AIRE survey2. Conclusions: this survey confirms that asthma patients overestimate their level of asthma control and are therefore likely to under-report symptoms, making correct assessment of control difficult. References 1. Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s. 2. Rabe K et al. Eur Respir J 2000;16:802–807. Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s

Case 2 Mrs TL 24/10/1984 Clinic Jul 2006 Asthma age 12
2 x pregnancies – deteriorated during, brittle++ (Newcastle) BIH Night waking, morning dipping, wheeze, SOB – 10/40

Case 2 Guinea pig and rabbit, shop assistant.
Bec puffs bd, SV 4 puffs bd, ventolin and combivent prn. SaO2 98%, 2.69/3.58 (3.21/3.68). What to do?

Case 2 Write to chest consultant
RNS review – management plan, education QVAR - Thrush Combination inhaler - tried ?LTRA ?Nebuliser Standby steroids

Case 2 Clinic Aug 2006 Stable 2.84/3.67 litres Plan – no change DNA…

Case 3 23-year old woman with history of childhood asthma
Started fitness campaign but suffers from breathlessness on exertion At clinic, PEF normal

Case 3 What advice would you give Laura?
What therapy would you recommend if a peak flow diary showed a stable baseline but short lived dips after running?

Remember to make an assessment of the probability of asthma.
Case 3 Remember to make an assessment of the probability of asthma. Diagnose before treating – try to confirm diagnosis with objective tests before long term therapy is started.

Case 3 Increasing symptoms – some help from blue inhaler
Interested in complementary therapy - Buteyko Husband noticed night time coughing – keeping him awake! What would you advise Laura about complementary treatments for asthma? Becomes pregnant.

Case 3 What would you do now if she was:
(a) not distressed, slightly wheezy with respiratory rate of 20 breaths/minute, pulse 100 beats/minute and PEF of 390 L/minute? (b) looks dreadful, cannot complete sentences, with very quiet breath sounds on auscultation, respiratory rate 30 breaths/minute, pulse 120 beats/minute and PEF of 120 L/minute?

Continue usual asthma therapy in pregnancy
Case 3 No consistent evidence to support use of complementary or alternative treatments in asthma Continue usual asthma therapy in pregnancy Monitor pregnant women with asthma closely to ensure therapy is appropriate for symptoms.

Any Questions?

Case 4 Mr DC 02/09/1969 Clinic Apr 2004 - Exacerbation March 2004
Known asthmatic (eczema) – control not so good recently (nocturnal symptoms, SOB, reliever ++, PEFR down). Symbicort 200/6 2 puffs bd Green sputum – cefalexin, prednisolone What to do?

Case 4 Question diagnosis? Recent CT scan, alpha-1-antitrypsin level N
Increase dose Symbicort LTRA trial – previously negative Bisphosphonate

Case 4 Clinic June 2004 Ig E > 15,000 RAST Aspergillus >4
Probable Allergic Bronchopulmonary Aspergillosis (ABPA) Plan - Maintenance prednisolone (10mg), Itraconazole

Case 4 Clinic Sept 2004 Symptomatic - Prednisolone <20mg
SOB increasing PEFR <160 l/min, FEV1/FVC 1.42/3.75 (3.71/4.4) Plan – increase inhaled steroid

Case 4 Clinic Oct 2004 Recent exacerbation 1.11/3.12
Plan – prednisolone 15mg od, nebuliser

Case 4 Clinic Jan 2005 onwards… Cramps
PPI/H2 Antagonist – some benefit Not taking ICS! Compliance Deranged Liver function tests 1.57/3.49 Diabetes - ? Steroid induced

A Clinical update in Asthma

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