1. The Modern Management of Asthma: Getting it right Part 2
Dr Richard Russell
Senior Lecturer
Nuffield Department of Medicine
University of Oxford

2. Step 1: Mild intermittent asthma
Prescribe inhaled SABA as short term reliever therapy for all patients with symptomatic asthma
Good asthma control is associated with little or no need for SABA
Using > 1 canister of SABA per month or > 8 puffs per day is a marker of poorly controlled asthma that puts individuals at risk of fatal or near-fatal asthma
Patients with high SABA use should have their asthma management reviewed
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Available from: [Accessed Dec 2016]

3. Daily dose of budesonide (µg)
Rapid improvements of symptoms and lung function even at low doses of corticosteroids
Daily dose of budesonide (µg)
Symptoms
FEV1
Exercise FEV1 NO
FEF25%-75%
Percent of maximum
100
200
300
400
500
600
700
800 10 20 30 40 50 60 70 80 90
Figure reproduced with permission from Barnes PJ, et al. Am J Respir Crit Care Med. 1998;157:S1-S53.

4. Underuse of inhaled corticosteroids
Quick-relief
Intermittent
medications
Inhaled
corticosteroids
Mild, persistent
Moderate, persistent
Severe, persistent
AIRE total
AIRE = Asthma Insights & Reality in Europe. 20 40 60 80
100
Patients, %
Figure adapted with permission from Rabe KF et al. Eur Respir J. 2000;16(5):802-7.

5. Few patients regularly use inhaled corticosteroids30
Irregular ICS use
Regular ICS use 25 20
ICS use (%) 15 10 5
All patients
Hospitalised
Figure produced by Russell R using data from Suissa S et al. Thorax. 2002;57:

6. Treatment-related barriers to adherence
Method of administration1,2
Frequent dosing1,2
Multiple different inhalers2
Fear of, or experience of, side effects1,2
Lack of understanding of asthma or treatment1,2
Denial about asthma or treatment2
Forgetfulness1,2
1. Jin et al. Ther Clin Risk Manag. 2008;4(1):
2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Available from: [Accessed Dec 2016]

7. Step 2: Who gets inhaled corticosteroids?
1 severe exacerbation of asthma in last year
Using SABA more than twice a week
Symptoms more than twice a week
Waking once a week or more
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Available from: [Accessed Dec 2016]

8. Step 3
A proportion of patients may not be adequately controlled at step 2
First choice as add-on therapy is an inhaled long-acting β2 agonist (LABA)
If still not controlled increase steroids as well
Consider: LTRA, Theophyllines
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Available from: [Accessed Dec 2016]

9. Long-acting beta2 agonists
Walters EH et al. Cochrane Database Syst Rev. 2003;(4):CD001385
“Long acting beta2 agonists are highly effective
in chronic asthma”
85 studies: 34 as add-on therapy
Fewer asthma symptoms by day or night
Less relief bronchodilator medication requirement
Better lung function
Lower risk of acute worsening of asthma
Better quality of life

10. Long-acting beta2 agonists
In the UK, prescribers are being reminded that:
“Patients treated with long-acting beta2 agonists (salmeterol/formoterol) should always be prescribed an inhaled corticosteroid”
The Pharmaceutical Journal, Vol. 277, p155. URI

11. FACET study – severe exacerbations: % reductions versus BUD 200 µg
1.0
0.5
BUD 800 µg > BUD 200 µg/FORM 12 µg
Exacerbations per patient per year
26%
49%
63%
BUD 200 µg
BUD 200 µg/FORM 12 µg
BUD 800 µg
BUD 800 µg/FORM 12 µg 1 2
BUD = Budesonide; FORM = Formoterol
P < vs BUD 200 µg
P < 0.03 vs BUD 200 µg / FORM 12 µg
Figure produced by Russell R using data from Pauwels RA et al. N Engl J Med. 1997;337:

12. 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 ~25-30% 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.
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Available from: [Accessed Dec 2016]

13. How do you get buy in? Language Education: Pictures Stories Colour
Disease
Drug
Device
Pictures
Stories
Colour

14. Self management You can do this! All patients should be offered
SMP and educations:
Personalised
Written
Structured
You can do this!

15. Evidence base for asthma action plans
Cochrane review1 demonstrates use of patient education and self-management associated with reductions in:
Unscheduled GP visits
Number of patients who were hospitalised
Number of days off work or school
Nocturnal asthma
Improvements in compliance2 and reduction in deaths also demonstrated3
Gibson PG et al. The Cochrane Library, Issue 3, 2002.
Boychuck et al. Ann Emerg Med. 2004;44(Supplement 4):S38.
(3) Abramson MJ et al. Am J Respir Crit Care Med. 2001;163(1):12-8.

16. Few other bits and bobs Fatal asthma Acute attacks
Associated with severe asthma and “adverse behavioural or psychosocial features”
Acute attacks
Oral steroids: 40-50mg for min 5 days or until recovered
Continue Inhaled therapy
British Thoracic Society, Scottish Intercollegiate Guidelines Network. SIGN 153: British guideline on the management of asthma. A national clinical guideline 2016.

17. So how do we do this? Stage 1: (no such thing!)
Stage 2: Inhaled steroids
Stage 3:
1. Add Long acting beta agonist
2. Increased dose of inhaled steroids
Stage 4: High dose steroids plus others
Stage 5: The Kitchen Sink

18. Asthma summary Treat each patient as an individual Right drug
Right dose
Right device
Self management plans work!