1. Monitoring asthma in primary care
Session 2
Monitoring asthma
in primary care

2. Supported Self-Management
All people with asthma or their parents/carers should be offered self-management education including written PAAP supported by regular review
In adults written PAAPs may be based on symptoms and/or PEF and should be culturally sensitive
General practices should ensure they have trained professions
Adherence to medication should be routinely checked and addressed

3. Non-pharmacological Management (SIGN 2016)
Physical and chemical methods of reducing HDM levels ineffective and should not be recommended by professionals
Smoking cessation / environmental tobacco smoke (ETS)
Weight reduction: may lead to improvement in symptoms
Breathing exercises can be offered as an adjunct
Identify triggers and reduce exposure
Occupational exposure

4. Annual Review for Adults
Closer monitoring if poor lung function and a history of attack in last year (SIGN 2016)
In adults written PAAPs may be based on symptoms /or PEF
Symptomatic asthma control
Lung function measured by spirometry or PEF
Asthma attacks in last years
Oral steroid use in last year
Time of work in last year
Inhaler technique
Adherence
Bronchodilator reliance
Possession of and use of PAAP

5. How to Assess Symptomatic Control
Current symptoms: cough wheeze, breathlessness, chest tightness
Lung function: Spirometry or PEF
Symptom control:
RCP 3 questions (not well validated in adults)
Asthma Control Questionnaire (ACQ) (well validated in adults
Asthma Control Test (ACT) (validated in adults)

6. RCP 3 Questions
1. Have you had difficulty sleeping because of your asthma symptoms including cough
2.Have you had your usual asthma symptoms during the day: cough; wheeze; breathlessness; chest tightness?
3. Has your asthma interfered with your usual activities?
No to all question consistent with controlled asthma
Not well validated in adults; not validate in children

7. Asthma Control Test
Response to 5 questions
3 related to symptoms
1 medication use
1 overall control
Point response score
Reasonably well controlled 20-24
Under control 25
Validated in adults and children 4 years and over; the childhood asthma control test is valid for 4-11 years

8. Asthma Control Questionnaire
Response to 7 questions (shorter 5 symptom only questionnaire as valid)
5 related to symptoms
1 rescue treatment use
1 FEV1
Response usually assessed over preceding week
Score ranges from 0 = total control and 6 = severely uncontrolled (excluding FEV1 if assessed prior to appointment)
Minimally important difference change in score of 0.5

9. Aim of Treatment (SIGN 2016)
No daytime symptoms
No night-time symptoms
No need for rescue medication
No asthma attacks
No limitation on activity including exercise
Normal lung function
Minimal side-effects from medication

10. Pharmacological Management
Patients may have different goals
May wish to balance aims of asthma management against potential side effects or inconvenience of taking medication
A phased approach to abolish symptoms ASAP and to optimise PEF by starting treatment at the level most likely to achieve this
Start treatment at level most appropriate to initial severity of asthma
Aim is to achieve early control and to maintain it by increasing treatment as necessary and decreasing treatment when control is good

11. New Recommendations for Pharmacological management
The Step approach has been superseded
There are differences in how the doses of ICS are expressed (ex-valve – the metered dose or ex-actuator – the delivered dose)
The doses of ICS are expressed as:
very low (generally paediatric doses)
low (generally starting dose for adults)
medium
high

12. Adult asthma diagnosed
Asthma suspected
Adult asthma diagnosed
Diagnosis and assessment
Evaluation: assess symptoms, measure lung function, check inhaler technique and adherence.
Adjust dose, update self-management plan, move up and down as appropriate
Continuous or frequent use of prednisolone
Use daily in lowest dose
Maintain high dose ICS
Consider other treatments to minimise S/E
Refer patient
High Dose Therapies
Consider increasing ICS to high dose
Addition of 4th drug:
LTRA
Theophylline
Oral SABA
LAMA
Refer patient
Additional add-on therapies
No response to LABA stop and consider increasing ICS to medium dose
If benefit from LABA but control still inadequate continue combination and consider trail of LTRA
Theophylline
LAMA
Initial add-on therapy
Add LABA to low dose ICS usually in combination inhaler
Regular Preventer
low dose ICS
Consider monitored
introduction treatment with
low dose ICS
Infrequent short lived wheeze
Move up to improve control as needed
Move down to find lowest controlling therapy

13. The following medicines act as short-acting Bronchodilators:
Prescribe an inhaled short-acting B2 for all patients with symptomatic asthma
The following medicines act as short-acting
Bronchodilators:
Inhaled short-acting B2 agonists
Inhaled ipratropium bromide
B2 agonist tablets or syrup
Theophyllines
Short-acting inhaled B2 work more quickly and/or
with fewer side-effects than the alternatives

14. Regular Preventer Therapy
Treatments have been judged on their ability to improve symptoms, improve lung function, and prevent asthma attacks, with an acceptable safety profile
Improvement of quality of life, while important, is the subject of too few studies to be used to make recommendations.

15. Adult Doses of ICS Low = Clenil or equivalent 100mcgs 2p BD
Medium = Clenil 200mcgs 2p BD
High = Clenil 200mcgs 4p BD

16. Initial Add-On Therapy
Before initiating a new drug therapy recheck:
adherence
inhaler technique
eliminate trigger factors
Duration of trial of add-on therapy will depend on the desired outcome
If no response to treatment drug should be stopped

17. Criteria for Introduction of Add-On Therapy
No exact dose of ICS deemed
Should be considered before increasing ICS
Only started in patients already on ICS
Must not be used as mono-therapy
Combination inhalers are recommended to:
Ensure LABA is not taken without ICS
Improve inhaler adherence
Combination inhalers can be use for SMART / MART regimes in adults 18+

18. Product ICS LABA Device SMART /MART dosing Max Daily Dose
MART/SMART Regime
Product
ICS
LABA
Device
SMART
/MART dosing
Max
Daily Dose
Symbicort 200/6
Budesonide 200
Formoterol 6
Turbohaler
1-2 bd up to additional 8 12
Symbicort 100/6
Budesonide 100
DuoResp 200/6
Spiromax
Fostair 100/6
Beclometasone
pMDI
2 bd up
to additional 6 10
Storrar and Chauhan (2015) Prescribing in Practice

19. Additional Add-On Therapies 1
Control poor on ICS + LABA:
Recheck diagnosis
Adherence
Inhaler technique
Triggers*
If improvement shown with LABA but control inadequate:
Continue LABA and increase ICS to medium
Continue current combination +: LTRA or
LAMA or
Theophylline

20. Additional Add-On Therapies 2
If no improvement with LABA – stop LABA
Increase the dose of ICS to medium or
LTRA (superior to ICS alone) or
LAMA (not licenced for this indication)

21. High Dose Therapies
If control remains inadequate on medium dose ICS + LABA consider:
Increasing dose ICS to high dose
Add LTRA
Add theophylline
Add slow release B2
Add tiotropium
At high dose ICS a spacer should be used

22. Continuous or Frequent Oral Steroids
Use daily prednisolone in lowest dose to control symptoms
Patients on long term or frequent oral steroid courses (3-4 year) at risk side effect; monitor: BP
Blood Glucose
Blood lipids
Bone mineral density
Cataracts
Glaucoma

23. Thank you