Management of Asthma

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Asthma in Ireland

•  470,000 people in Ireland have asthma, the fourth highest prevalence of asthma in the world
• Asthma is the most common chronic disease in Ireland
• More than 1 in every 10 people have asthma in Ireland
• 60% of people with asthma do not have their asthma under control
• Around 20,000 people visit hospital due to asthma every year
• At least 1 person a week dies from asthma
• 90% of these deaths are preventable
• Asthma causes adults to miss an average of 12 days of work each year
• Asthma causes children to miss an average of 10 days of school each year¹

Aims of Pharmaceutical Management

The goal of asthma management is control of the disease. Complete control is defined as:

• No daytime symptoms
• No night-time awakening due to asthma
• No need for rescue medication
• No asthma attacks
• No limitations on activity including exercise
• Normal lung function (FEV₁ and/or PEF >80% predicted or best)
• Minimal side effects from treatment

The Stepwise Approach to Management

•  Start treatment at the step most appropriate to initial severity of the disease
• Achieve early control
• Improve control by stepping up treatment as necessary, and stepping down when control is good to find and maintain the lowest controlling step

Stepping Up

Before stepping up, adherence with existing therapies, inhaler technique, persistent allergen exposure and comorbidities should be checked.

It is generally considered that combination inhalers aid adherence and also have the advantage of guaranteeing that the long-acting βbeta₂ agonist is not taken without the inhaled corticosteroid.

Stepping Down

Regular review of patients as treatment is stepped down is important. When deciding which drug to step down first and at what rate, the following should all be taken into account:

• Severity of asthma
• Side effects of the treatment
• Time on current dose
• Beneficial effect achieved
• Patient’s preference

Patients should be maintained at the lowest possible dose of inhaled corticosteroid. Reduction in inhaled corticosteroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every three months, decreasing the dose by approximately 25-50% each time.²

Managing Comorbidities

Several comorbidities are commonly present in patients with asthma, particularly those with difficult-to-treat or severe asthma. Active managment of comorbidities is recommended because they may contribute to symptom burden, impair quality of life, and lead to medication interactions. Some comorbidities also contribute to poor asthma control. Examples include:

• Obesity
• Gastroesophageal reflux disease
• Anxiety and depression
• Food allergy and anaphylaxis
• Rhinitis, sinusitis and nasal polyps³

Algorithms

Overview of the Stepwise Management of Asthma in Adults

Overview of the Stepwise Management of Asthma in Children aged 5 to 12 years

Overview of the Stepwise Management of Asthma in Children under 5 years

References:

1. Asthma Society of Ireland. Available at www.asthma.ie. Accessed 22nd May 2015.
2. British Thoracic Society/Scottish Intercollegiate Guidelines Network British Guideline on the Management of Asthma. Published October 2014. Available at www.brit-thoracic.org.uk/ and www.sign.ac.uk
3. Global Strategy for Asthma Management and Prevention. Revised 2014. Available at: www.ginasthma.org

Caroline McDermott