General practitioners frequently face the challenge of determining long-term treatment for patients with asthma. Patients do not always respond with the expected benefits of treatment and may need a change in treatment. The two most common reasons to consider changing treatments are increased symptoms (cough or breathlessness) and frequent asthma attacks.
Are you sure it is asthma?
The first question a GP should ask themselves when considering increasing treatment should be: ‘am I sure this is asthma?’ If you did not yourself prove the diagnosis, consider repeating the investigations to prove the diagnosis.1 Has the patient had spirometry proven airflow obstruction? Has the patient had variable peak flow to suggest asthma? Has airway inflammation, as measured by fractional exhaled nitric oxide (FeNO), been demonstrated? Often, the only evidence for asthma is a label previously given by another practitioner. Consider repeating tests and confirming the diagnosis prior to escalating therapy.
What am I treating?
Once satisfied that the patient does have asthma, GPs should identify the problem at hand. Did the patient respond initially to treatment and now this has changed? If persistent cough is the predominant issue, consider other causes for cough. Gastro-oesophageal reflux therapy or intranasal corticosteroids could be the right next step. If breathlessness is the issue, despite being on maximal inhaled therapy, consider other causes for breathlessness. Are there any features of heart failure? Is the patient obese or deconditioned? Pulmonary rehabilitation should be considered for all patients with asthma with persistent breathlessness due to deconditioning.2
Is the patient taking their medications?
Incomplete adherence to prescribed therapy is a very common problem in asthma care. It can also be challenging to establish this reduced adherence from a clinical consultation. Ideally, the treating practitioner should try to obtain objective evidence of adherence (e.g. number of prescription refills in the preceding 12 months). Even when adherence is good, poor inhaler technique can reduce the effectiveness of inhaled therapy. GPs should always assess the inhaler technique at follow up appointments to ensure continued correct use and should not increase treatment until inhaler technique is correct. Recently, a FeNO guided adherence assessment has been shown to be the gold standard of adherence assessment.3 If the patient has mild asthma, but has asthma attacks, ICS/LABA inhaler therapy is now recommended (given regularly and as needed) as a tool to improve adherence and reduce systemic corticosteroids (currently off-label use in the UK). This approach using a symptom-guided approach to anti-inflammatory reliever therapy has been shown to be effective in large multi-centre trials.4,5
Is it asthma with something else? H. influenzae, bronchiectasis, ABPA, EGPA (Asthma+)
GPs should consider co-existing syndromes that could be exacerbating the asthma control. GPs should consider further investigations to rule out allergic bronchopulmonary aspergillosis (ABPA), eosinophilic granulomatous polyangiitis and non-tuberculous mycobacterial infection. A chest X-ray, total serum IgE, serum antineutrophil cytoplasmic antibodies and a sputum assessment for acid fast bacilli can help begin the assessment for these conditions.
Referral for specialist input?
Asthma that does not respond to maximal inhaled therapy could be due to severe persistent inflammation in the lungs. However, most referrals to a specialist asthma clinic do not always require escalation to biologic therapy. Specialist asthma clinics will go through the above-mentioned questions in detail to ensure all the complexities of asthma care are assessed. GPs should consider referring those patients with persistent symptoms, frequent exacerbations (more than two courses of prednisolone in 12 months), very high reliever users (more than six salbutamol MDIs a year) and patients with complex comorbidities as well as those where there is diagnostic uncertainty to the specialist asthma clinic.6 It is important to remember that if a patient is taking their inhalers with the correct technique and regularly and has not responded then they probably do not have asthma.
Listen to Dr Richard Russell and Dr Sanjay Ramakrishnan discuss this topic here
(note that as-required budesonide and formoterol or as-required beclometasone and formoterol is currently off-label in the UK)
Dr Richard Russell, clinical researcher at the University of Oxford, consultant physician at Lymington New Forest Hospital and clinical lead for the NHS South East and Dr Sanjay Ramakrishnan research fellow, University of Oxford