Session 2

1. 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)

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 New Recommendations for Pharmacological management • The Step approach has been superseded • There are differences in how the doses of ICS are expressed (ex-valve – the metered dose or ex-actuator – the delivered dose) • The doses of ICS are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. 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. 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. MART/SMART Regime 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