Strategies to manage asthma - University of Tasmania · ,e vidence-base upd ate Thearticles in this...
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,e vidence-base update The articles in this seriesare Jndecenoenuy reseerchec and compil ed by PSA ccmmisslcnec authors and peer revrewec Strategies to manage asthma ByB onme Bmetllicki, Dr Luke B ereznir J<j and P lOfessnr GrOtj(Jry Pe ferson , Vllif fnrMed ication Oufc,omfiS R esearc.h amiEd ucation, School of Ptliirmacy. Vlliversity Of Tasmallia .I i Learning objectives: After re ad ing this article, the rea der should be able to: • U nderstand the t ypes of ma na gement strategi es for asthma; and • Discuss the eviden ce behind current asthma ma nagement strategies, and be confident in making recommendations to patients andGf's. Ca se study Mr RB, a 24 -year-old non-smoker, comes into your pharmacy and asks for a salbutamol inhaler. tie says he normally has a prescription for it but he has run out of repeats. You check his dispensing history and see that Mr RB has consistently received one budesonide 200 mcg turbuhalar every six to eight weeks and two salbutamol inhaters every month, over the last 18 months. You ask him how often he requires hIS salbutamol and he replies that he needs to use it every morning, and then occasionally throughou t the day. He saysthat his asthma 'has always been pretty bad' and he is 'used to putting up with it: Introducti on Asthma is rec ognised as a National Health Pr iority Area in Australia, and is responsible for significan t morbidity and mo rtality in the cummu nity. International p opu lation- bas ed studies suggest that Au stralia has one of the highest prevalence rates for asthma in the world,' affecting an estimated two million peo ple.' E xac erbations of asthma lead to approximately 40,000 hospitalisati ons and 105,000 eme rgency department visits an nually.' Despite the existence of national initiatives aiming to improve asthma care:· 5 findings from a recent National Health Survey showed that the ma nage men t of as thma remains suboptimal.' Significant clinical problem s persist. including unde r-treatment with i nhaled corticosteroids (ICSI, ove r-reliance on reliever medications, and poo r patien t self-management skills.' It is well-r ecognis ed that the achievement and main tenance of asth ma controt redu ces the risk of acute exace rbat ions and impr oves prog nos is. To ach ieve an d maintain asth ma control for prolonged periods, rec ommenda tions for asthma l ie sayS ira hk; af>ltrf IH '118$ ClMtays been {)fAtty tsed.: o-a re 'u. seer to ().d1ittfJ up with it.' manag em ent have been made in a number of interre lated areas. Th e focus of this article is to review theevide nce for the strategies used to optima lly manag e asthma and preve nt exacerbations, The Austra lian Asthma Management Plan The Australian Asthma Ma nagement Plan' was published in 1989 by the National Ast hma Council (NAC) ,' and was the first of ma ny international, consensus-based asthma guidelines. It provides gu id anc e and recomm endations for hea ith professiona ls in the m an a gement of a sthma according to a six-step plan . Th e Asthma Managem ent Plan is a dynamic docu men t. which has been m od ified to reflect chan ging evidence in be st p ractice. Althoug h theavailability of newer med ica tions has altered the mea ns by which best lung function is achi eved and mainta ined , theun de rlying concepts of the plan have remained the sarno . There is now good evidence that particular elements of tho As thma Managem en t Plan improve patient self-manageme nt through monitoring asthma symptoms, seeking regula r medical review, and using a written Asthma Action Plan IAAP).' Evidence- based review, ba sed on r and omised controlled trials {RCTs!. has demon strated the effic acy of so me aspects of the plan but cou ld find no evidence in favour of other aspe cts' For ex ample, there is good evi dence of the effectiveness of pr event ive medications, reliever med ications and symptom controll ers [lonq-actinq beta-2- agonists; ILABAslJ in the trea tme nt of asthma . The eviden ce for alt ern ative therapies I I I l I )
Transcript of Strategies to manage asthma - University of Tasmania · ,e vidence-base upd ate Thearticles in this...
,e vide nc e - ba s e upd at eThe articles in this series areJndecenoenuy reseerchec andcompiled by PSA ccmmisslcnec authors and peer revrewec
Strategies to manage asthmaByBonme Bmetllicki, DrLuke BereznirJ<j and PlOfessnrGrOtj(Jry Peferson,Vllif fnrMedication Oufc,omfiS Researc.h amiEducation,School of Ptliirmacy. Vlliversity Of Tasmallia
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Learning objectives:After read ing this article, the reader should be ableto:
• Understand the types of management strategiesfor asthma; and
• Discuss the evidence behind current asthmama nagement strategies, and be confident inmaking recommendations to patients andGf's.
Case studyMr RB, a 24 -year-old non-smoker, comes into yourpharmacy and asks for a salbutamol inhaler. tie sayshe normally has a prescript ion for it but he has run outof repeats. You check his dispensing history and seethat Mr RB has consistently received one budesonide200 mcg turbuhalar every six to eight weeks and twosalbutamol inhaters every month, over the last 18 months.You ask him how often he requires hIS salbutamol and hereplies that he needs to use it every morning, and thenoccasionally throughout the day. He says that his asthma'has always been pretty bad' and he is 'used to puttingup with it:
Introducti onAsthma is recognised as a National Health Pr iority Areain Australia, and is responsible for significant morbidityand mortality in the cummunity. International popu lationbased studies suggest that Australia has one of the highestprevalence rates for asthma in the world,' affecting anestimated two million people.' Exacerbations of asthmalead to approximately 40,000 hospitalisations and 105,000emergency department visits annually.' Despite the existenceof national init iatives aiming to improve asthma care:·5
findings from a recent National Health Survey showed thatthe management of asthma remains suboptimal.' Significantclinical problems persist. including under-treatment withinhaled corticosteroids (ICSI, over-reliance on relievermedications, and poor patient self-management skills.' Itis well-recognised that the achievement and maintenanceof asthma controt reduces the risk of acute exacerbat ionsand improves prognosis. To achieve and maintain asthmacontrol for prolonged periods, recommendations for asthma
l ie sayS ira hk; af>ltrf IH '118$ ClMtays been {)fAtty tsed.: o-a re ~ 'u.seer to
().d1ittfJ up with it.'
management have been made in a number of interre latedareas. The focus of this article is to review the evidence forthe strategies used to optima lly manage asthma and preventexacerbations,
The Austra lian Asthma Management PlanThe Australian Asthma Management Plan' was publishedin 1989 by the National Asthma Council (NAC),' and wasthe first of many international, consensus-based asthmaguidelines. It provides guidance and recommendations forheaith professiona ls in the management of asthma accordingto a six-stepplan. The Asthma ManagementPlan is a dynamicdocument. which has been modif ied to reflect changingevidence in best practice. Although theavailability of newermedica tions has altered the means by which best lungfunction is achieved and mainta ined, theunderlying conceptsof the plan haveremained the sarno .
There is now good evidence that particular elements of thoAsthma Management Plan improve patient self-managementthrough monitoring asthma symptoms, seekingregular medicalreview, and using a written Asthma Action Plan IAAP).'Evidence-based review, based on randomised controlled trials{RCTs!. has demonstrated the eff icacy of some aspects of theplan but could find no evidence in favour of other aspects'For example, there is good evidence of the effectiveness ofpreventive medications, reliever medications and symptomcontrollers [lonq-actinq beta-2-agonists; ILABAslJ in thetrea tme nt of asthma. The evidence for alternative therapies
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and the avoidance of trigger factors for asthma is not strong.Importantly, thereview found strong evidence for theprovisionof training in self-management involving sel f-monitoring ofsymptoms, regular medical review and use of writtenAAPs inadults. The As thma Management Plan rema ins the backboneof asthma care in Australian clinical practice.
Asthma Cycle of CareIn recognition of the signif icant burden that asthma placeson the Australian cornmunitv in terms of hea lth, social,economic and emotional costs, Australian Health Ministersannounced asthma as a National Health Priority Area in 1999.'Subsequently, the Commonwealth Government announcedthe $48.4 mill ion National GP Asthma Initiative in the 2001Nationa l Health Budget to improve hea lth outcomesof peoplewith moderate-to-severe asthma." The GP Asthma lnitiativepromotes the use of the Asthma Cycle of Care (formerly theAsthma 3+Visit Plan], which utilises a structured approach toasthma care, as thebest practice modelof managingasthma.recognising that effective long-term management requiresongo ing care and regular review, The Asthma Cycle of Careencourages partnerships in proactive asthma care betweenthe patient and their health professionals, and involves atleast two asthma-related consultations within 12 months for apatient with moderate to severe asthma. The visits include anassessment of asthma severity and level of asthma control, areview of the patient's use of asthma medica tion anddevices,asthma self-management education, and the development ofan AAP. Systematic review has shown that people who seetheir GP regularly, receive education in self-management andhave a wrinen AAP require significantly fewer emergencydepartment visits, hospital admissions, days off work orschool and unscheduled doctor visits, and have significantlyreduced nocturnal asthma symptoms and significantly higherquality of life scores.'
Ongoing patient education is a vital component of thepartnership between patients and healthcare professionals,and can contribute to successful asthma care." However. ithas been demonstrated that the acquisition of knowledge bypatients dues not necessa rily translate into effective self management behaviour" It is therefore imperative that thepatient not only understands their condition, including thepurpose of medication and correct inha lation technique, butalso the importance and value of self-management of theirasthma.
Asthma Action PlansAn integral part of the Asthma Cycle of Care is thedevelopment of a written AAP. which helps the pat ient orcarer recogniseworseningasthma. AAPs have become a core,albeit under-utilised. component of asthma management inAustralia in accordance with best practice guidelines. Thefunction of a written AAPis to prov ide the patient with a set
VoILme 27 I l\ulTIl>Hf f) IMay M 8
of rules by which to alter therapy. dependent on either peakexpiratory flow monitoring or symptom levels, The implicationis that an appropriate. early response to deterioration willprevent dangerous exacerbations and will genera lly improvehealth-related quality of life. AAPs contain the followingessential components:
i) Instructions on when and how to intensify treatment:ii) The duration of the. treatment increase; andiiil When to cease self-management aod seek med ical
help"
A key objective of AAP use is to help people with asthmato mon itor themselves and their own actions, learn fromthese actions to support self-care behaviours. and thenintegrate these into their daily routines." Increasing patientparticipation in their own care has bep.n assnciated withsignificantly improved asthma symptoms and adherencewith preventive med ication, as well as significantly fewerhospitalisations, days off school or work and reduced needfor reliever medication" It has also been found that thepossession of a written AAP reduces the risk of death fromasthma by 70%."
Ongoing patient educationis a vital component of thepartnership between patients andhealthcare professionals, and cancontribute to successful asthmacare,
Regular ICS therapyCurrent Australian guidelines recommend that all patientswith persistent asthma of all levels of sev.erity use ICS aspreventive therapy" ICS are currently themost effective antiinflammatory medication for the management of persistentasthma. Studies have demonstrated their efficacy in reducingasthma symptoms." improving lung function," controllingairway inll ammation," reducing the frequency and severityof exacerbations," andreducing asthma mortality." However,they do not cure asthma. and when they are discontinued.deterioration of clinical control follows within weeks tomonths in a proportion of patients." It iswell established thatin adults, persistent asthma requires long-term preventivemedication to mainta in good control." Evidence-basedguidelines over the past decade, including the NAC's six-stepAsthma Management Plan, have emphasised the importanceof the regular use of anti-inflammatorydrugs (preferably ICSjas first-line therapy for anything more severe than occasionalmild asthma, and a shift of approach away from relianceon relievers. There have he.en a number of studies in the
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The articlesin ttus series are lndepcndenur researcneo ann compiled byPSA ccmrmssroneuautnurs and peer H!'viewed
A'>ltlmiJ g.M:1ekle.s r~",rild tro1 rn.;;itriHfIf:dCH ICS ra{JICSCfbed i;lf IJ IfoI.tMcst ctfective r.b:;H HCr.O'T1r1g to tJ1f:I ~ity 01 ftc COf'ditffi
interna tional literature indicating that a hiqh usage of relievermedication, relative to preven ter medication, is associatedwith poorer clinical ou tcomes of asthma, incloding increasedemergency department visits and hospital admissions." !Short-acting beta-2-agonists are recommended in all stagesof asthma on an as-needed basis only. Asthma guidelinesrecommend that maintenance ICSbe prescribed at thelowesteffectivedose accord ing tn the severity of the condition." It isessential that the ICS treatment is individualised, as too higha dose may result in adverse effects and too Iowa dose mayresult in under- treatment and poorasthma control.
A systematic review of ACTs demonstrated that the additionof a lA BA to ICS therapy improves asthma symptoms. Theaddition of l ABA has an ICS-sparing effect, which permitsa reduct ion in ICS maintenance dose." Specifically, studiesthat compared reduced dose ICS/LABA combination toa fixed moderate-to-high dose ICS reported significantimprovements in lung function and percent rescue free dayswith the ICS/ l /\B/\ combination therapy." However, thereview also found no significant difference in the number
of severe exacerbations requiring oral corticosteroids whencomparing the combination to ICS alone. Greenstone, et a',reported similar findings, concluding that there is noapparentsuperiority of adding LABA to ICS in terms of exacerbations,bot improved symptoms and long function tests favoursadditional LABA therapy" The NAC recommends a LABAshould be the first choice for add-on therapy in patients forwhom adequate asthma control is not achieved despite lowdose ICS treatment. otter roling oot pooradherence and poorinhalation technique as causes." In an attempt to improveadherence, devices are ava ilable combining ICS and l ABAtherapy in a single inhaler.
Ma intenance and reliever therapyIn light of the growing evidence that many patients neglecttheir preventer medication and over-rely on relievermedication, a new asthma manauement strategy has recen tlybeen evalua ted in a series of clinical trials."' " The strategyutil ises a single inhaler containing an ICS (budeson ide) anda lABA leformoteroll for both maintenance therapy andsymptomrelief. For patients with persistent asthma symptomsdespite the regular use of ICS, studies have found thatfewer severe exacerbations occurred with the maintenanceand reliever regimen when compared to the conventionalcombination regimen of regular ICS plus a short-acting beta2-agonist when required. Table 1 summarises the results ofCOMPASS, the only published double-blind trial where themaintenance and reliever reg imenwas compared toa higherdose convent ional reg imen.28
InAugust 2007, thePharmaceutical Benefits Scheme hstmq ofbudesonide with eformotero I 100/6~g and 200/6~g ISymbicortjwas extended to allow Australianswho experience frequentasthma symptoms while receiving combinat ion ICS/LABAtherapy or ICS alone to use the aiternative budesonide withefarmoterol maintenance and reliever regimen." The NAChas endorsed this new regimen (commonly ca lled Symbicort
Tab le 1. Rates of severe exacerbations in the COMPASS triaF6
Treatment group Severe exacerbat ions per 100 Average daily les dosepatients per six months (budesonide equivalentl
Budesanidewith eformaterol 12" 604~g
Imaintenance and reliever regimen)n = 1107
Budesonide with eformoterol plus terbutaline 16 800~g
asneeded (conventional regimen!n = 11 05
Fluticasanewith salmeterol plus terbutaline 19 800 ~g
as needed (conventional regimen)n =1123
"Thenumberof severe exacerbationswas significantly less thanwith lhe budesonide with eformoterol conventional reg imenIP= 0.00481and also significantly less than with the Iluticasone with salmeterol conventional regimen (P< 0.001!.
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,-ev i denc e- base updateThe articles in this series are inll cpendelilly researcned anncompiled by p~ commissioned aumcrsand peer revtewed.
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Maintenance And Reliever Therapy: SMART). with a SMARTspecific written AAP nowavailable."
Whilethe drug treatments used in the management of asthmahave proven efficacy, effective management strategies andadherence with therapy are imperative to reduce the morbidityandmortality associa tedwith the condition. Even in patientswith uncontrolled asthma. guideline-defined control can beach ieved and maintained with appropriate treatment." Theaforementioned strategies are useful and provenapproachesto aid in the ach ievement of treatment goals in asthma, andshould be promoted bypharmacists.
Case studyYou advise M, RB that he shouldn't have to put up withhis asthma symptoms as evidence has demonstrated thateven patients with severe asthma can gain control of theirsymptoms with appropriate therapy. You indicate to M,RB that you are concerned that his asthma could be bettercunuotled, and recommend that he see his GP as soon aspossible for a review of his asthma therapy, and for thedevelopment of an lndividualised Asthma Action Plan. Youprovide Mr RB with a salbutamol inhale' to use in the interimand check his inhale' technique. You also provide him withsome educational materials fromthe Asthma Foundation andthe Pharmacy Self Care Fact Cards on Asthma and AsthmaMedicines.
Bonnie Bereznicki. Or Iekn Rp.[p. lnicki and Professor Gregurv Peterson arefrom the Unit tor MedicationOutcomes Research andEducation. School ofPharmacy, University of Tasmania.
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Cpt] Questions CHI p.1ge 420-422
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