THE Scottish Intercollegiate Guideline Network (SIGN) and the British Thoracic Society have collaborated over many years now to develop a guideline for asthma.
It is recommended that asthmatic patients are managed in a stepwise manner. There are five steps. Step 1 asthmatics have mild/moderate symptoms that are easily controlled with a reliever inhaler or other preparation when required. Conversely, step 5 patients have really quite severe symptoms and can often need oral steroids as well as multiple inhaled preparations to achieve control.
Below is an image that describes each step taken straight from SIGN 141. These steps are designed to guide clinicians managing adults and I should say there are slight variations when managing other groups like children.
It is recommended that patients should be placed on the therapeutic step that best controls their symptoms. Stepping up should be considered if symptoms persist. Step down is considered only if the patient is symptom free for three months or more. It’s also important to question the asthma diagnosis, especially if compliance to therapy is good and symptoms unexpectedly deteriorate. It’s also useful to recognise that asthma is a reversible chronic disease and can be worse in certain circumstances (e.g. after exercise) or at certain times of year (e.g. extremes of temperature).
A step one asthmatic will usually be prescribed a Beta-2-agonist like salbutamol for example. Salbutamol will temporarily cause bronchdilation of the airways and hence relieve symptoms. Asthmatics often quite like and can rely on these reliever preparations, because they get an almost instant relief from annoying or distressing symptoms.
“Good asthma control asthma control is associated with little or no use of a Beta-2-agonist” [SIGN 141].
If we take this statement to its logical conclusion then by definition step 1 asthmatics that use a Beta-2-agonist even once could be regarded as having uncontrolled asthma.
There is therefore, an argument for prescribing these inhalers for use when an inhaled steroid inhaler fails to control symptoms. Asthma is a reversible chronic disease so ideally patients should on the whole be symptom free.
Perhaps every asthmatic should be started straight on to step 2 with the goal of therapy being to reduce the inflammation using an oral steroid rather than constantly rescuing using the previously mentioned Beta-2-agonists like salbutamol.
I have spent quite a bit of time during the last year trying to opportunistically identify high risk asthmatics as they collect their inhalers from my community pharmacy. It is worth noting that the three factors I use to identify higher risk asthmatics are:
- deteriorating symptoms
- non-attendance at the annual asthma review
- overuse of short term bronchodilators e.g. Beta-2-agonists like salbutamol.
The question is, I guess, in the light of the National Review of Asthma Deaths (NRAD) would it be prudent to lower our threshold of what a controlled asthmatic looks like and go straight in at step 2.
To be honest, right now I’m not sure, so it will be interesting to hear if more experienced prescribers have a view on this. If you have thoughts do share.
Johnathan Laird is a community pharmacist independent prescriber with a special interest in asthma. He is based in based in Aberdeen.
Follow Johnathan @JohnathanLaird