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SUMMARY
Asthma is a chronic disease characterised by recurrent attacks
of breathlessness and wheezing. Symptoms can occur several times a day
and, in some people,
can be worse during physical activity or at night. The impact of these
symptoms can be seen on both the NHS expenditure and patients’ health-related
quality of life.
Each year, the NHS spends almost £1bn treating asthma and advances
in treatments and management over the past 20 years mean that patients
should not be putting up with symptoms.
However, asthma is still uncontrolled
and patients often do not adhere to their prescribed treatment regimens,
increasing their chances of attacks. “Unwitting non-adherence”,
as defined by the World Health Organization, accounts for a large number
of asthma patients who fail to use their medicines correctly because
they do not understand their regimen or the importance of correct use.
For
example, patients can misinterpret “use twice a day” as “use
twice a day when you are unwell”.
Lack of adherence to preventer medicines, such as inhaled corticosteroids,
can lead to poor symptom control and greater reliance on reliever therapy.
Studies have shown that between 6 and 44 per cent of prescriptions for
asthma medicines go unfilled, and that long-term adherence to preventer
therapy is poor even when prescriptions are filled.
Asthma has a number of clinical variants, including occupational, exercise-induced,
allergic and aspirin-sensitive. Although the condition cannot be cured,
appropriate management can help to keep it under control and enable people
to enjoy a good quality of life.
Pharmacists can play a crucial role
in ensuring patients are managed following clinical evidence and guidelines
so that patient outcomes are improved. Full article PDF 80K
Panel 1: New advances in asthma
management
Omalizumab Omalizumab (Xolair), an anti-immunoglobulin-E
antibody, reduces exacerbations and the requirement for steroids
in allergic
asthma. Patients with this type of asthma produce high levels
of IgE, which means their airways are over-responsive to common
stimuli, such as dust. Omalizumab, which is administered via subcutaneous
injection every two to four weeks, blocks the IgE, reducing the
body’s normal response to triggers.
The National Institute for Health and Clinical Excellence published
a technology
appraisal on the use of omalizumab for England and
Wales in November 2007. Omalizumab is recommended as a possible
treatment for adults and children over 12 years with severe persistent
allergic asthma when all of the following circumstances apply:
• The patient has allergic asthma which has been confirmed by
checking past symptoms and skin testing for allergies
• The patient’s asthma is severe and unstable despite best
efforts to control it with other medicines taken as directed
• The patient is a non-smoker (smokers should stop smoking before
omalizumab is prescribed)
• The patient has had at least two asthma attacks within the
past year that have resulted in hospital admission, or he or
she has had three or more severe asthma attacks within the past
year, one needing hospital admission and the other two needing
additional treatment in an accident and emergency department
Omalizumab treatment should be given alongside
the patient’s
current asthma medicines. The prescriber must be experienced
in asthma and allergy medicine at a specialist centre. If omalizumab
does not control the asthma after 16 weeks’ treatment should
be stopped.
The SMART strategy Simplicity
in the treatment of asthma, through reducing the number of medicines
or inhalers, has been identified
as an important aspect of a more desirable management strategy,
and provides healthcare professionals with a practical consideration
when aiming to adopt a more patient-centred approach to care.
Symbicort
maintenance and reliever therapy (SMART) is, perhaps, the most
important advance in management for all pharmacists
to be aware of. Until last summer, patients might have used one
or two inhalers daily to control their asthma, plus an additional
inhaler to relieve breakthrough symptoms, such as cough and wheeze.
SMART
allows patients to manage persistent asthma using a single inhaler
as both maintenance and relief.7 With the SMART approach,
patients take a maintenance dose both morning and night and then
use the inhaler as needed to provide asthma control. A maximum
of 10 extra puffs can be taken each day (ie, 12 puffs in total).
A separate reliever inhaler is not required and it is important
that patients understand this.
The SMART approach is possible because Symbicort combines budesonide
with formoterol, a rapid and long-acting bronchodilator. This
means that when the combination is for maintenance and relief,
not only is the bronchoconstriction relieved, but each inhalation
also treats inflammation.
Symbicort 100/6 and 200/6 have been
licensed for use in adults aged 18 years or over who are suitable
for this combination therapy (ie, patients not adequately controlled
with inhaled corticosteroids and as needed inhaled SABA or patients
already adequately controlled on both inhaled corticosteroids
and LABA plus as needed SABA). Prescriptions for SMART are likely
to read “budesonide/formoterol 200/6, one puff bd plus
as needed”.
SMART is consistent with the principles of current treatment
guidelines, which reflect disease severity. Although SMART is
not yet included in the current guidelines, use is based on the
principle of achieving and maintaining asthma control with the
lowest effective dose of inhaled steroid. SMART would probably
fit in at step 3 of the asthma management guidelines.
SMART was
devised by AstraZeneca. |
Panel 2: Practical tips for
asthma sufferers
How to recognise worsening symptoms
If
symptoms are getting worse, patients with asthma may recognise
some or
all of the following: • Needing more and more reliever treatment
• Waking at night with coughing, wheezing, shortness of breath
or a tight chest
• Having to take time off work or school because of their asthma
• Feeling that they cannot keep up with normal level of activity
or exercise
What to do during an asthma attack
An asthma attack card is
available from Asthma UK, which tells people what to do in an
attack. This includes:
• Take two puffs of your reliever (blue) inhaler
• Sit up and loosen tight clothing
• If there is no immediate improvement, continue to take one
puff of reliever inhaler every minute for five minutes or until
symptoms improve
• If symptoms do not improve in five minutes, or if in doubt,
call 999 or a doctor, especially if you are too breathless or
exhausted to talk or your lips are blue |
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The
Pharmaceutical Journal