INTRODUCTIONOver a decade on from the National Review of Asthma Deaths (NRAD), the number of annual asthma deaths has increased by 25%, and complacency around asthma continues to lead to thousands of preventable deaths.1,2Up to 200,000 people in the UK have severe or uncontrolled asthma, which has a significant impact on their quality of life.3 Asthma + Lung UK reports that 12,000 people have died from asthma attacks since NRAD was published, and there are four deaths caused by asthma every day. The charity also says that 70% of people with asthma are not receiving basic standards of asthma care. Hospital admission rates have remained constant at over 60,000 a year since the NRAD report.2 ‘Basic’ care should include annual asthma reviews, inhaler technique checks and written asthma action plans. Patients who are admitted to hospital or attend an emergency department should be reviewed by their GP or general practice nurse within 48 hours of discharge but less than 20% receive this follow up.2 Asthma control should be assessed at every review. Complete control of asthma is defined as:4
In addition to asking about symptoms, check:4
A validated symptom questionnaire should be used to provide a more objective assessment of control – NICE recommends the Asthma Control Questionnaire (ACQ), Asthma Control Test (ACT) or the Childhood Asthma Control test (C-ACT).4 If asthma appears to be uncontrolled, address possible reasons before adjusting medication. These may include:4
If possible, check FeNO level when asthma is uncontrolled: if this is raised, it may indicate poor adherence or the need for an increased dose of inhaled corticosteroid (ICS).4 One of the key risk factors for asthma deaths is overuse of ‘reliever’ inhalers – short-acting beta2 agonists (SABA).1 NICE states categorically: Do not prescribe SABA to people of any age with asthma without a concomitant prescription of ICS.4 NICE therefore recommends ICS/formoterol combination inhaler to be taken as needed for symptom relief (as needed anti-inflammatory-reliever [AIR] therapy).4 This ensures that if symptoms worsen, the dose of ICS is automatically increased, and conversely, when symptoms improve and the need for reliever medication decreases, the dose of ICS is also decreased. Only formoterol-containing combination inhalers are recommended for AIR therapy, because formoterol is both long-acting and has a rapid onset of action. Several studies have demonstrated that severe exacerbations in people using AIR were lower than in those using ICS plus as-needed SABA by over 50%. A Cochrane meta-analysis concluded that as required ICS/formoterol reduced exacerbations, hospital admissions, unscheduled healthcare visits, average expose to ICS and exposure to systemic corticosteroids, and was unlikely to be associated with adverse events.5 Consider changing treatment to low-dose maintenance and reliever therapy (MART)* for people whose asthma is not controlled using:4
If these options do not produce adequate control, increase treatment to moderate-dose MART *Combined ICS plus formoterol in a single inhaler used for daily maintenance treatment and the relief of symptoms as needed. The terms low-dose MART and moderate-dose MART refer to the dose of the ICS component. People using MART do not generally require a SABA. When changing from low- or moderate-dose ICS (or ICS/LABA combination inhaler) plus supplementary therapy (e.g. leukotriene receptor antagonist [LTRA] or long-acting muscarinic receptor antagonist [LAMA]) to MART, consider whether to stop or continue the supplementary therapy based on the degree of benefit achieved when first introduced.4 Refer people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA and a LAMA.4 Indicators of severe/uncontrolled asthma3Over previous 12 months, any of:
*Note, more recent guidelines suggest that more than three prescriptions for SABA indicate that asthma is poorly controlled.6 References1. Royal College of Physicians. Why asthma still kills: The National Review of Asthma Deaths (NRAD); 2014 https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills 2. Asthma + Lung UK. Asthma care in crisis; April 2024. https://www.asthmaandlung.org.uk/media/press-releases/asthma-care-crisis-charity-sounds-siren-asthma-death-toll-rises 3. AAC consensus pathway: management of uncontrolled asthma in adults; June 2022. https://www.healthinnovationoxford.org/our-work/respiratory/asthma-biologics-toolkit/aac-consensus-pathway-for-management-of-uncontrolled-asthma-in-adults/ 4. NICE NG245. Asthma: diagnosis, monitoring and chronic asthma management; November 2024. https://www.nice.org.uk/guidance/ng245 5. Crossingham I, Turner S, Ramakrishnan S, et al. Combination fixed-dose beta agonist and steroid inhaler as required for adults or children with mild asthma. Cochrane Database Syst Rev2021;5(5):CD013518. https://doi.org/10.1002/14651858.CD013518.pub2 6. Global Initiative for Asthma (GINA). Pocket guide for health professionals; updated 2023. https://ginasthma.org/wp-content/uploads/2023/07/GINA-2023-Pocket-Guide-WMS.pdf |
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