Adult asthma

Current British Guidelines on the Management of Asthma provide the following recommendations for the management of asthma.¹

General principles of adult asthma management

• Step up/down treatment according to disease severity to maintain good control and minimise drug-related side-effects.

• Start at the step most fitting to the initial severity of the asthma.

• Treatment plans and goals should be negotiated with the patient but usual aims would be to minimise impact of adult asthma symptoms on life, reduce reliance on reliever medication and prevent severe exacerbations.

• Self-management education including individualised written asthma action plans should be offered.

• Always check concordance with medication/existing action plan, effective inhaler technique and the presence/absence of trigger factors before initiating new drug therapy.

• It is very important to consider the upper respiratory tract when treating asthma. It is much more difficult to treat asthma successfully if co-existing allergic rhinitis is not adequately controlled.²

See also the separate Occupational Asthma, Asthma (bronchial) and Acute Severe Asthma and Status Asthmaticus articles.

Asthma reviews

Routine asthma care is largely carried out in primary care. Practices must keep a register of patients with asthma to ensure adequate follow-up and audit. All patients with asthma should be reviewed at least annually, more often if disease is less well controlled or recently diagnosed. Reviews should be carried out by a nurse or doctor with appropriate and up-to-date training and should include:

• Current symptoms using objective measures:
  

  The 'three questions' of the Royal College of Physicians (RCP) are widely used:

  • In the last month/week have you had difficulty sleeping due to your asthma (including cough symptoms)?

  • Have you had your usual asthma symptoms (eg, cough, wheeze, chest tightness, shortness of breath) during the day?

  • Has your asthma interfered with your usual daily activities (eg, school, work, housework)?

  Note: one 'yes' indicates medium morbidity and two or three 'yes' answers indicate high morbidity.

  
  Alternatives include the Asthma Control Questionnaire, Asthma Control Test and Mini Asthma Quality of Life Questionnaire.

• Record an up-to-date smoking status; offer smoking cessation advice and support where appropriate.

• Record any acute exacerbations since last seen.

• Check medication use - a prescription count can indicate overuse/underuse of medication, inhaler and spacer, problems and side-effects. The use of more than two canisters of short-acting beta₂ agonist per month - or 10-12 puffs per day - is associated with poorly controlled and higher-risk asthma.

• Check immunisation (pneumococcal/influenza) status.

• Review peak flow diaries and record current peak expiratory flow rate (PEFR)/spirometry values.

• Address any educational needs.

• Provide/update a written action plan.

• Consider home monitoring of PEFR - useful particularly in those with severe or brittle asthma and those who have difficulty recognising symptom deterioration.

• Agree duration of subsequent follow-up and ensure the patient is aware of how to seek help if their asthma deteriorates.

Asthma action plans³

All patients with asthma should have an individually tailored action plan to include:

• What medication they are on and how it works.

• How to titrate their medication in times of exacerbation and when to seek help.

• How to manage severe asthma symptoms.

• When to contact emergency services.

The National Institute for Health and Care Excellence (NICE) has also advised that approaches to reducing air pollution (both indoors and outdoors) should be part of this plan, as pollution can trigger and exacerbate asthma. These should include:⁴

• Approaches to minimising indoor air pollution and reducing exposure to outdoor air pollution should be included in a personalised action plan because pollution can trigger and exacerbate asthma.

• Advising patient about indoor air pollutants - including nitrogen dioxide, damp, mould, particulate matter and volatile organic compounds (VOCs).

• If mould or other indoor pollutants could be exacerbating a patient's symptoms, they should be helped to request a housing assessment from the local authority.

• Avoiding household sprays, air fresheners or aerosols and using non-spray alternatives, if patients' sympoms are triggered by these.

The use of remote technology such as telephone reviews, SMS and the internet has received mixed response from patients and healthcare professionals alike.⁵ However, the British guideline on asthma still acknowledges telephone contact as being effective in providing ongoing support and advice.¹

Non-drug treatment for adult asthma¹

All people with asthma (and/or their carers) should be offered self-management education (including a written personalised asthma action plan as discussed above) and be supported by regular professional reviews. Self-management could include:

• Smoking cessation. Smoking exacerbates asthma symptoms. It increases the risk of persistent asthma in teenagers who smoke. Clear personalised advice should be given to stop smoking and help provided with nicotine replacement therapy, etc, where appropriate.

• Weight reduction in obese patients improves asthma symptoms and should be encouraged.

• Breathing exercise programmes can be offered to people with asthma as an adjuvant to pharmacological treatment, to improve quality of life and reduce symptoms.

• Allergen avoidance. There is little evidence that reducing allergen exposure reduces morbidity from asthma and it does not appear to be a cost-effective treatment for asthma. Avoiding house dust mite allergen (bed covers, carpet removal, high-temperature washing of bedding, dehumidification and use of acaricides on soft furnishings) requires commitment beyond what is possible in most households. Similarly, cat and dog allergens are potent triggers for many people's asthma. Again, however, observational evidence that removal of the pet from the household improves asthma control, is lacking. Nonetheless, expert consensus usually advocates their removal.

Dietary modifications (use of probiotics, antioxidants, fish oils/lipid supplements, magnesium) and complementary therapies are not currently supported by the guidelines.

Drug treatment¹

Step up/down management of chronic asthma:

Step 1: mild, intermittent asthma

Prescribe an inhaled short-acting beta₂ agonist as a short-term reliever for all patients with symptomatic asthma.

Good asthma control is associated with little or no need for a short-acting beta₂ agonist. Anyone prescribed more than one short-acting bronchodilator inhaler device a month should be identified and have their asthma assessed urgently and measures taken to improve asthma control if this is poor. Regular use of bronchodilators alone may be linked with worsening asthma and asthma deaths.

Step 2: introduction of regular preventer therapy

Inhaled corticosteroids (ICS) are the most effective preventer drug for adults and older children for achieving overall treatment goals. ICS should be considered for patients with any of the following asthma-related features:

• Asthma attack in the last two years.

• Using inhaled beta₂ agonists three times a week or more.

• Symptomatic three times a week or more.

• Waking one night a week.

Titrate the dose of ICS to the lowest dose at which effective control of asthma is maintained. Smokers may require higher preventive doses than non-smokers.

ICS are the first-choice preventer drug. There are alternative, less effective preventer therapies for patients taking short-acting beta₂ agonists alone:

• Leukotriene receptor antagonists (LTRAs) have some beneficial clinical effect.

• Sodium cromoglicate and nedocromil sodium are of some benefit.

• Theophyllines have some beneficial effect.

• Antihistamines and ketotifen are ineffective.

Step 3: add-on therapy

NICE advises that an LTRA such as montelukast should be tried as initial add-on therapy before considering an inhaled long-acting beta₂ agonist (LABA).

LABAs include salmeterol and formoterol. The addition of an inhaled LABA to ICS alone improves lung function and symptoms and decreases asthma attacks in adults. Inhaled LABAs should not be used without ICS.

• Review after a trial of therapy - continue if successful in controlling symptoms well.

• Discontinue after a trial of therapy if no benefit is seen. Then, increase the inhaled steroid dose to 800 micrograms/day beclometasone propionate or equivalent. If control remains suboptimal, consider a trial of another add-on therapy such as modified-release theophylline.

If asthma control remains suboptimal after the addition of an inhaled LABA then the dose of ICS should be increased from low dose to medium dose, if not already on this dose.

Step 4: poor control on moderate dose of inhaled steroid plus add-on therapy

If control remains poor on low-dose ICS plus an LRTA and an LABA, recheck the diagnosis, assess adherence to existing medication and check inhaler technique before increasing therapy. If more intense treatment is appropriate, the following alternatives can be considered.

• Discuss with the patient whether or not the LRTA should be continued.

• If there is an improvement when a LABA is added (with or without an LRTA) but control remains inadequate: continue the LABA and increase the dose of ICS, or continue the LABA and the ICS and add tiotropium bromide (a long-acting muscarinic antagonist - LAMA).

• If there is no improvement when a LABA is added, stop the LABA and try: an increased dose of ICS, or LAMA (LAMAs are not licensed for this indication).

Other approaches

• Theophyllines may improve lung function and symptoms; however, side-effects occur more often.

• Slow-release beta₂-agonist tablets may also improve lung function and symptoms but side effects occur more often.

• The addition of short-acting anticholinergics is generally of no value. The addition of nedocromil is of marginal benefit.

• If control remains inadequate after stopping a LABA and increasing the dose of ICS, consider sequential trials of add-on therapy, ie theophyllines, or slow-release beta₂-agonist tablets (in adults only).

If control remains inadequate on medium dose of an ICS plus a LABA, the following interventions can be considered:

• Increase the ICS to high dose (adults) or

• Consider changing to an inhaler which delivers a combination of ICS and a fast-acting LABA. This is called maintenance and reliever therapy (MART).

• Add a theophylline; or

• Add slow-release beta₂-agonist tablets, although caution needs to be used in patients already on LABAs; or

• Add tiotropium (adults).

At high doses of ICS via a pressurised metered-dose inhaler (pMDI), a spacer device should be used.

Step 5: continuous or frequent use of oral steroids

For the small number of patients not controlled on high-dose therapies, use daily steroid tablets in the lowest dose providing adequate control. These patients should always be under the care of a respiratory physician. Patients on long-term steroid tablets (longer than three months) or requiring frequent courses of steroid tablets (three to four per year) will be at risk of systemic side-effects:

• Blood pressure should be monitored.

• Urine or blood sugar and cholesterol should be checked: diabetes mellitus and hyperlipidaemia may occur.

• Bone mineral density should be monitored in adults. When a significant reduction occurs, treatment with a long-acting bisphosphonate should be offered.

• Cataracts and glaucoma may be screened for through community optometric services.

Stepping down

Review treatment every three months. Step it down if possible (but consider seasonal variation in symptoms, severity of asthma, risk of adverse effects, patient preference) and use the lowest possible dose of ICS to control the asthma symptoms. When reducing inhaled steroids, cut the dose slowly by 25-50% each time.

Combination products
Increasingly, combination inhalers of LABAs and low-dose inhaled steroids (eg, Symbicort® = formoterol and budesonide, Seretide® = salmeterol and fluticasone) are being marketed and used. These products are convenient since many patients are on a maintenance dose of both types of drugs and should be expected to improve adherence. However, they should only be used if the patient requires both drugs and has previously been stabilised on a dosage regimen that is deliverable by the combination inhaler. Using combined inhalers makes it harder to assess whether a patient still requires both drugs and in what doses and so the LABA or ICS may not be stepped down appropriately.

Biologic treatments - monoclonal antibodies

There are currently five biological treatments approved for use in the UK and available on the NHS to treat severe asthma. All can be started by specialists under certain criteria. All are injections, apart from reslizumab which is delivered via intravenous infusion.

These are:

• Omalizumab (Xolair®).

• Mepolizumab (Nucala®).

• Reslizumab (Cinqaero®).

• Benralizumab (Fasenra®).

• Dupilumab (Dupixent®).

Omalizumab⁶
NICE recommends omalizumab as an option for treating severe persistent confirmed allergic IgE-mediated asthma as an add-on to optimised standard therapy in people aged 6 years and older who need continuous or frequent treatment with oral corticosteroids (defined as four or more courses in the previous year). Omalizumab should only be initiated by a specialist.

Optimised standard therapy is defined as a full trial of and, if tolerated, documented compliance with high-dose ICS, LABAs, LRTAs, theophyllines, oral corticosteroids, and smoking cessation if clinically appropriate.

Mepolizumab⁷
NICE has issued recommendations on the use of mepolizumab in patients with severe eosinophilic asthma. It is only recommended as an add-on therapy to patients with severe refractory asthma not controlled with an optimised standard treatment plan. It is given as an injection every four weeks.

Mepolizumab may be suitable for age 6 years and above. Only children aged 12 years or above can be given treatments to use at home.

In addition, they must fulfil the following criteria:

• Blood eosinophil count has been recorded as at least 300 cells/mcl or more and they have had at least four exacerbations needing systemic corticosteroids in the previous year, or had continuous oral corticosteroids of at least the equivalent of prednisolone 5 mg per day over the previous six months; or

• Blood eosinophil count has been recorded as at least 400 cells/mcl and they have had at least three exacerbations needing systemic corticosteroids in the previous year.

Reslisumab⁸
Reslizumab is suitable for adults aged 18 and over. It is given as an intravenous infusion every four weeks.

Patients must fulfil the following criteria:

• Eosinophil count has reached 400 cells or more and they have had at least three or more asthma attacks needing steroid tablets or injections in the past 12 months.

• Patient is based in England, Wales or Northern Ireland. It's not available in Scotland yet.

Benralizumab⁹
Benralizumab is suitable for adults aged 18 and over. It is given as an injection every four weeks for the first three doses, then eight-weekly thereafter.

Patients must fulfil the following criteria:

• Eosinophil count has reached 300 cells or more; and

• Had four or more asthma attacks needing steroid tablets or injections in the past 12 months; or

• Had continuous steroids of at least 5 mg prednisolone per day over the previous six months.

If the patient has responded well to benralizumab after 12 months, they can continue on it with a yearly review.

Dupilumab¹⁰
Dupilumab as an option for add-on maintenance therapy in severe asthma with type 2 inflammation that is inadequately controlled in people aged 12 years and over, despite maintenance therapy with high-dose inhaled corticosteroids and another maintenance treatment, if:

• The dosage used is 400 mg initially and then 200 mg subcutaneously every other week.

• The person has agreed to and follows an optimised standard treatment plan.

• The person has a blood eosinophil count of at least 150 cells/mcl and FeNO of at least 25 parts/billion, and has had at least four or more exacerbations in the previous 12 months.

• The person is not eligible for mepolizumab, reslizumab or benralizumab, or has asthma that has not responded adequately to these biological therapies.

Management of acute asthma

See the separate Acute Severe Asthma and Status Asthmaticus article - treat as an emergency.

Current evidence does not support increasing the dose of ICS as part of a self-initiated action plan to treat exacerbations in patients with mild-to-moderate asthma. Increased ICS dose is not associated with a statistically significant reduction in the odds of requiring rescue oral corticosteroids for the exacerbation, or of having adverse events, compared with a stable ICS dose.¹²

Asthma in pregnancy¹¹³

Asthma's course in pregnancy is very variable. The risk of deterioration is highest in those with severe asthma but, equally approximately, a third of women with asthma improve symptomatically during pregnancy. Up to a fifth of pregnant women with asthma require emergency treatment, of which two thirds require hospitalisation.

Well-controlled asthma minimises the risk of fetal and maternal complications. Pre-pregnancy, optimise control and emphasise the importance of continuing medication in pregnancy. Closely monitor pregnant women with asthma, so that appropriate changes to their treatment can be quickly implemented in response to changed symptoms.

Treat exacerbations vigorously, in particular ensuring oxygen saturation is maintained above 95%. In general, asthma medications are believed to be safe in pregnancy - women should be reassured regarding treatments. Inhaled short- and long-acting beta₂ antagonists, ICS and oral and intravenous theophyllines can be used as normal during pregnancy.

Acute severe asthma in pregnancy is an emergency and should be treated vigorously in hospital.

Smoking cessation and breastfeeding should be particularly encouraged in women with asthma. Asthma drugs can be used as normal in breastfeeding women.

Inhaler and spacer devices

See also the separate Which Device in Asthma? and Nebulisers in General Practice articles.

Asthma management can be confusing given the array of devices, masks and spacers used to deliver inhaled drugs. When considering which inhaler device, consider manual dexterity and other necessary abilities to activate a particular device, factors such as portability and convenience and the patient's willingness to use a particular device.

Whenever an inhaler is prescribed, training should be given and technique checked regularly to ensure that it is being used correctly.

The first-line choice for delivery of ICS and bronchodilators in the treatment of stable asthma is the pMDI +/- a spacer device. Other alternative inhaler devices have not been shown to be more effective than pMDI and are more expensive. They are also considered first-line for the delivery of treatment for mild-to-moderate asthma exacerbations and are at least as effective as a nebuliser in these situations.

Large-volume spacer devices are useful for increasing drug delivery to the lungs and may be used for all patients but are strongly indicated for those who have difficulty co-ordinating pMDI activation with inhalation and those on high doses of ICS (>800 micrograms/day). Portability of spacers can be an issue. In the very young, a face mask should be used with the pMDI and spacer combination, until the spacer mouthpiece can be reliably used. If this is ineffective, a nebuliser should be considered.

pMDIs vary in their global-warming potential, and where a number of devices are equally effective and acceptable to patients, prescribers are advised to select the one with the least environmental impact. Patients should be advised to ask a pharmacist whether their device is recyclable.

Referral¹⁴

The decision to refer is influenced by local referral pathways, the individual and the experience of the primary healthcare provider. In addition to respiratory physicians and paediatricians with a specialised interest in respiratory medicine, other specialists such as dieticians, physiotherapists, occupational therapists and respiratory nurse specialists may be involved in the management of asthma. Admit or refer adults for specialist assessment or further investigation in the following situations:

• Severe acute asthma.

• The diagnosis is unclear or in doubt:

  • Unexpected clinical findings (for example, crackles, clubbing, cyanosis, cardiac disease).

  • Persistent non-variable breathlessness.

  • Monophonic, unilateral or fixed wheeze or stridor.

  • Persistent chest pain or atypical features.

  • Prominent systemic features (for example, weight loss, myalgia, fever).

  • Persistent cough or sputum production.

  • Spirometric or PEFR measurements that do not fit the clinical picture (for example, unexplained restrictive spirometry).

• Suspected occupational asthma.

• Non-resolving pneumonia.

• Inadequate response to maximum guideline treatment.