Principles of Pharmacological management
Be aware of the definition of uncontrolled asthma (1):
- this term is used when asthma is having an impact on a person's lifestyle, or is restricting their normal activities, because of symptoms such as coughing, wheezing, shortness of breath and chest tightness. Uncontrolled asthma can include one or both of:
- any asthma exacerbation needing treatment with oral corticosteroids
- frequent regular symptoms such as:
- needing a reliever inhaler 3 or more days per week, or
- having 1 or more nights per week when asthma causes night-time waking
- these can be quantified by questionnaires such as the Asthma Control Questionnaire or Asthma Control test
The aim of asthma management is control of the disease. Complete control is defined as:
- no daytime symptoms
- no night-time awakening due to asthma
- no need for rescue medication
- no asthma attacks
- no limitations on activity including exercise
- normal lung function (in practical terms FEV1and/or PEF >80% predicted or best)
- minimal side effects from medication
Take into account and try to address the possible reasons for uncontrolled asthma before starting or adjusting medicines for asthma in adults, young people and children. These may include:
- alternative diagnoses or comorbidities
- suboptimal adherence
- suboptimal inhaler technique
- smoking (active or passive), including vaping using e-cigarettes
- occupational exposures
- psychosocial factors (for example, anxiety and depression, relationships and social networks)
- seasonal factors
- environmental factors
If possible, check the fractional exhaled nitric oxide (FeNO) level when asthma is uncontrolled. If it is raised this may indicate poor adherence to treatment or the need for an increased dose of inhaled corticosteroid (ICS).
Do not prescribe short-acting beta2 agonists to people of any age with asthma without a concomitant prescription of an ICS.
After starting or adjusting medicines for asthma, review the response to treatment in 8 to 12 weeks
With respect to inhalers:
- Base the choice of inhaler(s) for asthma on:
- an assessment of correct technique
- the preference of the person receiving the treatment
- the lowest environmental impact among suitable devices
- the presence of an integral dose counter
- Observe the person using their inhaler device (and spacer if used) to check they can use it properly:
- at every asthma review, either routine or unscheduled
- at every asthma-related consultation
- when there is deterioration in asthma control
- when the inhaler device is changed
- when the person asks for it to be checked or changed
If possible, prescribe the same type of device to deliver preventer and reliever treatments where more than one inhaler is needed. Consider providing an additional metered dose short-acting beta2 agonist (SABA) inhaler plus spacer for emergency use for children under 12 years who may be unable to activate a dry powder inhaler during an acute asthma attack.
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