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Management of Chronic Asthma
Factors Compromising Response to Therapy Table 3: Possible Causes of Impaired Response to
The factors that may compromise the response of patients to therapy
Asthma Terapy
are summarised in Table 3. Aside from incorrect diagnosis and
insufficient treatment, poor compliance and inhaler technique are by
Incorrect or additional diagnosis
Poor inhaler technique
far the most important.
Inadequate dosages of therapy
Poor patient compliance or understanding
Choice of Inhaler Device
Allergen exposure
No topical medication will be effective unless delivered efficiently to
Allergic bronchopulmonary aspergillosis
the respiratory mucosa, yet this fundamental aspect of asthma
Drugs: β-blockers, aspirin/NSAIDs
management receives scant attention in guidelines, which hold that, Smoking (active or passive)
collectively speaking, the clinical efficacy of metered-dose inhalers Occupational disease
(MDIs) with spacers is indistinguishable from that of dry-powder
Hormonal: pre-menstrual asthma, hypothyroidsism
inhaler (DPI) devices, while ignoring the fact that individual patients
Underlying vasculitis (Churg-Strauss syndrome)
may use some devices much less efficiently than others. One group
True steroid-refractoriness/resistance
of interested physicians, the ADMIT group (www.admit-online.info),
NSAIDs = non-steroidal anti-inflammatory drugs.
has taken the initiative in producing guidelines that help prescribers
match patients with inhalation devices they can use efficiently. In • measurement of lung function (PEF);
children below five years of age it is usual to prescribe an MDI with • inhaler technique;
a spacer and a face mask. Older children and adults should be • morbidity;
offered a choice of inhalers. Some prefer an MDI, others a DPI • current treatment; and
device. Breath-activated devices are loved by some and abhorred by • an asthma action plan for severe and unstable patients.
others. For patients who require auditory and visual reassurance of
safe drug delivery, a device such as the Novolizer
®
may be Asthma action plans may be based on symptoms and/or PEF
considered. Corticosteroid MDIs should always be used with an measurements depending on patient ability. In many studies they
appropriate spacer device. Incorrect inhaler technique is very have been shown to improve health outcomes,
17–20
since most
common and improved by training,
11
which should be given by a asthmatics deteriorate slowly and there is time for intervention.
trained health professional and re-assessed periodically as part of Instructions on how to deal with asthma exacerbations is an
a structured clinical review. essential part of action plans: in those taking low/moderate dosages
of inhaled corticosteroid, a temporary increase of the dosage by up
Compliance to five-fold is effective. More severe exacerbations will require oral
Patient compliance is also an important issue compromising the corticosteroid therapy. A number of model plans is available from
response to prescribed therapy.
12
Monitoring of the dosing habits of Asthma UK (www.asthma.org.uk/control).
patients with electronic recorders suggests that they take their
recommended dosages of medication on only 20–73% of days. Allergen Exposure
Over-usage is far less common. Patients may distrust medication Exposure to aeroallergens exacerbates asthma
21–24
in some allergic
(partially for fear of side effects), stop it if symptoms have been stable individuals. Clinical suspicion of sensitivity to particular allergens
should be ratified (when not obvious) by skin-prick testing or
specific IgE determination interpreted preferably by an allergist.
Exacerbations on exposure to family pets and seasonal pollens or
In contrast to Europe and the US, mould spores are usually easily identified and may be severe. In
allergen immunotherapy is not currently
infants, food allergies (most commonly milk, eggs, nuts and grains)
may be important triggers for asthma. Specific inquiry should be
recommended in the UK for the made about allergens to which patients may be sensitised in their
treatment of atopic asthma.
own homes. Advice about allergen avoidance covering asthma,
eczema, food allergy and allergic rhinitis, preferably from a
specialist allergy team, is essential in such cases. It has been
difficult to show therapeutic benefits of avoidance of some allergens
or absent and be subject to the psychosocial influences mentioned such as the house dust mite,
25,26
possibly because clinically effective
above. These factors must be exposed and addressed at review. avoidance is impossible.
Education increases compliance with dosing regimens.
13
There is an
assumption that compliance decreases as the number of inhalations Approximately 75%
27
of atopic asthmatics have concomitant allergic
prescribed per day increases. While some studies support this,
14
seasonal and/or perennial rhinitis, which should always be treated. If
others do not.
15
It seems sensible to maximise the convenience of leukotriene receptor antagonists are used as a treatment for asthma,
dosing regimens for patients, and wherever possible to use the same they have the additional benefit of being at least as efficacious as
delivery device (one that suits the patient best) for all inhaled drugs. antihistamines for amelioration of allergic rhinitis, although a regular
topical nasal corticosteroid should also be used for anything more
To help counter these problems, a trained health professional should than mild intermittent symptoms.
review asthmatics identified as being ‘at-risk’.
16
Any review should be
proactive and empower patients or their parents/carers to undertake In contrast to Europe and the US, allergen immunotherapy is not
self-management effectively. It should include: currently recommended in the UK for the treatment of atopic
EUROPEAN RESPIRATORY DISEASE 23
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