Asthma far from solved

A LEADING respiratory expert says the message behind asthma awareness must be refocused, after new research showed a significant proportion of adults have poor symptom control or undertreated symptoms of the disease.

Dr Jonathan Burdon, chair of the National Asthma Council of Australia, told MJA InSight that information about asthma treatment should be presented in a similar way to that for blood pressure and cholesterol medication.

“It’s about prevention. Asthma should not be looked at as an acute condition to be treated from time to time, but a chronic condition requiring ongoing management — even in patients who think they are asymptomatic.”

Professor Burdon was responding to the results of a web-based survey of adults with current asthma published by the MJA this week. The survey of 2686 adults aged 16 years and over was conducted in 2012. Results were weighted to reflect national proportions of adults with asthma. The median age of the group was 40–49 years, and 57.1% of respondents were female. (1)

The survey participants were asked about their symptom control, their health care utilisation and their medication use.

The self-reports of symptom control were assessed with the Asthma Control Test (ACT). The mean ACT score was 19.2, with asthma classified as “well controlled” (score of 20-25) for 54.4% of participants, “not well controlled” (16-19) for 22.7% and “very poorly controlled” (5-16) for 23.0%.

The authors found that 60.8% of participants reported using preventer medication during the previous year. However, more than half of those with uncontrolled symptoms did not use preventer medication as recommended.

Most participants using preventer medication used inhalers containing combinations of corticosteroids and a long-acting β2-agonist, although, less expensive corticosteroid-only inhalers would help most people with asthma.

Almost a quarter of participants had made at least one urgent visit to a GP concerning their asthma, and 10.0% reported at least one emergency department visit. Urgent consultations were more common among the “very poorly controlled” group than the “well controlled” adults.

The authors said their study provided the first national representative data on asthma control and treatment for Australians with asthma, and substantial problems with respect to prescribing and medication use were identified.

“For almost half the participants there was a gap between the potential control of their asthma symptoms and the level currently experienced.”

They said their findings challenged the perception that asthma was a “solved” problem in Australia, and reinforced the key recommendations for GPs published in the Australian Asthma Handbook, which include regular and structured assessment, checking for problems, and appropriate prescribing of preventer medications. (2)

Dr Ryan Hoy, respiratory and sleep physician at The Alfred Hospital, Melbourne, and research fellow at the Monash centre for occupational and environmental health, said he was concerned by the rates of poorly controlled and undertreated adults, which highlighted the complacency that still existed around asthma.

“I’m also amazed by the number of patients with asthma who continue to smoke — this is a worry”, said Dr Hoy on the study finding that 20.4% of participants were current smokers.

He told MJA InSight the results underlined the importance of GPs providing patients with up-to-date asthma management plans, but also “ensuring that patients actually understand the plan and know how follow it”.

Dr Hoy recommended that future research investigate the association between asthma and workplace exposures in adults, saying there was a need to determine whether a person’s job might be exacerbating their asthma.

Associate Professor Hubertus Jersmann, a respiratory and sleep physician at the University of Adelaide, told MJA InSight that he supported the wider implementation of routine patient questionnaires at GP clinics to get a detailed picture of their asthma status.

Professor Jersmann said that specific questions should include how many times a patient had been out of breath in the past week, and whether they wheezed and coughed at night.

“The more questions we ask a patient, the more we can control their asthma”, he said.

Associate Professor Janet Rimmer, respiratory physician and allergist at Sydney Medical School at the University of Sydney, believed that education initiatives should be stepped up and include everyone involved in asthma, such as GPs, specialists, nurses, nurse educators, and patients, as well as the families of patients.

“There are also successful programs that have been run through pharmacies, however the extension of these requires government assistance”, she told MJA InSight. “For example, a pharmacy intervention program can be used to improve inhaler technique, but this does need reinforcing at regular 6-month intervals.”

Professor Rimmer said an Australia-wide asthma strategy was being developed by key stakeholders to provide “an opportunity for the different groups and government to support current national guidelines for asthma management”.

1. MJA 2015; 202: 492-497
2. Australian Asthma Handbook 2014

(Photo: Ian Hooton / Science Photo Library)