Asthma

Think radically to drive real change in asthma outcomes, experts say


Dumping the age-old focus on treating asthma symptoms as well as improving risk stratification and having sanctions for non-compliance with guidelines, will be crucial to improving asthma outcomes, respiratory experts in the UK have suggested.

Writing in The Lancet, Respiratory Consultants Professor Andrew Bush and Professor Ian Pavord highlighted the huge discordance between having “excellent, evidence-based guidelines” but poor asthma outcomes.

Addressing this evidence-practice gap must be a priority for parties currently shaping new guidelines on the diagnosis, monitoring and management of chronic asthma, they said.

In clinical practice there needs to be  a move away from the focus on symptoms as a basis for treatment, and to focus instead of treating asthma traits, they suggested.

As well, significant improvement is needed in risk stratification to reduce asthma overdiagnosis and identify and reach those patients most at risk, and also in monitoring of adherence as a means to ensuring that patients are receiving the right therapy.

In their Lancet comment, Professors Pavord and Bush stressed that “symptom-guided treatment with up and down titration, which led to many patients receiving unnecessary high doses of [inhaled corticosteroid], has been a central tenet of asthma management guidelines and must be discarded”.

Instead, a greater focus on measurement will help to determine what type of asthma is present, and thus how best to treat it, they said.

The authors highlighted five important treatable traits that drive morbidity in asthma that should be assessed at all levels of care. As well as airflow limitation, these included type-2 airway inflammation, smoking, obesity and poor adherence.

They recommended that biomarker-guided management should be enshrined in the routine clinical care of less severe disease. “It is not good enough to say that the methods to measure biomarkers of type-2 inflammation are not widely available; we are failing patients with asthma if we do not make them available,” they wrote.

A quality improvement programme alongside effective new guidelines on asthma diagnosis and management will be critical for improving asthma outcomes, they argued. And as Professor Bush told the limbic, “there needs to be some urgency about it.”

He said current guidelines were good but there needed to be strategy in getting people to follow them. “If you look at asthma deaths in childhood, for example, it’s not because somebody has failed to do something frightfully clever, it’s because the simple basics have just not been gotten right,” he said.

“We still take asthma attacks as sort of a trivial inconvenience. But the biggest risk factor in all studies for an asthma attack is having had a previous bad asthma attack. There must be a really focused response to this. Everybody thinks that asthma is a really easy disease, and if you get the basics right it is, but we are the sick man of Europe when it comes to asthma outcomes, and as a country we need to confront that.”

Professors Bush and Pavord urged guideline developers such as UK National Institute for Health and Care Excellence (NICE) and the British Thoracic Society (BTS) to “think radically and produce a document that drives real change in outcomes”. This should include mandating sanctions for noncompliance with new clinical practice recommendations, with mandatory, public reporting of outcomes to increase accountability and also to help spread best practice.

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