Asthma affects 5.4m people in the UK, many of who manage and control their condition effectively using preventer medication. However, about half of people with the condition have asthma that is poorly controlled or sometimes referred to as difficult to control, which Asthma + Lung UK defines as needing oral steroids or six or more reliever inhalers in the past year.
Reliever inhalers are useful in treating symptoms and can be life-saving during asthma attacks, but they will only ever be a temporary fix as they do nothing to treat the inflammation in the airways that causes asthma symptoms and asthma attacks in the first place. That's the role of preventer inhalers which, if taken every day and with an adequate inhaler technique, suppress the inflammation that leads to symptoms and an increased risk of asthma attacks.
However, more than a million people are overusing their reliever inhalers, with a similar number not even prescribed a preventer inhaler and therefore missing out on vital preventive medicine.
Importance of better asthma control
In April 2022, new incentives were introduced for PCNs as part of the Investment and Impact Fund (IIF). They include an incentive for increasing prescribing of preventer inhalers and reducing prescribing of reliever inhalers. These targets have been introduced with the aim of optimising treatment and addressing asthma symptoms, which for too long has been a neglected part of asthma care.
These incentives are welcome, but it is essential that they are achieved as a result of better asthma control through adherence with preventer therapies, rather than simply a change in prescribing.
Reliever inhalers should not be restricted from people who may require them when they get symptoms or in an asthma attack. These incentives must be accompanied by proper treatment optimisation and a structured review, such as the SIMPLES assessment (see below).
If someone receives two or more courses of oral steroids in a year and their asthma does not improve, they should be urgently referred to a specialist for a potentially life-changing biologic treatment.
Managing uncontrolled asthma
Research from Asthma + Lung UK’s has found that in the past year many people with uncontrolled asthma did not get the support they need to manage their asthma effectively.
Less than one in three people surveyed said they had their inhaler technique checked. More than one in three say they were not asked about their asthma symptoms and two in three didn’t think they had been given enough information to understand their condition or their treatments.
GPs have a vital role to play in not only providing preventer inhalers but proactively identifying people with uncontrolled asthma and systematically assessing them to make sure they are managing their asthma the best that they can.
A recent programme by the Accelerated Access Collaborative (AAC) has produced a toolkit which includes an uncontrolled asthma pathway, a useful digital tool that can be used on GP systems to help identify people with uncontrolled asthma (SPECTRA), and explains when someone should be referred to a specialist for biologic treatments.
When assessing a patient with asthma, you can keep a helpful acronym called SIMPLES, published in the Primary Care Respiratory Journal, handy:
- Support to stop smoking: Smoking can worsen people’s asthma control, so ask your patient if they smoke and if the answer’s yes then offer support for smoking cessation.
- Inhaler technique check: It’s vital people with asthma are using their inhalers correctly and effectively, so talk through and demonstrate how a patient should use their inhaler – you may find Asthma + Lung UK’s inhaler videos useful. If they are on a metered dose inhaler, you should also offer the patient a spacer, to help them get their medicine into their lungs more effectively.
- Monitoring: Teach the patient how to monitor their symptoms by taking peak flow reading and asking themselves questions about how their symptoms are affecting their life, for example ‘is my asthma waking me up at night?’ and ‘is my asthma stopping me from doing anything?’ If the answer is yes then it should prompt the patient to check they’ve taken their preventer inhaler regularly and correctly.
- Pharmacotherapy: As discussed, patients do not always take their preventer medication, so this should be checked and discussed at every review. Try to address poor adherence by adapting the medication to their lifestyle. Some patients may have better adherence with a different inhaler type, different dosing or MART.
- Lifestyle advice: Ask questions and advise on lifestyle including diet, alcohol consumption and known triggers. It’s also important to enquire into co-morbidities such as gastroesophageal reflux, anxiety and rhinitis.
- Education: Make sure your patient understands what asthma is, what they should do in an emergency and how they should be monitoring their symptoms and taking their medications day to day. A written asthma action plan can help with this.
- Support: Make sure you review your patient to check their asthma control has improved and that their medicines are suiting them. Make sure they know who to contact if they develop poor control again.
Using the SIMPLES technique can help GPs to assess patients and help patients better manage their asthma, reducing asthma attacks and saving lives. For more information on asthma management visit the Asthma + Lung UK website.
- Dr Whittamore is clinical lead at Asthma + Lung and a practising GP