3. Asthma is so common….
1 in 10 of your patients !
♦ Most patients prefer treatment from
their family doctor rather than a Chest
Physician
♦ Physicians / GPs can treat asthma just
as well as Chest Physicians ( even
better )
4. The 4 keys to
successful asthma practice
“Is it asthma?”
Just a few questions in
a few minutes
1
5. The 4 keys to
successful asthma practice
Treating the disease2
Not much time
……..and easily.
6. The 4 keys to
successful asthma practice
Making things simple for
your patient
3
Child’s play
Low cost
7. The 4 keys to
successful asthma practice
Saying the right things
Answering patients’
questions
“Jo bolega, karega”
4
8. Which secret do you
want to unlock?
1. “Is it asthma?”
2. Treating the disease
3. Making things simple
4. Saying the right things
9. Diagnosis:
Why make it ?
♦ The patient has alternatives
(if you don’t, someone else will !)
♦ Excellent prognosis, esp. in children
♦ Treatment is so simple
10. Do I need a lot of tests?
Nothing usually, besides a
sharp history
11. What questions or
statements can suggest
asthma?
♦ Do you have a persistent cough ?
♦ Do you wheeze or often feel breathless while
coughing ?
♦ Do your symptoms worsen with climate
change, or dust /other allergens ?
12. What questions or
statements …
♦Do the symptoms get worse at
night ?
♦Do you get chest tightness with
the cough ?
♦Does it all start with a cold ?
♦Do your colds often “go down” into
the chest ?
13. What questions or
statements …
♦ Do your symptoms get worse after
extremes of happiness or sadness ?
(emotional swings)
♦ Do heavy meals or late nights worsen
your symptoms ? (GE reflux)
♦ Are your symptoms worse at work than
at home ? (occupational asthma)
14. What questions or
statements …
♦ Does anyone else in your family
suffer from any allergies ?
Ask about:
skin allergies
eczema
frequent colds
‘bronchitis’
15. What questions or
statements …
“I get relief with this medicine.”
Ask: which medicine?
(always check for bronchodilator)
16. Diagnosis in children
♦ Commonest cause of a persistent
cough is asthma
♦ Cough after exercise, activity, play
♦ Vomiting
♦ Failure to thrive
( poor sleep, poor growth )
17. When do you need lung
function tests ?
♦ Spirometry ( 250 to 350 rupees )
♦ To re-confirm the diagnosis
♦ When in doubt
♦ Normal Spirometry ( Challenge tests )
18. Things the patient may
not tell you …
♦Stigma and discrimination
from a “word”
♦Work/school absenteeism
♦Marital discord
♦Travel & holidays ‘controlled’
19. Other ‘advice’ the patient gets
Grandparents/neighbours/ ‘friends’ –
Inhalers ???
Steroids ???
20. Make the diagnosis but
emphasize the prognosis
Instead of asthma controlling your
patient,
the patient can control asthma
21. Asthma therapy in India today
♦Completely control symptoms and
fast
♦Normal life
♦As good as abroad ( even better )
♦General practice and physician level
♦Doesn’t need Chest Physicians !
22. Asthma Disease:
Spasm and swelling
♦ Spasm needs a reliever
Bronchodilator
♦ Swelling needs a contoller
Anti-inflammatory
23. Two types of drugs:
Reliever & Controller
Reliever
♦Bronchodilator (beta2 agonist)
♦Quickly relieves symptoms
(within 2-3 minutes)
♦Not for regular use
25. ♦Anti-inflammatory
♦Takes time to act (1-3 hours)
♦Long-term effect (12-24 hours)
♦Only for regular use
(whether well or not well)
Controller
26. If your patient uses reliever
medication every day, or even
more than three or four times a
week, preventive medication
must be added to the treatment
plan.
GINA Workshop Report, December 1995
27. WHAT HAPPENS WHEN YOU
DON’T TREAT ASTHMA WELL
N o r m a l
I n f la m e d
( A s t h m a )
P a r t ly T r e a te d
F ix e d O b s t r u c t io n
( L e a d P ip e )
R e m o d e lle d
A ir w a y
28. What is changing the lives
of our asthma patients
today?
Inhaled steroid
29. THE STORY OF ASTHMA
TREATMENT
N o r m a l I n f la m e d ( u n t r e a t e d )
R e g u la r
I n h a le d
S t e r o id
P a r t ly
T r e a t e d
30. Corticosteroids are the most potent
and effective anti-inflammatory
medication currently available
for asthma*
*GINA (NHLBI & WHO Workshop Report), December 1995
*Guidelines for the diagnosis and management of Asthma NIH,
NHLBI, May 1997
31. Controller ..
Inhaled corticosteroids
♦ Budesonide/ beclomethasone/
fluticasone/ciclesonide – use any
♦ Start (400-1000 mcg/day approx. in
2 divided doses)
♦ Maintain for 3 months
♦ Taper slowly
♦ Safe for long-term use (years)
32. Controllers …
Inhaled corticosteroids: how safe?
♦ Even in small children for several
years
♦ 30% of Olympic athletes
♦ Not anabolic (performance-enhancing)
steroid
♦ Even highest ICS dose is safer than
low dose oral steroid
♦ Best “Addiction” for asthmatics
33. Inhaled steroids : safe even
for children?
♦ 400 mcg/day (budesonide)
♦ Over 13 years of continuous use
♦ No growth retardation
♦ Uncontrolled asthma causes growth
retardation
Pedersen & Agertoft NEJM 2000
34. Pregnancy and asthma
♦ Don’t x-ray (if possible)
♦ All asthma medication is safe
♦ Even oral corticosteroids are safe for
exacerbations
♦ Uncontrolled asthma during pregnancy
is a serious risk factor for foetal distress
and anoxia
Thorax
35. Inhaled Steroids Not
Working ?
Add SR
theophylline
Check Inhaler
Technique /
Check Regular Use
Add LABA
Formoterol /
Salmeterol
Increase dose
of inhaled
steroid
Add Leukotriene
modifier
36. Leukotriene Modifiers
♦ Oral anti-inflammatory
♦ Not as effective as inhaled steroid
♦ First-line for 2 to 5 yr. olds.
♦ All your ‘regular’ bronchodilator users.
37. Theophylline
♦ Sustained release for regular use
♦ Inexpensive , but toxic
♦ Not more than 600 mg per day usually
♦ Weak bronchodilator, but A-I effects
38. Add-on drugs : ICS + ?
1. Long acting Beta²-agonist ( LABA )
2. Montelukast
3. SR Theophylline
39. ICS + LABA
♦ Which ICS ?
Budesonide: Once daily
Even children < 4 years
Safe for long term use
40. ICS + LABA
Which LABA ?
Formoterol: Immediate relief (as fast as
salbutamol)
12 hours effect
Can be combined with
budesonide
41. Ideal combination
♦Formoterol ( fast relief and
sustained relief ) +
♦Budesonide ( twice or even
once daily use )
Dose: 1- 4 puffs ( OD/BD )
42. Can be used for relief as
well as control
FORACORT
43. Guidelines for using SMART
with FOACORT
• SMART means patients take a daily maintenance dose of
FORACORT and in combination take FORACORT as needed in
response to symptoms.
The recommended maintenance dosage is 2 inhalations per day
Patients should take 1 additional inhalation as needed in
response to symptoms. If symptoms persist after a few minutes,
an additional inhalation should be taken. Not more than 6
inhalations should be taken on any single occasion.
A total daily dose of up of 12 inhalations could be used for a
limited period.
Patients using more than 8 inhalations daily should be strongly
recommended to seek medical advice.
44. Oral Steroid
♦ Prednisolone
♦ Acute severe episodes
(20-60 mg/day “burst”
along with bronchodilators)
♦ Dispense preferably
♦ Steroid-dependent asthma
47. Why doctors don’t use
inhalation therapy
♦ Status quo :
“my practice is good or ‘great’”
♦ Oral therapy is easy
♦ Too busy
♦ Cost
♦ Headache to explain
49. Scope for Inhalation
Therapy highest in a child
♦ < 5 yrs - High incidence of
wheezing
♦ Parents want the best for
their child
50. The Rotahaler
♦Has transformed inhalation therapy
♦Child’s play (Insert -Twist - Inhale)
♦Economical (Rs. 74)
♦Acceptable (v/s difficulties with MDI)
♦Every drug you need
51. Child below 3, or adult over 85
♦ MDI + Spacer
♦ MDI + Spacer + Baby Mask
When can you not use a
Rotahaler ?
52.
53. Why use a Spacer ?
♦ Ensures correct use of an MDI by
correcting co-ordination problems.
♦ Reduces incidence of throat infections
with inhaled steroid
♦ As good as nebuliser for acute
exacerbations ( with MDI )
54. Then do we need nebulisers ?
– YES
♦ Acute severe asthma with impending
respiratory failure
♦ Intensive care / Hospital / Clinic /
Ambulances
55. Managing asthma in clinic
(patient who walks in wheezing quite badly)
♦ Oral prednisolone 20 mg/day x 1 week
♦ Foracort Rotacaps (100/200/400) (Form +
Bud) twice daily x 1 week and also as
rescue
56. Call patient after 1 week
If much better
♦Taper or omit Prednisolone
♦Continue Foracort Rotacaps
for 2 months in same dose
♦Foracort Rotacaps SOS
57. Call patient after 1 week …
If not much better /
still needs salbutamol often
♦Check Rotahaler Technique
♦Check whether using Foracort
regularly
58. If still not better at 2-3
months
♦ Consider adding SR theophylline or
montelukast
♦ Look for aggravating factors
– GE Reflux
– Emotions/ stress
– Sinusitis
– Allergic Rhinitis
– Persistent allergens
60. What do you tell patients ?
Oh no ! I have asthma ?
♦Allergic disorder (allergies don’t
have cures)
♦You could call it “allergic bronchitis”
♦To lead a normal life, accept regular
therapy (like DM/ HT/ Epilepsy)
61. What do you tell patients …
How long do I need this inhaler?
Wont I get addicted ?
♦ Inhalers are a delivery system, not the
drug
♦ The drug is in a “homeopathic” dose
♦ The earlier you start steroid, the better.
….. best “addiction”
♦ Untreated asthma will cripple you
62. What should you keep in
your asthma clinic ?
♦ Rotahaler/ Revolizer
♦ Placebo Rotacaps
♦ Placebo MDI/ Spacer/ Baby Mask
♦ Nebuliser ( for emergencies only )
♦ Height measure
♦ Breathe-o-meter
♦ Education material ( available in 9
languages )
63. The Breathe-o-Meter
like a thermometer for asthma
♦ Inexpensive clinic
instrument
♦ Monitoring
♦ Builds confidence in
treatment
♦ One ‘hard, fast blow’
64. The Breathe-o-Meter…
♦ First visit and follow-ups
♦ Improving symptoms
= improving peak flows
= improving confidence
♦ Rarely for home use
65. What do you tell patients …
Today’s asthmatics are suffering as
they never received regular inhaled
steroids as children.
What costs more is not better (e.g.
nebulisers for home use)
Studies from across the world and India suggest that asthma is one of the most common chronic ailments that present in general practice.
In fact, respiratory diseases form a major chunk of outpatient diseases and asthma is one of the most common of these diseases.
In fact, a general practitioner seeing about 50 patients per day would easily land up seeing at least 5 patients with asthma every day. This reflects how common the condition is. Most patients who start coughing or feel breathless would first go to their family physician, and not a chest physician.
Asthma can be treated by a general practitioner as well as a chest physician would treat it (sometimes better!)
The whole discussion on asthma focuses around 4 basic issues.
The first is the diagnosis – Does my patient have asthma?
You will realize that diagnosis involves just a few questions asked pointedly to the patient. This involves a few minutes and doesn’t need any complicated set of investigations or tests.
Listening to the patient’s complaints plays an important part in the diagnosis of asthma.
Once the diagnosis is confirmed, you have to ensure that your patient gets the best possible treatment available without having to travel too far for it.
Asthma management today, thanks to inhaled steroids, hardly takes much time and is easily available in even remote parts of our country.
As most general practitioners would realize, understanding that inhaled steroid is the best treatment for asthma is not the end of the story. One has to be able to convince patients to take it not only properly, but regularly.
With this simple Rotahaler, inhaled steroid therapy has almost become child’s play. A simple insert-rotate-inhale mechanism ensures that even a child of 4 years of age can use this device effectively.
Added to this, the low initial cost of the device makes it the most affordable inhaler, and being so easy to use, the most acceptable.
Finally, success in your prescription is only proportionate to the correctness with which you reply to your patients’ numerous queries.
When it comes to asthma, patients have hundreds of questions, and often make indiscriminate and blanket statements about the disease based on hearsay.
You have to reassure the patient about the illness and communicate correctly in this regard. Patient education is the heart of successful asthma management. A well-educated patient remains on regular treatment and complies strictly with doctor’s orders. Such patients are so devoted to their doctor that they rush to the doctor for any important decision regarding their health.
Which of these issues in the comprehensive management of asthma concerns you the most?
Successful management of asthma in practice revolves around all these four issues and each will be discussed in detail.
Many doctors hesitate to make a diagnosis of asthma because they feel the patient may get scared and quickly change their doctor in the hope of a more reassuring diagnosis.
This is where opportunity lies. Today’s patient has a choice. If you don’t diagnose asthma, there will be another GP who makes the diagnosis and thereby wins that patient for life.
Asthma is is one of the few chronic ailments in medicine that has such an excellent prognosis, especially when diagnosed in children. Also, when treatment is so simple, why worry about making the diagnosis?
The most surprising part of asthma diagnosis is that hardly any tests are required.
The CBC should be done to rule out anemia and infections and a regular chest x-ray to rule out pneumonia and tuberculosis. These investigations don’t help to diagnose asthma, but rule out other conditions.
A sharp history is all you need for arriving at your diagnosis. It is important therefore, to ask all the right questions.
For patients who are still not convinced that they have asthma, spirometry can be done to reconfirm the diagnosis.
These are the questions that you must ask every patient whom you may suspect to have asthma.
Cough is the commonest symptom of asthma. It is usually recurrent, persistent and often aggravated by triggers like weather change, dust, pollen, firecrackers and environmental pollution. Many patients feel breathless only at the time of coughing and not otherwise.
The breathlessness often has a sudden onset and is associated with a wheeze (musical sounds while breathing). Many patients also complain of breathlessness on exertion.
All the symptoms of asthma get aggravated at night, due to circadian variation in the level of circulating steroid in the blood. Most patients complain that their symptoms are worse late at night or in the early hours of the morning.
Chest tightness is often associated with the coughing and should be asked about. Many patients complain of a squeezing sensation in the chest.
Allergic rhinitis co-exists with asthma in many patients. These patients complain of a perennial cold; and the symptoms of asthma often begin with a bad cold which the patient describes as having ‘gone down into the chest’. These patients have what is called ENT aggravated asthma. Without proper treatment of the allergic rhinitis, the asthma often fails to get effectively controlled.
Emotions are an often neglected part of the asthma history. Extremes of sadness and happiness often aggravate symptoms of asthma. Patients with severe asthma often have a strong emotional component. Depression and anxiety should be looked for and treated; if not, asthma often remains poorly controlled.
Gastroesophageal reflux is a common aggravating factor for asthma. Patients’ complaints that their symptoms are triggered by meals, late nights or other trigger factors of hyperacidity and GE reflux. Treatment must include general anti-reflux measures, and may often require proton pump inhibitors and/or prokinetic agents.
Finally, occupational asthma is a relatively simple diagnosis with the patient feeling significantly better when at home (and not at work). The principles of treatment here remain the same. Change of occupation is also advisable, though many patients continue to have problems.
Unlike COPD, it is extremely important to rule out a history of any allergic disorder in the family, especially asthma. Most patients will not tell you or may not be aware that a family member has or was suffering from asthma. Therefore it is important to ask whether anyone in the family suffers from frequent skin rashes (allergic dermatitis, eczema or urticaria), frequent colds (allergic rhinitis) or allergic ‘bronchitis’ which is basically asthma.
It is important to ask for a history of ‘bronchitis’ in the family as many patients are not told by their doctor that they have asthma.
Finally, this is one of the most important clues to a diagnosis of asthma. Very often patients come to you with a thick file consisting of various medications that they have been prescribed in the past. Always look for syrups or tablets that contain bronchodilators.
Ask the patient whether he has got relief with any particular preparation. Relief of the symptoms with bronchodilator is almost confirmatory of a diagnosis of asthma, especially in small children.
Another important point to look for is whether symptoms have dramatically improved with a short course of oral steroid. This is also highly suggestive of asthma, especially when the chest x-rays are normal.
The diagnosis of asthma in a child is extremely rewarding because parents cannot thank you enough for the relief their child gets and an end to those sleepless nights!
Children rarely complain of breathlessness. In fact, the commonest cause of a persistent cough in a child is asthma. Small children often tend to vomit after a coughing bout and this should not mislead the physicians into suspecting a GI problem.
A persistent cough or uncontrolled asthma in children results in poor sleep and therefore growth retardation. These children are often sluggish, poor eaters and fail to thrive. Treatment with bronchodilators and corticosteroids dramatically reverses this trend.
To confirm or re-confirm a diagnosis of asthma, you do not need complete lung function studies. All you need is basic spirometry. Spirometry costs anywhere between about Rs. 250 to Rs. 400 depending on the laboratory or hospital usually.
It takes about 20 – 25 minutes to perform and is important to re-confirm the clinical diagnosis that has already been made. It is also extremely useful to differentiate asthma from COPD when in doubt.
At times your patient has normal spirometry, but insists he feels better with a bronchodilator whenever he has a coughing bout. In such patients, histamine or metacholine challenge tests are extremely useful.
There are certain thing about asthma suffering that patients rarely land up telling the doctor unless probed for.
There is tremendous stigma about asthma in India and many patients feel that they are destined to have crippled or ‘weak’ lungs for life once diagnosed with asthma.
Adults often have to miss work due to symptoms or are unable to cope with their work because of poorly controlled asthma. Children often miss school due to symptoms and perform poorly in class due to uncontrolled asthma.
Asthma symptoms in women in India often leads to marital discord. Many patients complain that their whole life is controlled by their asthma. All their travel plans and holidays are made based on the degree of their asthma control.
This silent suffering of patients is only brought out on more focused questioning. Very often the patients reveal these problems once they are confident that their doctor is able to understand their suffering, and also able to offer a permanent solution (regular inhaled steroid) for the patients.
Sometimes, despite all the good work that you do in confirming the diagnosis and instituting appropriate treatment, well-meaning people can often discourage the patient about the treatment you have prescribed.
Myths and misconceptions about asthma are common and many people feel that inhalers are a last resort for asthma and that steroids have lots of side effects (without realizing how inhaled steroids have revolutionized the treatment of asthma).
Such people like grandparents, neighbours and friends have extremely good intentions , but give terrible advice to patients.
Therefore, make your diagnosis of asthma, but never forget to emphasize to your patient that this is a disease with an excellent prognosis, and that with regular treatment one is almost completely ‘cured’ of the disease and hardly experiences any symptoms.
Today asthma is compatible with a completely normal life, thanks to modern medication and excellent delivery systems.
The most reassuring part of asthma therapy in India is that the same therapy which is available in the United States or Europe today is available in even small villages in India. Also that therapy in India offers a much larger choice at a much more affordable cost. Asthma therapy in India is therefore at par or even better than in many parts of the world.
The range of therapy available today can be easily used at the general practitioner level and rarely needs chest physicians.
Basically, what chest physicians do for their asthma patients today can easily be done by general practitioners, and in fact it can be done better and at a more affordable level.
To understand asthma pathology does not require a detailed discussion of airway inflammation.
It is sufficient to know that asthma is basically a combination of airway smooth muscle contraction (bronchospasm or SPASM) and airway lining oedema with mucus hypersecretion (inflammation or SWELLING). Treatment of the SWELLING or inflammation requires anti-inflammatory drugs which are basically the most important drugs for the regular treatment of asthma. These drugs are called preventers.
The SPASM on the other hand needs smooth muscle relaxant drugs called bronchodilators or RELIEVERS.
Often, in the beginning of asthma management you may need both these classes of drugs and as the patient gets better, you may need only need preventers.
Reliever drugs are basically bronchodilators. The most important relievers are the beta2-agonists which include salbutamol and terbutaline.
These drugs are meant to be used for immediate (within 3 minutes) relief of symptoms. They can be used up to 3 to 4 times per day. The more they are used, the worse is the control of asthma. Frequent use of relievers indicates poor control of asthma disease and probable under-use of preventers.
Reliever drugs are not recommended for regular use in asthma. A patient who needs to use salbutamol daily is either suffering an acute exacerbation of the disease or is under-using preventive medication.
Today, relief medication needs to be administered mainly by metered dose inhalers (spray inhalers) or dry powder inhalers (Rotahalers).
Relievers are given through a nebuliser only for acute exacerbations of asthma at a hospital or nursing home/clinic. Frequent use of nebulised bronchodilators is dangerous and can cause significant adverse effects.
Oral bronchodilators are rarely required today in asthma, barring cases where bronchodilator use is for the first time and the anticipated need is of a short duration. Unfortunately , these still remain highly-used products in India.
Unlike relievers, preventers take time to act and control airway inflammation, the root pathology of asthma disease. Hence these drugs need to be used regularly, whether the patient is symptomatic or not.
Most preventers need to be administered only once or twice daily, since they have prolonged effect.
Since they do not give any immediate relief from symptoms unless the patient is told to take them regularly, patients often stop these drugs because of lack of any immediate benefit. Hence, patient education is critical to the correct and regular use of preventer medication in asthma.
Do all patients need preventer medication ?
Most do. But patients who need relief medication once in a month or once in 2 to 3 months have intermittent asthma, and do not need any regular preventive medication.
As a rule of thumb, any patient who needs relief medication even 3 times a week is a candidate for preventive medication. In fact any patient who uses a reliever every day for control of his asthma is either not using or under-using preventive medication.
This diagram first shows you the caliber and appearance of a normal airway.
Below it, you can see an inflamed, asthmatic airway. With some treatment, the patient reaches the airway below that, but does not normalize. Most asthma patients in our country shuttle between these 2 types of airways and rarely reverse back to normal for a long time (i.e. sustained control).
The consequence of this poor control is a ‘remodeled airway after years of poor control. This airway is like an ‘inflexible’ lead pipe, a so-called fixed obstruction. Such a patient behaves similarly to a patient with COPD, and the prognosis is bad, unlike asthma diagnosed earlier and treated early.
The biggest therapeutic advance in asthma management has been the inhaled steroid.
It has changed the way we understand and treat asthma, and transformed the lives of our patients with asthma.
If we can manage asthma easily today and our patients can lead normal lives, it is only because of inhaled steroid.
This is the story of asthma treatment in India. Patients develop airway inflammation (swelling) and then start shuttling between “part” treatment and “no” treatment. This shuttling occurs in most of our patients in India.
It is only with regular inhaled steroid that this airway will return to normal. This should be our objective in asthma management.
All international guidelines today strongly endorse the glucocorticosteroids as the most effective and potent medication currently available for asthma.
As of today, no better medication has been discovered for asthma.
The safest and most effective preventive medication for asthma are obviously the inhaled corticosteroids.
Don’t spend time trying to decide which one to use. Use any, as long as the patient uses the inhaler correctly and regularly. It is recommended to start with slightly higher doses of about 800 to 1000 mcg per day, and then maintain that dose for at least 3 months before gradually stepping down the dose to the minimal effective dose. In very mild persistent asthma , you could also start with doses of 400 mcg per day.
Inhaled corticosteroids are never to be administered for days or weeks, but months to years.
This slide illustrates a lot of misconceptions about the use of inhaled corticosteroids. Tiny tots can be given these drugs safely for several years.
International athletic meets permit the use of these drugs for asthma control. These are not to be confused with Ben Johnson’s ‘steroid’! That was an anabolic steroid which is classified as a performance-enhancing steroid and therefore banned at athletic meets.
People who feel they are addicted to these drugs should realise that there is no better addiction for an asthmatic! In fact it is sad to see so many patients using regular low doses of oral steroid (for years on end) for asthma control, and who have never used a steroid inhaler in their life, let alone the highest possible dose of inhaled steroid, before becoming dependent on oral steroid.
A landmark study done by Agertoft and Pedersen was published 2 years ago which has dispelled most doubts about the safety of inhaled corticosteroids in children.
332 children were recruited in this study with a mean age of 3.4 years in the steroid-treated group. The mean budesonide dose was 412 mcg per day through the study.
Although growth rates were reduced during the first years of budesonide treatment, these changes were not significantly associated with adult height. It was concluded that children who receive budesonide for long-term treatment of their asthma attain normal adult height.
It is also clear now that uncontrolled asthma is far more likely to cause growth retardation.
Gynecologists often stop asthma treatment once pregnancy has occurred. This is another misconception that needs to be dispelled.
All anti-asthma drugs are safe during pregnancy. As far as possible inhaled medication should be used. However, if a pregnant asthmatic develops an exacerbation, then even oral or parenteral steroids may need to be promptly begun. The risks to the foetus are far higher from uncontrolled asthma during pregnancy than from any of the anti-asthma drugs.
Asthma during pregnancy has an unpredictable course (some patients actually feel better, some worsen, and some remain the same) and therefore patients should be strongly advised to continue their preventive medication throughout their pregnancy.
An excellent position paper in Thorax has outlined guidelines for the management of asthma during pregnancy.
What if inhaled steroids don’t work ?
First check whether the patient is using his inhaler correctly. If he is using it correctly, then check whether he is using it regularly. Most patients who come to chest physicians with uncontrolled asthma are either not using any preventive medication or even if they have been prescribed it, are using the inhaler wrongly or irregularly.
Only once you are sure that the inhaled steroid is being used correctly and regularly, should you consider the usage of add-on medication.
The first choice add-on medication would be long-acting beta2-agonist, followed by a leukotriene modifier and finally sustained-release theophylline. Increasing the dose of inhaled steroid as was formerly recommended, is no longer a preferred option.
We should realise now that though these are new, oral anti-inflammatory drugs for asthma, they are nowhere near the potency of inhaled corticosteroids. Being oral, these drugs have become convenient for doctors and patients alike.
Probably, one of the few indications to use these drugs first-line has been asthma in 2 to 5 years old children where one 4 mg chewable tablet needs to be given daily. In this age group it is impossible to objectively confirm a diagnosis of asthma and preventer treatment is usually based on clinical grounds. In the event of strong reluctance from parents to use inhaled steroids, a trial of montelukast may be worthwhile.
Also, all patients feeling well or partly well with ‘regular’ bronchodilators are also candidates for Montelukast, since there will be at least some anti-inflammatory activity. However, this activity if far less than that of inhaled steroids.
Like leukotriene modifiers, theophylline is also available only orally at present. Though cheaper, this drug is a bit more toxic, especially in patients with liver disease, congestive cardiac failure, elderly etc.
Theophylline is a weak bronchodilator, but has some anti-inflammatory effects. In this regard, theophylline is recommended an add-on agent in a sustained-release formulation for regular use, either once or twice daily.
Gastritis, cardiac and neurological side effects warrant caution and extreme care should be taken when using these drugs in elderly patients.
So you have 3 add-on options for asthma for patients not controlled sufficiently with inhaled steroid.
Which one would you prefer?
Ideally as mentioned, the safest and best option today is a combination of inhaled corticosteroid with long-acting beta2- agonist. The issue is, which inhaled steroid is preferred.
Personally I prefer budesonide for the following reasons: There are a significant number of trials on budesonide for even once-daily usage. This makes it very convenient to use even in the long term.
Budesonide is also licensed for use even in children below the age of 4 years. This makes it the inhaled steroid of choice in young children as well as adults. Finally, with Pedersen’s study the safety of this drug even in long-term use has been adequately demonstrated.
Formoterol would be the long-acting beta2-agonist of choice.
This drug amazingly acts as fast as salbutamol, but has a prolonged 12-hour effect as well. Therefore it combines immediate relief with sustained relief. This makes it the ideal beta2-agonist for use in asthma.
The beauty is that formoterol can be combined with budesonide in the same inhaled formulation today and therefore provides the ideal combination for long-term use.
This combination is available today in both metered dose and dry powder inhalers (Rotacaps).
It is available in 3 different Rotacap strengths where the dose of formoterol remains constant but the budesonide dose varies according to the need (severity of asthma); i.e. 100, 200 and 400 mcg of budesonide in 3 different Rotacaps.
Oral steroid is essential for the management of asthma in practice. Oral steroids are extremely important drugs for treating acute exacerbations. However, long term use is associated with significant adverse effects.
Also, since these drugs are cheap they are often misused by patients who find these drugs a quick and inexpensive way to control their asthma. In general practice, therefore, it may we wiser to dispense these drugs rather than prescribe them.
Prednisolone is the oral steroid of choice in managing acute exacerbations of asthma. It has minimal mineralocorticoid activity and is quite safe for short term use.
This is asthma that needs regular treatment with oral steroids for achieving and maintaining control.
Patients who use only regular inhaled steroids are not labelled as steroid-dependent.
This illustrates a lady with steroid-dependent asthma. Years of oral steroid use is associated with severe myopathy and osteoporosis. Many of these patients develop frequent infection and often steroid-induced diabetes. Fluid retention is common. A redistribution of body fat makes these patients look puffed up in the face as well.
The sad part is that once these side effects have occurred, it is often too late to reverse them significantly.
Many doctors feel that if they are busy in practice, they don’t need to really update themselves on newer advances in management. This is extremely true for asthma. Patients more and more, want precise information from their doctor about their disease, its prognosis, and the best available treatment.
Doctors who tend to ignore new developments in treatment often get left behind when it comes to managing difficult patients. In fact, being very busy in practice can often be a disadvantage when it comes to the time you can spend with the patient. More and more patients are complaining that their doctors don’t give them enough time. This is dangerous because poor communication between the patient and doctor is one of the commonest reasons of consumer court cases against doctors.
Doctors cannot any longer opt for second-best options for lack of time because more and more patients expect the best treatment from their doctor.
Cost of inhalation therapy is also becoming less and less of an issue when patients realise the huge amounts of money they have to pay when they get hospitalised for asthma.
Therefore, patients will soon no longer tolerate excuses from doctors on why they never received any inhalation therapy.
With such a large number of inhalation devices available for treatment, patients and doctors often get confused on which device to use.
The metered dose inhaler and the Rotahaler are the commonest inhalation devices currently used for asthma management in India.
The nebuliser is only meant for treatment of acute severe episode in a hospital or nursing home/clinic situations. Nebulisers are rarely required for home use in asthma
The scope for using inhalers is highest in children. As general practitioners you would be seeing a large number of children with recurrent coughs and many of these children would have bronchospasm as an underlying cause of their cough.
Wheezing in childhood is very common and on close questioning of the parent, you will always realise that parents want the best for their child. It is for this reason that if you can successfully convince the parent that inhalers are needed for their child with asthma, and the parents see the benefit, the child and parents will remain forever grateful to their doctor for the timely and correct advice.
This device has completely transformed inhalation therapy in India. Its ease of use (insert-rotate-inhale) and transparent nature has made it the most acceptable inhalation device for asthma.
At a price of Rs. 45, it is affordable to almost every patient with the disease and very few questions are asked to the doctor about whether it is really required (unlike MDIs where there is still a tremendous stigma about using the device).
Thanks to the usage of capsules, and the transparency of the device, patients relate much better to the therapy and don’t feel that some ‘powerful unknown’ medication is being used (unlike MDIs).
Finally, for us respiratory physicians every drug for inhalation therapy is available in Rotacaps today. Therefore, with one device one can use any kind or combination of medication for asthma.
It is very rare that you can’t use a Rotahaler.
Barring children below the age of 3 years and very elderly patients, almost every patient (aged 4 – 84) can use a Rotahaler very easily.
In children below 3 years a soft silicone baby mask can be attached to an MDI + Spacer for use. This can also be done for very old patients (edentulous) who are extremely weak and have poor inspiratory efforts.
A spacer ensures that an MDI (spray inhaler) prescribed is used correctly. There are no co-ordination problems when using spacers.
Also, when using high doses of inhaled steroids, spacers protect from excess oro-pharyngeal depositions and thereby help in preventing URTIs and oral candidiasis.
Most importantly, in situations where a nebuliser is not available, an MDI with spacer proves to be an equally effective option for treating acute exacerbations.
Do we still need nebulisers?
Yes, we do.
In acute severe asthma with impending respiratory facilities, nebulisers can be life-saving. In such situations nebulisers are often used to nebulise medications to patients who are already on mechanical ventilation.
In a hospital/ clinic emergency setting, these machines are extremely useful and necessary.
Here is an example of how to manage the average asthmatic who walks into your clinic wheezing badly.
Your first objective should be to achieve a rapid control of symptoms and effective treatment of the airway inflammation (swelling). Asthalin Rotacaps will relieve symptoms rapidly and oral prednisolone will rapidly control the airway swelling.
Though inhaled steroid will take long to act, it is a good strategy to start it on day 1 so that as the patient gets better you can explain to him the difference between oral and inhaled steroid. For patients who don’t want to know the difference, it provides an opportunity to tell them that the Foracort Rotacaps are the most important therapy for their long term management.
Let all this medication continue for the first 5 to 7 days.
When you see the patient a week later, he is invariably much better with the oral prednisolone (if not, your diagnosis of asthma was not correct!).
In the event that there is significant improvement, taper the prednisolone slowly before omitting it (about 5 mg reductions every 3rd day). This is especially so if patients have received oral steroids frequently in the past. If this is the first time, you could even abruptly omit the prednisolone.
Spend time telling the patient now that he has to use Foracort Rotacaps regularly for the next 2 to 3 months. If he gets any symptoms in-between, he can use either Asthalin Rotacaps or even an extra dose of Foracort Rotacaps once in a while.
Never forget to check two things if your patient is not feeling significantly better:
Is your patient using his Rotahaler correctly ? Most patients who don’t get adequate control, are not using it correctly.
Is your patient using the Foracort Rotacaps irregularly ? Many patients stop using, or use the Foracort Rotacaps very irregularly, once they start feeling better. It is very important to stress to patients to use the Foracort Rotacaps regularly regardless of whether they feel absolutely well or not.
If after 2 to 3 months your patient still feels unwell and inhaler technique and regularity have been checked, then you could consider the addition of drugs like montelukast or sustained-release theophylline.
Always look for other aggravating factors like allergic rhinitis, GE reflux, emotional swings, sinusitis and any other persistent allergens like house dust mite, carpets, thick curtains at home etc.
Often treating these aggravating factors appropriately dramatically relieves the asthma symptoms and thereby helps you to step down asthma treatment over a period of time.
As mentioned before, never forget to check Rotahaler technique and regularity of steroid use before labelling a patient as unresponsive to inhaled steroid therapy.
Finally, what you tell your patients when you diagnose asthma is extremely important.
Many patients get so scared when you mention the word asthma that they rush to see another doctor. Emphasize to them that this is a simple allergic condition of the airways which they could even call allergic bronchitis if they want to. Most allergic problems don’t have permanent cures and so regular treatment is often required to keep them under complete control.
In fact, most chronic ailments in medicine like diabetes, hypertension and epilepsy need regular treatment for good control. Asthma is one of the simplest chronic ailments to manage in practice. Patients are often more worried about the word asthma than the disease itself.
When it comes to treatment, patient often feels that an inhaler is the last resort for asthma. This is completely untrue, and patient should be told that inhalers deliver medicine much faster, much more safely and effectively and in much lower doses than tablets or syrups would do.
There is no better addiction for asthmatics than a regular inhaled steroid. Inhaled steroid taken for months and years is the best treatment that the doctor can offer his asthma patient.
Patients should be told that the inhaler is only a delivery system and not the drug itself. The drug itself is in almost a ‘homeopathic’ dose.
Studies have now shown that the earlier you start inhaled steroid therapy for children with asthma, the better in the long run. The later you start therapy, the less the benefit especially when it comes to severe uncontrolled disease over the past many years.
Untreated asthma over years leads to fixed airway obstruction and is extremely disabling (almost like COPD).
Always keep a Rotahaler and Placebo Rotacaps to demonstrate to your patients correct technique. A placebo MDI with Spacer and Babymask is also a requisite for your clinic.
A nebuliser is optional, though extremely useful for emergencies.
A peak flow meter for asthma monitoring is like a sphygmomanomen for blood transfusion monitoring.
Finally, always keep education material on asthma in the local language/s and English readily available in your clinic.
The peak flow meter you can see on this slide is not to be meant for the diagnosis of asthma. Peak flow meters at monitoring tools.
Not very expensive, ask your patients to take peak flow readings each time they visit you. An improving peak flow trend is a very positive feedback to the patient and builds tremendous confidence in the treatment he is being given.
Ask patients to be give one ‘hard fast blow.’ This is the simplest way to explain the technique of peak flow to patients. Patients should seal their lips around the peak flow rotahaler mouthpiece. If the patient coughs into a peak flow meter, that reading should be discarded.
This instrument has a tremendous capacity to draw a patient back to your clinic.
Follow up visits showing improving symptoms and peak flows improving patient confidence and adherence to treatment protocols.
Peak flow meters, for obvious reasons, are not recommended for home use routinely. Their presence and use in the doctor’s clinic are far more important.
Many patients see other asthma patients suffering today. Most of the suffering is due to no use or under-use of inhaled steroid when these patients were children. This is a fact, and the only way for asthmatics to live normal lives now and in the future is to institute inhaled steroid therapy as early as possible in the course of persistent asthma.
Always remind your patients that, unlike in consumer appliances, inhalers that cost more are not necessarily better. A classical example is the nebuliser which, because it is so expensive, is perceived to be the ‘best’ device for asthma.
As the slide clearly illustrates, there is nothing better than regular inhaled steroids for asthmatics today.
And, in closing, I would like to sat that there is nothing ‘specialist’ about asthma management today!
