Find out about good asthma control and how you can help your patient achieve it.
What is good asthma control?
Good asthma control is demonstrated by having:
No symptoms
No asthma attacks.
No limitations on activity including exercise.
No flare-ups or exacerbations
Having symptoms at night-time or early in the morning is a sign of poor control that needs urgent review.
Good control is achieved by using inhaled corticosteroids (ICS) to damp down the inflammation that causes asthma symptoms.
All patients with asthma must be prescribed an inhaler containing an inhaled corticosteroid (ICS) from the point of diagnosis, including a trial of treatment.
You should review your patient 4-8 weeks after any change to treatment and adjust as necessary. Your patient should be on the lowest treatment dose possible for them to maintain good asthma control.
Preventer inhalers
Inhaled corticosteroid (ICS) inhalers are often called preventer inhalers.
These inhalers build up over time to reduce airway inflammation. They need to be taken every day, even when well.
People who are using ICS inhalers should rinse their mouth out after use. This is to help to avoid side effects such as a sore throat, hoarse voice or oral thrush.
Good inhaler technique is essential to make sure that the medication gets to the airways where it's needed.
Some patients worry that inhaled steroids have the same side effects as steroid tablets (prednisolone) or confuse them with anabolic steroids. This can lead to patients not taking their ICS regularly.
You can reassure them about this by explaining that:
- inhaled corticosteroids steroids mimic cortisol, the anti-inflammatory hormone that is produced naturally in the body.
- inhaled steroids work directly in the airways meaning they can be taken in very small doses which reduces systemic side effects.
- taking a preventer inhaler regularly will help control asthma and avoid flare ups that require a course of steroid tablets.
Reliever inhalers
Reliever inhalers contain a short acting bronchodilator (SABA) which works quickly to open the airways.
SABA inhalers only treat symptoms. Unlike ICS, they do not treat the cause of the symptoms.
People with asthma should never be prescribed SABAs alone. This is because studies show that only using a SABA to treat asthma is associated with a greater risk of fatal asthma attacks.
People with asthma often say they prefer their SABA to their ICS inhaler. This is because they can feel it working and it gives them instant symptom relief. So it’s important to explain to your patient that although their SABA makes them feel better immediately, it’s not actually treating the underlying problem, which is the inflammation in their airways.
Find out more about SABA overuse and how you can help your patients here.
Combination inhalers
Combination inhalers for asthma contain an ICS and a long acting bronchodilator (LABA). LABAs last for around 12 hours (apart from Vilanterol which lasts 24 hours) whereas SABAs lasts for 4-6 hours.
Some combination inhalers contain the long acting bronchodilator Formoterol. Formoterol is different from other LABAs because it has a rapid onset of action. Like a SABA, it works quickly to open the airways but it lasts longer.
This means that an ICS-Formoterol inhaler can be used as a preventer and a reliever. This helps your patient stay safe and reduces their risk of an asthma attack because every time they use their inhaler to treat symptoms, they’re also giving themselves a dose of ICS, which will help treat the underlying inflammation.
This approach is called Maintenance And Reliever Therapy (MART)
Your patient will take a maintenance dose of their ICS-Formoterol inhaler twice daily, and then use the same inhaler to treat any symptoms that arise. The number of additional doses depends on the inhaler that you prescribe. For more details see RightBreathe.
Your patient on a MART regime does not need a salbutamol inhaler. Some patients are worried about this change, so ensure that you explain how the MART approach works and how it can benefit them.
Click here to find our MART asthma action plan and our guide to completing it with your patient
ICS–Formoterol inhalers can also be used on an as needed (PRN) basis for patients who have occasional asthma symptoms. This is called Anti Inflammatory Reliever (AIR) therapy.
Click here to find our AIR asthma action plan and our guide to completing it with your patient
Click here for help on choosing the right inhaler device for your patient
Factors that can affect asthma control
If your patient is showing signs of uncontrolled asthma, it's important to check the following factors before making any changes to their treatment.
Inhaler technique
Have they got good inhaler technique?
Is their inhaler device right for them?
It’s essential that patients are shown how to use their inhalers and are prescribed a device that is suitable for them. Click here for help on choosing the right inhaler device for your patient
Metered dose inhalers (MDIs) should always be used with a spacer.
Are they remembering to take their inhalers?
Suggesting your patient sets a reminder on their phone, downloads an app or keeps their inhaler next to their toothbrush might help them to remember to use it.
Exploring any worries or concerns about their medication will increase their understanding and adherence.
Triggers
Triggers are anything that causes asthma symptoms and vary from person to person. They often change over time. See here for more information on triggers
Are they smoking or exposed to smoke?
Offer smoking cessation support.
Click here to see Asthma + Lung UK's "How to stop smoking" leaflet
Are there any occupational exposures that are triggering their symptoms?
Are there any seasonal or environmental triggers, such as hayfever, pets, mould, air pollution?
Antihistamines are effective in treating allergies, seasonal or otherwise, that make asthma symptoms worse.
Gastric reflux
Do they have reflux?
People with asthma are more likely to get gastric reflux. Gastric reflux makes asthma symptoms worse as it causes irritation to the airways.
Although it’s not yet clear whether treating acid reflux improves asthma symptoms, there is some evidence to say it might improve them for some people.
Nasal symptoms
Can your patient breathe through their nose?
A runny nose (rhinitis) or nasal polyps can make asthma worse – it will be harder to breathe, and post-nasal drip (a feeling of mucus running down the back of the throat) may make your patient cough more.
Nasal steroids are effective in treating nasal symptoms.
Stepping up treatment
Once you are certain that all of the above have been assessed and treated, you can consider changing your patient’s asthma treatment.
If your patient is uncontrolled on a Maintenance And Reliever Therapy (MART) regime, guidelines recommend a trial of a leukotriene receptor agonist (LTRA, also known as Montelukast)
Montelukast is taken at night time in tablet form. It should be trialed for 4-8 weeks and then reviewed. Ask your patient to keep a symptom diary during their trial of treatment.
Montelukast is an effective option for some people with asthma. As with all medicines it is important to outline common or serious side effects. Rarely, some people on Montelukast have sleep disturbance, behaviour changes and mental health problems including suicidal thoughts. This can make patients worried about taking it. You can reassure your patient that these side effects are rare, and disappear when the medicine is stopped
Increasing inhaled steroids
If Montelukast has not helped, inhaled steroids can be increased to a medium maintenance dose. This should be in a combination inhaler with a LABA. See here for NICE's guide on low, moderate and high ICS dosages for adult and paediatric maintenance therapy.
At this point in your patient’s treatment, if you have checked technique, inhaler suitability, adherence and all the factors which affect asthma detailed above, it is time to refer your patient into secondary care for further testing and treatment.
Stepping down treatment
Once your patient's asthma is fully controlled for 3 months or longer, it is appropriate to step their treatment down. Changes in medication need to be discussed with your patient to make sure they are happy to step down and understand why this is appropriate for them.
Before stepping down treatment - consider:
How easy was it to get their asthma under control?
Have previous attempts to step down resulted in a flare up of symptoms?
Have they had a flare up or needed oral steroids (prednisolone) in the past 6 months? If so, delay stepping down for another 3 months.
Are they under respiratory specialist review or pregnant (only step-down if agreed with the specialist).
Are there any seasonal considerations - for example, reviewing a patient outside of their hayfever season may not give an accurate picture of their asthma. In this case, reschedule the stepdown review until after the season has ended.
Are there any lifestyle considerations where stability is crucial, such as impending exams?
Reduce the dose of ICS gradually, 25%-50% at a time. Make sure your patient knows to contact an HCP if their symptoms worsen, their reliever inhaler use increases, or their peak flow decreases
Every appointment should to be used to check and reinforce your patient’s inhaler technique. Update their asthma action plan and explain that if symptoms worsen, they should contact a healthcare provider.
Agree a review date for 3 months' time and repeat the stepping down process until they are on the lowest dose of medication that controls their symptoms