GPs can help patients understand why treating airway inflammation, not just symptoms, is key to better asthma control.
Shifting patients away from their attachment to the blue puffer is emerging as a key challenge for GPs as asthma treatment moves towards anti-inflammatory relievers.
Perth GP and chair of the National Asthma Council Australia’s Guidelines Committee Dr Brett Montgomery said the message that adults and adolescents should no longer manage asthma with a short-acting beta2 agonist (SABA) alone was gradually filtering into practice but had yet to fully reach patients.
“I think the message is slowly getting through, but in all parts of medicine, there is often a slow translation from research evidence into practice,” he told The Medical Republic.
“I’d like to think most GPs have heard the messages of the new handbook, but my impression is that for many people with asthma, health consumers more than health professionals, that’s still something that is making its way into the public consciousness.”
The latest Australian Asthma Handbook recommends anti-inflammatory reliever (AIR) therapy, taken as needed when symptoms occur, as the starting treatment for most adults and adolescents with asthma.
Maintenance-and-reliever therapy (MART) is recommended for patients requiring maintenance treatment, while SABA-only treatment is no longer recommended for adults or adolescents.
Dr Montgomery said the scale of poor asthma control suggested there was still considerable work to do.
“Our most recent data suggests that you know about half of people with asthma in Australia have poor control, and about half of them are using little or no inhaled corticosteroids, getting little or no of that treatment that’s targeting the inflammation, which is really the at the root of asthma that we could control better,” Dr Montgomery said.
Australia’s over-the-counter access to SABA relievers could compound the problem.
“I think Australia also has this somewhat unusual situation of very easy access to the blue puffers, short-acting beta agonists over the counter in pharmacies,” Dr Montgomery said.
“So, for health consumers who are tending not to see their doctor to manage their asthma, we have a system that makes it easy to do the wrong thing in terms of asthma control.”
With the beginning of peak pollen season arriving last week and coinciding with National Asthma Week, the NAC was keen to encourage health professionals to help patients understand that asthma treatment needs to address airway inflammation rather than simply provide rapid symptom relief.
Dr Montgomery said that distinction could be difficult for patients because the immediate effect of a SABA made it particularly convincing as a treatment.
“The blue puffer, the short-acting beta agonist makes you feel better really quickly. It’s nice that it works so quickly. It’s very persuasive. People take it; they can really feel it works, and they really believe in that medicine,” he said.
“The inhaled steroids, unfortunately, do their magic a little more slowly, and it can take longer for people to perceive their benefit.”
That difference had historically made adherence to inhaled corticosteroids challenging, because patients did not receive the same immediate feedback they experienced with a reliever.
Combination inhalers offered an important advantage by bringing symptom relief and anti-inflammatory treatment together, said Dr Montgomery.
“This new era of the combination puffer that has the long-acting beta agonist that has quick onset to give that sense of immediate relief, coupled with the steroid, I think means we can sneak in the slower-acting but more healthy and more powerful medicine, along with the one that’s giving them immediate relief, and it just makes it easier for everyone to do the right thing,” he told TMR.
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Dr Montgomery said that when starting a discussion about asthma management he often began by finding out what patients already understood about the common but deadly respiratory disease.
“I like to ask what they understand about their asthma, and I build education from there,” he said.
“I often find pictures are useful, illustrating the inflammation, mucus, tight airway muscles, and illustrating that your blue puffer might just relax these muscles, but look at all this swelling. Look at these inflammatory cells.
“To treat those, we need a different medicine and make sense of it from there.”
The council has also developed patient resources explaining inflammation by comparing airway swelling with more familiar experiences, such as a mosquito bite or nasal blockage with hay fever.
Changing long-established behaviour could nevertheless take time, particularly among people who had successfully relied on a blue puffer for years, Dr Montgomery said.
“We know that some patients can be reluctant, scared and hesitant about changing, especially when they’ve been using a certain approach to managing a disease for a long time, they’ve got used to it. They trust what they’re doing, so hesitancy is natural,” he said.
Continuity of care could make those conversations easier.
“I think I have the greatest success when I’m talking about this to a patient who’s very used to me as well as very used to their medicine,” he said.
“That sort of an environment of trust and familiarity, I think, can help them to trust my suggestion that a change is worthwhile.
“Listening to concerns, making time to hear and address patient concerns, I think is really helpful in making change happen.”
The use of a blue puffer on more than two days a week on average may indicate inadequate asthma control, according to the NAC.
SABA overuse is associated with an increased risk of exacerbations, while use of 12 or more canisters a year has been associated with a significantly increased risk of asthma-related death.
But poorly controlled asthma did not automatically mean a patient needed specialist treatment, Dr Montgomery stressed.
“I think most asthma can be managed successfully in general practice, and a lot of the time, people who have poorly managed symptoms, it’s not that they need fancy, expensive biological therapies,” he said.
“It’s that there’s some barriers in terms of education or device technique that we need to work with them on.”
Patients whose asthma remained difficult to treat despite good adherence, correct inhaler technique and escalation of therapy were candidates for specialist assessment, he said.
“They’re the sort of people that I would consider referring to a respiratory physician to see if to see what the next step would be,” Dr Montgomery said.
For appropriate patients with evidence of severe disease, biologic therapies could substantially reduce exacerbation risk.
“There’s biomarkers we look for to prove that in the right person, biological therapies can be very potent in reducing the risk of exacerbations of asthma,” he said.
But Dr Montgomery said getting basic asthma management right remained the priority, particularly given the potential consequences of inadequate control.
“We do have a few 100 lives lost every year in Australia to severe asthma exacerbations, and so we do need to be more vigilant,” he said.
