Can we prevent asthma attacks?
Despite years of asthma education describing the importance of regular treatment with inhaled steroids and the use of self-management plans, many patients continue to live with poorly controlled asthma and are, therefore, at risk of asthma attacks and death.
Asthma is a common, inflammatory condition of the airways, which leads to shortness of breath, coughing and wheezing, particularly while exercising, on exposure to a variety of common allergens and irritants and upper respiratory tract infections. Severe episodes of shortness of breath and wheezing are termed asthma exacerbations or attacks. Asthma attacks are frustrating due to their unpredictability and are frightening due to their severity and sometimes poor response to treatment. Asthma attacks occasionally lead to hospital admission and even death, many of which could be prevented by better use of available medication. Predicting asthma attacks and finding interventions to prevent them is, therefore, crucial and has been the main focus of my research over the last 15 years.
Preventing asthma attacks
Even mild asthma is associated with an eosinophilic inflammation in the airways and the degree of inflammation is correlated with the risk of asthma attacks.
Prevention strategies focus on reducing this inflammation primarily with inhaled steroids, with or without long-acting beta-agonists and sometimes long-acting anticholinergics. Due to adverse effects from high dose inhaled steroids the preferred option is to use low-to-moderate doses most of the time increasing to a high dose at the early signs of an attack; something which can be achieved in several ways.
Traditionally patients with asthma have been taught to identify precipitants that lead to asthma attacks, or to recognise a reduction in their asthma control, an increase in their asthma symptoms, or their reliever medication use. They use this information to adjust their maintenance treatment with the aim of preventing a full-blown attack.
Increasing inhaled steroid dose
Back in 2004 we demonstrated that doubling the dose of inhaled steroid at the first sign of an asthma attack does not reduce the need for prednisolone. However, our latest NIHR-funded trial, the Fourfold Asthma Study (FAST) compared no change in steroid dose with a four-fold increase in steroid dose when asthma control started to deteriorate.
Our results showed a 20% reduction in severe asthma attacks. In addition, only three patients were admitted to hospital in the quadrupling group compared with 18 in the non-quadrupling group. Overall 15 patients had to be shown how to use the self-management plan to prevent one asthma attack.
Is this the solution?
I fear, sadly not. I believe one of the main reasons for this is the early and widespread use of short-acting beta agonist inhalers (SABA). The majority of patients with newly diagnosed asthma are started on a SABA for symptom relief and told to take extra doses when they develop symptoms. As a result, patients come to rely on their reliever inhalers and many use them at the expense of their maintenance treatment. Overuse of SABA and underuse of inhaled steroids is very common and both are related to death from asthma.
Time for a new approach to symptom relief
If we remove SABA therapy and instead use inhalers that contain a rapid acting bronchodilator and an inhaled steroid for symptom relief, patients will get more corticosteroid as and when it is needed even if they have stopped their regular maintenance therapy. Overuse of SABA at the expense of inhaled steroids is no longer possible.
Unfortunately, this approach is currently only licensed in patients with moderate to severe asthma (the so-called maintenance and relief therapy with formoterol and budesonide combination inhalers) but I believe replacing SABA with anti-inflammatory relievers across the spectrum of asthma severity would reduce asthma attacks and even asthma deaths particularly in countries where overuse of SABA’s is common practice.
I believe the widespread use of an affordable anti-inflammatory reliever (perhaps “salbutamol-plus”) could be the next step change in overall asthma mortality. Whatever happened to Ventide? It was a combination of salbutamol and beclomethasone dipropionate in a single inhaler now only available in Peru!
The journal article ’Quadrupling Inhaled Glucocorticoid Dose to Abort Asthma Exacerbations’ was also published in the New England Journal of Medicine (NEJM).
The views and opinions expressed in this blog are those of the authors and do not necessarily reflect those of the NIHR or the Department of Health and Social Care.