There is currently no cure for most types of adult asthma, and the primary goals of management are: 1) to achieve and maintain control of symptoms; and 2) to prevent asthma exacerbations. In many cases, it is also possible to improve and/or maintain respiratory function, to retain normal activity levels, to prevent the development of irreversible airway narrowing and to prevent deaths from asthma. Clearly, it is also desirable to avoid short- and long-term adverse events from asthma medication.
Management starts with the identification of factors that trigger or worsen asthma. Avoiding passive or active smoking, exposure to high levels of airborne allergens or environmental pollution, and certain medications that may provoke asthma can each help improve control. Appropriate patient education and self-management are important aspects of care; in many countries, this is efficiently delivered and supervised by specialist asthma nurses.
Pharmacological treatment comprises ‘controller’ medication, exemplified by inhaled corticosteroids (ICS), with or without long-acting β2-agonists (LABA), and ‘reliever’ medication taken as required to relieve symptoms, exemplified by short-acting β2- agonists (SABA). The amount of treatment is adjusted according to the severity and frequency of asthma symptoms. Patients’ needs for treatment may change over time and treatment should be adjusted accordingly.
Mild asthma is usually controlled using SABA alone and on demand, or by the addition of low doses of ICS. Asthma of moderate severity can be controlled with a combination of low- or high-dose ICS with LABA. More severe asthma may necessitate the addition of other controller medications such as leukotriene inhibitors and slow-release theophylline. Oral corticosteroids may be needed intermittently for treatment of exacerbations, or on a daily basis in those with the most severe disease. In some countries, anti-immunoglobulin (Ig)E antibody treatment is now available as an additional therapy for patients with severe allergic asthma.
Using established treatment guidelines, most adult patients with asthma can be managed adequately in general practice, but those with more severe disease, and particularly those who present with recurrent exacerbations of asthma, are managed in hospital clinics. The rate of acute hospital admission for asthma varies widely across Europe (figure 3) but in most countries admission is less common than it used to be, probably reflecting improvements in the delivery of asthma care and the increased use of ICS therapies.
Medication use in Europe
In the Asthma Insights and Reality (AIRE) study of seven western European countries, published in 2002, 2083 adults and children with asthma or their parents were surveyed about their asthma by telephone interview. In this survey, 12–18% of children and 15–28% of adults were classified as having severe persistent asthma. However, in the severe category, only 14–83% of children and 8–49% of adults were being treated with ICS therapy. The country with the highest use of ICS in both children and adults was Sweden. Because it would be expected that all patients with severe persistent asthma would be taking ICS, the survey indicated that there was severe undertreatment of asthma, the major reason perhaps being the lack of uniform application of asthma management guidelines across these countries.
However, in both France and the UK, there is evidence that the number of prescriptions for anti-asthma drugs more than doubled between 1980 and 1990, particularly for SABA and ICS. In the UK, the number of prescriptions for ICS in 1980 was approximately 1.2 million, increasing to 7 million in 1992. In a cross-sectional review of treatment carried out in five large general practices in the UK, 54% of adult patients with asthma were prescribed SABA alone, with most of the remainder using various combinations of additional drugs; 8% were using no treatment at all. Over the previous year, 14% had received 10 or more prescriptions for SABA/LABA and 13% had been prescribed at least one course of oral corticosteroids. Both of the latter occurred more frequently in patients taking more prophylactic treatment, indicating that there is a group of individuals, albeit relatively small in number, who have asthma that is refractory to the best available treatments.