curate diagnostics in many cases. Formoterol is the recommended as-needed medication due to its faster onset of action (equivalent to SABAs) as opposed to salmeterol. However, the cost of these medications may be a barrier for some patients and will raise the cost of inhalers for the vast majority of asthma patients and the State, which funds the majority of the treatments. Further studies may be needed on this in countries with different healthcare structures and costs. There are studies showing that it is cost-effective in reducing the costs of exacerbations and hospitalisations. GPs and practice nurses will have to ensure the correct technique is used for the new inhalers.
than if symptoms have been present for more than two-to-four years. • In occupational asthma, early removal from the trigger factors at work are the key element in improving the situation. Most patients with asthma do not need more than low-dose ICS, because most of the benefit is achieved at low-dose treatment. For most patients a controller can be started with either as-needed ICS-formoterol (or if not available, low-dose ICS whenever SABA is taken) or with regular low-dose ICS.
Step 1 This step was SABA when needed in previous guidelines. This is now only recommended for patients with symptoms less than twice a month and no exacerbations. The new guidelines recommend as needed low-dose ICS-formoterol. The factors that influenced this decision were: • These patients can have severe exacerbations despite minimal interval symptoms. • Use of ICS-formoterol was associated with reduced exacerbations and 20 per cent reduction in ICS use as opposed to regular low-dose ICS. • To reduce conflicting messages in the past where patients were told to use their SABA medication as much as they needed and then being told that they needed to reduce SABA use to gain control. • ICS adherence in patients is poor and exposes patients to risks of SABA use only. All studies so far have been with budesonide-formoterol but beclomethasone-formoterol may also be suitable. This new guideline will have implications for all clinicians treating asthma as it is no longer recommended to start with a SABA-only treatment. It will therefore be important to make an accurate diagnosis and it is estimated that up to 30 per cent of patients with GP diagnoses of asthma may not in fact have asthma. This is due to lack of resourcing of ac-
The key element of assess, adjust and review remain in place when dealing with patients with asthma. Assessing: • Confirming the diagnosis. • Symptoms control. • Comorbidities. • Inhaler technique and adherence. • Patient goals. • • •
Adjusting: Treatment of modifiable risk factors and comorbidities. Non pharmacological strategies. Education and skills training.
• • • • •
Reviewing: Symptoms. Exacerbations. Side effects. Lung function. Patient satisfaction.
The use of tiotropium was in the last guidelines at step 4, for patients over the age of 12 years with exacerbations but the age of this has been reduced down to patients over six years in line with manufacturers licencing policy. The use of sublingual immunotherapy (SLIT) has been kept in the guidelines at step 3 for patients who are allergic to house dust mites (proven on skin prick test or SpIGe testing) who are over 12 years with exacerbations.
In summary The new guidelines are an important step to try to reduce the burden of asthma but will present challenges to doctors to alter older prescribing patterns, to patients who have to adapt to a different management approach and to funders who may expect to see an initial rise in cost of medications. One would expect savings to be made with less secondary care costs and less indirect costs such as time off work. The new guidelines need to be considered at national level before widespread adoption. See www.ginaasthma.org for more information.
Clinical Journal for all healthcare professionals specialising in, or with an interest in, respiratory medicine