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Drs Neville and Higgins ask what more can be done to provide better asthma care.1 They mention the importance of education but, before we can teach patients, we must resolve our own confusion about treatment.
Evidence shows that it is important to stamp out the inflammatory process in the bronchial tree as soon as the diagnosis of asthma has been confirmed, yet patients are still prescribed a short acting β agonist bronchodilator as the drug of first choice. This is given partly as a diagnostic test and partly because step 1 of the BTS guidelines2 seems a good place to start. Although the guidelines state that treatment should start at the step most appropriate to the initial severity, little guidance is given as to how this should be assessed.
Bronchodilators have a dramatic short term effect so patients learn that these are the correct treatment for their asthma and rapidly become dependent on them; inhalations are repeated as symptoms recur and they start to take much more than the doctor realises or intended.3 It is then difficult to introduce steroids as additional treatment as patients feel these drugs are less effective because of their delayed action. The result is that most asthmatic patients persist in using short acting β agonists on their own, or sometimes with an inadequate dose of inhaled steroids, to try to control their symptoms. Mucosal inflammation and bronchial hyperreactivity persist, the frequency of symptoms is not reduced, and optimal lung function is never achieved. These patients do not realise the importance of steroids and, when their symptoms become worse, they increase their bronchodilators but delay taking steroids until it is too late to prevent an acute attack.
Another approach to management is to start all new asthmatic patients at step 2 of the BTS guidelines, using a large dose of steroids as soon as the diagnosis has been confirmed by PFR monitoring. There is then no agonising over whether or not to give steroids or what dose to use. These patients learn that steroids are the correct treatment for their asthma. The large initial dose recommended stamps out the active inflammatory process and achieves symptom control with full reversibility and optimal lung function. The dose is then gradually reduced to the minimum necessary to maintain optimum lung function and freedom from symptoms. Beta agonist bronchodilators are not prescribed initially but kept in reserve for emergencies.
The latter approach is being increasingly adopted by asthma nurses and many thinking doctors but some still misinterpret the BTS guidelines and allow their patients to become addicted to β agonists.
Perhaps we need guidance on the use of the guidelines?
authors' reply Dr Strube's letter addresses an interesting and important question. It is an issue which deserves proper debate, and most Thoraxreaders will recognise that that is exactly what it has had in the recent pages of the BMJ.1-1Because of this, and because the question has, we would suggest, only the most tenuous link to our article, we will reply only briefly.
Dr Strube makes the case for using inhaled steroids in all asthma with conviction, but his supporting arguments are a mixture of circumstantial evidence and his own perception of the psychology of asthmatic patients. There is simply no direct trial evidence to show benefit from blanket administration of inhaled steroids to all new asthmatics. Good evidence certainly exists in asthma of moderate severity or greater,1-2 but the situation is less straightforward in patients with mild asthma where the case is unproven. Since there are valid reasons, aired elsewhere,1-1for not using inhaled steroids unless necessary, it is fair to ask for some proof before committing patients to long term therapy in this way.
In addition to the lack of evidence, the approach advocated by Dr Strube assumes a certainty of diagnosis which many would feel to be unrealistic at the mild end of the asthma spectrum. It is easy to write that inhaled steroids should be started “as soon as the diagnosis has been confirmed by PFR monitoring”, but this is an insensitive test which is least likely to confirm asthma in those in whom the need for inhaled steroids is most debatable.
A further part of his argument is that the current guidelines on introduction of inhaled steroids are misused. This, as Mike Rudolf pointed out in the published debate with Dr Strube,1-1 is irrelevant to the main question; if the guidelines are being misinterpreted, the remedy is to attack the misinterpretation, not the guideline.
We would point out that we are not attempting to prove Dr Strube wrong. We cannot do so, any more than he can prove that he is right. What is important is that guidelines are based on the best evidence available, and at the moment we lack the information needed to resolve the issue. If and when the evidence is strong enough, the recommendation will appear as Dr Strube wishes. Until then, this is a question of faith rather than fact.
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