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As a nurse consultant in respiratory diseases, I am writing to express my concern in relation to the lack of guidance in the section on patient education and self-management in the recently published BTS/SIGN guideline on the management of asthma1. Although I fully support the importance of patient education as a key component to effective asthma management, I do have unease around the issue of inhaled steroids. I appreciate that doubling the dose of an inhaled steroid at the time of an exacerbation is of unproven value; however, anecdotally, I think we can all bring patients to mind where this has happened and their asthma symptoms have settled. I now feel slightly bewildered, like many of my nurse colleagues, as to the advice patients should be given. It appears that the only options available during an exacerbation are to increase the use of bronchodilator therapy and, if this fails, to seek medical help or commence a course of prednisolone. The latter option concerns me as this may result in an increase in prednisolone usage, some of which may be unnecessary.
The lack of clarity on the pharmacological management during an exacerbation may result in groups of professionals coming together to write their own guidance, which could potentially create disparity of treatment interventions and standards of care. The National Asthma Campaign personal diary and action plan, which is promoted by the new guidelines, could be interpreted as suggesting a change in the inhaled steroid dosage during an exacerbation.
I appreciate the hard work and dedication of the committee involved in reviewing the literature before these new asthma guidelines were produced. However, do you envisage any further work being undertaken on the asthma action plan in relation to pharmacological management during an exacerbation?
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Authors’ reply
We are grateful to Karen Clancy for raising an issue which has emerged in discussion at numerous meetings on the new asthma guidelines.
The BTS/SIGN guideline on the management of asthma1 strongly advocates the use of asthma action plans because they have been shown to improve several important outcome measures. Most such plans advise patients to double their usual dose of inhaled corticosteroid for a few days to cover non-severe exacerbations of their asthma. We therefore looked for evidence on the efficacy of this specific manoeuvre, but could not find any. This is potentially confusing. Asthma action plans work, but there is no evidence to support one of their key features.
It is important to emphasise exactly what is stated in the asthma guideline. We do not say that doubling the dose of inhaled corticosteroid does not work, but we do say that the value of this intervention is unproven. We do not recommend amendment of existing plans until there is a proven alternative. It may be useful to know precisely why asthma action plans do work, and further research here would be interesting. It is possible that, in patients who do not regularly take their full daily dose of inhaled steroid, “doubling” their prescribed dose improves compliance, at least temporarily.
In the meantime we would advise that health professionals continue to use asthma action plans which have been shown to be effective and with which they are familiar.