Asthma: Treatment

00:01 How do you treat asthma? Essentially, it’s via inhalers, which inhaler the patient use depends on which they get on with.

00:08 There’s a huge variety of different types of inhalers and they all have their little pros and cons, and it depends really which the patient prefers. It’s important that the patient is compliant with treatment and is effective at using the inhaler. So one of the major things that a respiratory physician and the respiratory nurses need to be sure about and need to teach the patient about is the inhaler technique to ensure that they’re taking an adequate amount of drug and it’s reaching the lungs. With asthma, we use a stepwise treatment.

00:41 With increasing levels of severity, we use increasingly more treatment. Mostly, that’s inhaled. But more severe chronic disease may need oral medication as well. When somebody comes to hospital with an exacerbation, the mainstay of treatment there are nebulized bronchodilators. And we’ll discuss that a little bit more detail later in the talk.

01:05 So, what’s the aim of treatment? Well, the aim of treatment really is for the patient not to realize they have asthma anymore, to get rid of their symptom so they don’t have asthma symptoms when they’re running for a bus. They don’t wake up in the middle of the night coughing, and they can do whatever exercise they want to do without feeling that the asthma might kick off. In addition, we want to prevent acute exacerbations. We want to prevent patients having an exacerbation that means they come into hospital because that’s both life threatening, inconvenient and unpleasant for the patient and also expensive for the healthcare services. In theory, we want to minimize the need for using bronchodilator rescue treatment so that we use regular inhaler to prevent the asthma causing problems that then the patient will use ventolin salbutamol bronchodilator inhaler to improve the symptoms for. Because essentially, bronchodilators don’t treat the cause of asthma, they treat the symptoms. So, this is a description of the U.K. guidelines.

02:12 And really, what happens here is you have a stepwise treatment, step one, step two, step three, step four, step five. And you go up these steps depending on whether the asthma is controlled by the first step, especially if the lung function shows that there’s ongoing evidence of airways obstruction with variable peak flow or an FEV1 lower than predicted or the best that the patient has ever achieved. S, for very mild disease, this is asthma which only occurs very occasionally and can be relieved easily by salbutamol inhaler, and that’s not being used very frequently. I mean, less than once a week, for example. Then you probably can just give them a short-acting bronchodilator, and that will be adequate for treatment.

02:56 However, the majority of patients require the mainstay therapy for asthma which is inhaled corticosteroids.

03:03 Asthma inflammation is very easily treatable in the majority of patients with corticosteroids.

03:13 An inhaled corticosteroid means that corticosteroid is delivered directly to the lung in high enough doses to settle the lung inflammation, but in low enough doses that does not get absorbed and there are no systemic complications or it’s unlikely the patient will develop systemic complications of steroid inhaler therapy unless they take very high doses.

03:35 An inhaled steroid will reverse the information associated with asthma and minimize the symptoms the patient has. So the step two is to start an inhaled steroid. Now, it may be that an inhaled steroid in itself is not adequate enough to control the patient’s symptoms.

03:56 The next step, actually, will be to increase the amount of inhaled steroid the patient is taking. So you start over relatively with some low dose. And then if the patient is still not well controlled, you increase to a moderate dose.

04:08 In addition, we do know that adding in a long-acting beta-agonist bronchodilator, such as salmeterol or formoterol is synergistic with inhaled steroids in improving control of asthma.

04:21 So if somebody is still getting symptoms despite a medium dose with inhaled steroid, then the addition or long-acting beta-agonist is a good move and would likely make a substantial difference to their symptoms. It’s particularly useful for patients who are waking at night with cough because the long-acting beta agonist will cover the period when they’re asleep and make them less likely to wake up at night with the cough.

04:44 Other medications that could be considered at this stage are leukotriene inhibitors.

04:47 A leukotriene inhibitor, leukotrienes are one of the main mediators of asthma, and the inhibitors can prevent information due to asthma. And in some patients, a leukotriene inhibitor has a very beneficial effect but not all.

05:02 Now, an important point about this medication is that if the patient is well controlled on a high dose of inhaled steroid, they’ve had poor control with lots of cough, lots of breathlessness and wheeze and maybe an occasional admission to hospital, and they’re needing quite a high dose inhaled steroid to control that. Once it’s been brought under control. In fact, many patients can get away with a lower dose inhaled steroid.

05:27 So the patient’s treatment may give up and down the stepwise model depending on the severity of the disease. Once it’s being controlled, they drop down a step or two. And then if the symptoms returned, they may need to go back up to the higher step treatment.

05:43 Step four is when you’re actually giving patients triple therapy, essentially they have an inhaled steroid, they have a long-acting beta agonist, they may have an oral theophylline, or we may add instead a long-acting muscarinic antagonist such as tiotropium or to a leukotriene inhibitor. And then step five is really very limited number of patients reach this step.

06:03 These has patients who have got poorly controlled disease and they may need oral corticosteroids.

06:09 Now, we use those very frequently for exacerbations but only for five days, seven days at a time.

06:16 For patients with long-term asthma that’s poor controlled, however, we sometimes need to use a low dose of oral corticosteroids, prednisolone 5-10 milligrams, for example, to control their disease. But they are very much the very severe under the spectrum and there should be a very limited number of people who recall oral corticosteroids because the side effects are very complicated and not good.

06:42 So additional treatment considerations. Right, If the patient loses weight, if they stop smoking, if they avoid the allergens, then that’s all going to make the control of the asthma much better. If they’re working in a job where they are exposed in occupational trigger, clearly, it needs to be addressed as well. There are certain breathing exercises and psychological input can be beneficial as well. Of these, probably the most likely and most important here is to stop smoking. There’s something very specific about cigarette smoking that makes the ability of inhaled steroids to control asthma much worse.

07:19 So if you smoke and have asthma, then inhaled steroids essentially are much less effective than they should be. So not only is it the smoking stimulating the airways information and kicking off the asthma, it also prevents the mainstay of therapy inhaled corticosteroids from actually controlling the disease. So smoking and asthma is a very big problem, and patients who have asthma must be strongly encouraged to stop smoking.

07:48 So if somebody has poor control despite going through the stepwise treatment and increasing the treatment and they’re still not doing well, then there are various considerations you can think about. The first and the most obvious is, are they actually taking the inhaler? Do they fully understand that the inhaler has to be taken regularly? Because many patients will actually take the inhaler regularly. When the asthma gets a bit better, they will stop the inhaler corticosteroid, and guess what, the asthma comes back.

08:14 Inhaled corticosteroids take about 10 to 14 days to actually improve asthma control.

08:21 It’s actually difficult then for the patient to associate stopping inhaler with reduced control of the asthma in some ways because what will happen is that they will stop the corticosteroid and it would be a week or two before the asthma starts kicking off again. So education to make sure they’re compliant is very important. The other thing that needs to be checked is inhaler technique because it’s quite possible that the inhaler is being used in a way which means that most of the drug is not being delivered to the lung. And in that situation, it’s very easy to resolve a situation with a better inhaler technique, a different inhaler which the patient is more able to use or whatever to make sure they’re actually getting drug delivery. The third thing to think about are continuing triggers. Now, we’ve already discussed smoking. That is the most important continuing trigger.

09:06 But psychosocial stress is often a problem and is very difficult to deal with because that’s outside the remit of the doctor. The patient may have a pet, that are setting things off, and there may be occupational asthma that’s been previously unrecognized.

09:20 And the last thing to consider is that some patients who develop a complication of asthma called allergic bronchopulmonary aspergillosis which in itself leads to poor control of the disease, and it’s worth screening in the patients for that using the blood tests which are relevant for that and I discussed this disease in one of the later talks of this series.

09:39 The other treatment considerations are for patients with very severe disease where they require oral prednisolone. There are some additional treatments that you may come across.

09:47 One is an antibody treatment to deplete IgE because the IgE is the antibody that drives the allergic response, and therefore, drives the asthmatic information in some patients.

10:00 And then there’s a a procedure called bronchial thermoplasty where the smooth muscle discoursing bronchoconstriction is damaged by applying heat within the bronchial tree. It's a slightly unusual sounding treatment. But there are reasonable data showing that it can be affected in very selected patients.