May is National Asthma and Allergy Awareness Month. At 3M Drug Delivery Systems, asthma is a disease we are focused on every day. We have a long history of innovation in inhalation therapy and are constantly working to find new ways to improve the lives of patients.
We know education about this disease is critical for the wellbeing of patients. To help raise awareness, 3M asked Dr Andy Whittamore, Asthma UK’s in-house GP, to answer a few questions about asthma. We’d like to thank him for taking the time to give us such in-depth and thorough answers on this subject. We also encourage readers to share this information with family and friends.
Dr Whittamore: You are absolutely right that we have the building blocks to treat most people’s asthma successfully. However, there are a few areas which are frustrating- more people (healthcare professionals, patients and public in general) need to know more about asthma and need to treat it more seriously, and further research is needed to fill some big gaps in our knowledge. There are several reasons why asthma is not sorted:
1. Asthma is very common (5.4m in the UK, 1 in 11 people) but varies tremendously, leading to a lot of complacency. Pre-conceptions about what asthma is and looks like makes many people play down the severity of their own asthma. We hear ‘it’s only asthma’ from so many people, including those who are living with it, yet too many people die each year from asthma- many of whom are children. Research shows that two thirds of asthma deaths could be prevented with the correct management and self-management.
2. Asthma is by nature a variable disease; it comes and goes. Some people have good weeks, good months or even good years where they get few or no symptoms. This in turn adds to the complacency leading people to stop their preventer medication and being unprepared for a recurrence of their symptoms. The variability makes it harder to diagnose too – tests and clinical examination can show completely normal results when someone with asthma is well.
3. The medication used to ‘rescue’ people when they are having symptoms is extremely effective. The blue reliever inhaler is very good at stopping the cough, wheeze and breathlessness associated with asthma. However, it does nothing to treat the underlying cause of these symptoms. Asthma is an inflammatory condition and needs anti-inflammatory medication (a preventer inhaler containing inhaled corticosteroids). Because the preventer inhaler usually does not provide rapid relief, yet the reliever inhaler does, people with asthma tend to rely too much on treating symptoms rather than preventing them. Undertreated inflammation not only leads to more symptoms, but also increases the risk of asthma attacks which can be life threatening. We need people to take their asthma symptoms seriously. We know that having symptoms three or more times per week- whether a reliever is used or not- suggests untreated inflammation and increased risk for the patient. These people need to take action (including seeking a clinical review) to help them get back in control of their asthma and reduce their risk of an asthma attack, hospitalization and even death.
4. Asthma is unpredictable. Even people who are getting regular symptoms due to untreated inflammation can usually ‘get by’ with increased use of their reliever inhaler. The risk of this developing into an asthma attack varies from person to person and can depend on a lot of internal and external triggers. For some people, internal issues such as stress and hormones can increase their likelihood of having problems with their asthma. For others, viruses, changes in the weather, pollution levels, pollen levels, other allergies and things in the air can make sudden and unpredictable changes that lead to asthma attacks. Last year, Melbourne, Australia saw a sudden epidemic of asthma symptoms and attacks over just a few hours which resulted in 9 deaths. This came about due to a combination of weather and pollen levels catching many people with so-called ‘mild asthma’ unawares. Some people never knew that they had asthma before this thunderstorm asthma struck. People with asthma need to do everything they can to treat their inflammation to help protect themselves against these unpredictable, but increasingly common, changes to their environment.
6. The best medicines for asthma are inhalers. This is essential for getting the medication to the lungs, where they are needed most. People need training to use inhalers, as even with the best technique only a small fraction of the drug gets to the intended target. Whenever I see someone with asthma, it is very rare that I do not make any suggestions on how they could use their inhaler better.
5. Asthma is not just one disease but a combination of several different disease processes that cause similar effects. This is one of the reasons why people with asthma may behave differently in terms of symptoms, pattern of symptoms and response to medication. More research is needed to help us understand these different types of asthma and help pinpoint tests and therapies that identify and treat them. We estimate that around 250,000 people in the UK have severe asthma – a particular group of conditions that do not respond to the best preventer medication that we have. This group often relies on steroid tablets for long periods of time and at doses that unfortunately cause a lot of other problems – weight gain, osteoporosis, diabetes and skin and eyesight problems. We have recently seen the introduction of some novel therapies, but they are very expensive and even then only work in a small proportion of this severe asthma group of patients. More research needs to be done to understand the different types of severe asthma and to identify new ways to treat them.
A 2016 study revealed that inhaler use is poor and has not improved over the last 40 years (Sanchis J, Gich I, Pedersen S Systematic Review of Errors in Inhaler Use: Has Patient Technique Improved Over Time? Chest. 2016 Apr 6. pii: S0012-3692(16)47571-9. )
Many healthcare professionals are unaware of the correct way to use many inhalers and there are increasing numbers of different devices with different techniques now available. This is an opportunity to match the right inhaler to every patient but relies on correct instruction, and for those instructions to be repeated perhaps twice a day for the next year.
Dr Whittamore: Asthma attacks are scary. They are scary for the patient, they are scary for their family and friends and they can be scary for the healthcare team trying to treat it. Having seen a young child die from an asthma attack, every asthma attack that I am involved in kicks my adrenaline into overdrive.
These are episodes of severe acute asthma. It is important to recognize and treat an increase in symptoms earlier and before they become severe.
People may experience:
We are regularly hearing from people who do not wheeze when they are having a flare up. They often worry about not getting the same treatment as someone who is badly wheezing. Both need treatment to address the inflammation causing their symptoms whether it be a cough, breathlessness or wheezing.
It’s important to plan, be aware of symptoms and do not delay! See the asthma UK webpage what to do in an asthma attack https://www.asthma.org.uk/advice/asthma-attacks/
Dr Whittamore: We see far too many people with asthma not having the basics in place to keep them well. Attending an annual review, being given a written asthma action plan, taking medication as prescribed and seeking help when their symptoms are uncontrolled (3 or more times per week) will all make a big difference in improving the lives of people with asthma and reducing the risk of life threatening asthma attacks.
We also hear that there is a stigma around having asthma. People do not like to show that they have asthma and do not like carrying or taking their inhalers. There are also misconceptions about what asthma ‘looks like’. These misconceptions may be polar opposites, with many people playing down their symptoms as they know someone more severe or imagine asthma to be more severe. The opposite is that people feel that asthma shouldn’t be seen to be interfering with their lives; ‘it’s only asthma’ is a common statement we hear.
These viewpoints extend throughout society. Asthma UK regularly hears that ignorance and/or fear create significant impact in the school and workplace.
The significance of someone with asthma experiencing symptoms 3 or more times per week is underplayed by both the public and healthcare. By not regularly assessing and addressing symptom control, there is a collusion that makes poor control an acceptable entity and is putting people at risk of life-threatening asthma attacks and a poor quality of life.
The NHS is under increasing pressures too. Demands on access to timely healthcare and a changing workforce means that many people are not seeking or getting the support that they need for their asthma. ‘Making a fuss’ and attending GP or A&E is being increasingly seen as negative. The skills required to provide adequate support to people with asthma in primary care are increasingly diluted. The way incentives have been used in primary care have benefitted many conditions, but have been counterproductive in asthma. An annual review is neither patient-centric nor disease-centric in asthma and does not incentivize things that improve care.
There are many people with asthma who are not getting access to the support and treatments that they need. Ensuring more people with asthma and more people in healthcare are correctly addressing poorly controlled asthma will improve outcomes in terms of quality of life and costs to the NHS. More people need to be given access to specialist asthma services to help gain control of symptoms and prevent flare-ups. There are novel treatments for asthma that can transform lives but very few get the opportunity to be assessed for them.
Dr Whittamore: Not only do many children find it hard to communicate how they are feeling, it is harder to monitor their asthma objectively. This makes supporting a child with asthma particularly difficult.
Diagnosis is challenging without reliable objective measures– it takes time and for many, a ‘trial of treatment’ feels inadequate and too uncertain. The symptoms of asthma are also very closely mimicked by the effect of viruses.
Because asthma varies over time, symptoms may get better leaving parents either complacent or merely hopeful that symptoms will again improve on their own or with reliever medication. We hear from parents who do not want to be seen to be overreacting by taking their child to the GP or A&E.
Adults and children can both find it difficult to remember to take preventer medication (especially when they feel well) and may not take their medication correctly. The child and their caregiver need careful education and advice about managing asthma to keep the child with asthma well. Medication will need to be routinely observed to check adherence and correct technique.
There needs to be a great deal of trust, too. Parents are not the only responsible adults who need to be helping monitor and treat asthma symptoms. Parents of friends, school staff and the people who help at sports and youth clubs need to be aware of what to do should the child experience asthma symptoms.
Action plans are a great way of helping everyone understand the needs of the child with asthma. Although a little bit of work is required to share this with responsible adults, it is a simple way to allow the child to do the normal things that children should be doing without putting them at unnecessary risk and ruining their confidence.
Education is important. Many parents of children with asthma worry about the effects of taking regular preventative (steroid) medication. The doses given are safe and effective, but steroids have a bad reputation. Regularly taking inhaled corticosteroids can be lifesaving and provide lower overall levels of steroids than occasional courses of steroid tablets. Inhaled corticosteroids treat the inflammation that causes symptoms, putting people in control of their disease and helping children with asthma to lead normal lives.
Dr Whittamore: The NHS and healthcare, in general, are changing rapidly, bringing both challenges and solutions. One of the obvious solutions is the greater use of technology to help healthcare professionals and people with asthma to be more responsive to the needs of their asthma.
This may range from simple reminders to take medication on a phone or computer, to electronic asthma action plans, to using apps to monitor symptoms and medication use. One of the major developments that we will see in coming years is a greater use of smart inhalers – inhalers with technology that can help monitor inhaler use for the patient and even their healthcare professional.
These changes can help prompt people with asthma and their healthcare team to be more responsive to symptoms and provide more personalized care.
We are beginning to see new medications for some people with more severe allergic asthma. These aren’t suitable for everyone but are truly life changing for many people starting on them. We need to make sure more people with asthma have access to the assessments needed to identify who will benefit from these treatments.
There are some amazing developments in the field of genomics and Asthma UK is supporting efforts to help make sure that people with asthma will be able to benefit.
Dr Whittamore: I think the main thing that we all need to address is an understanding of asthma and the relevance of symptoms. Asthma is a variable disease that comes and goes depending on things inside of us and around us. There are unpredictable environmental factors that can make someone with controlled asthma become uncontrolled and someone with mild symptoms have a life-threatening asthma attack.
Symptoms are usually closely linked to inflammation. The inflammation increases the risk of problems that are hard to predict and might be mild or severe. That inflammation needs treating with preventer medication as reliever medication does not treat inflammation. Using a reliever inhaler or having symptoms 3 times a week or more suggests an increased risk of having severe problems with asthma.
We need more people to understand asthma and to take responsibility for the basic steps in managing their asthma, including attending reviews and taking medication regularly and correctly.
Diagnosis and monitoring are difficult in asthma. Because asthma is a collection of overlapping conditions, there is no one test to diagnose or monitor asthma and more work needs to be done in this area.
The NHS and people with asthma can embrace technology now – to help communicate and monitor asthma; to share information and education (including inhaler technique videos); to use social media channels for education, information and prompts including weather and pollution alerts.
For more information visit www.asthma.org.uk advice or follow us on Facebook or Twitter.