Asthma Worsenings: Approaches to Prevention and Management from the Asthma Worsenings Working Group

Abstract

A sthma is a variable disease characterized by periods of generally well-controlled asthma interspersed with worsenings and, if allowed to progress, more severe exacerbations. The current management of asthma focuses on achieving optimal asthma control through the use of recommended maintenance therapies such as inhaled corticosteroids (ICSs), leukotriene receptor antagonists (LTRAs), or ICS/ long-acting beta-2 agonist (LABA) combinations (1,2). Despite these treatments, asthma control remains suboptimal (3). Surveys of asthma patients have shown that the majority of those prescribed a combination ICS/LABA treatment or ICS therapy alone still experience periods of asthma worsenings requiring daily short-acting beta-2 agonist (SABA) therapy at least once per day, with high proportions reporting daytime symptoms, night-time awakenings and hospital admissions due to asthma (4-7). Furthermore, even those with well-controlled disease experience periods of asthma worsenings (4). A recent randomized trial of over 2000 asthma patients who had experienced an exacerbation in the previous year found that despite using moderate to high doses of combination ICS/LABA therapy, episodes of high reliever use on a single day were common and were often associated with a high subsequent risk of an exacerbation (8). AsthmA WorseninGs WorkinG Group©2008 Pulsus Group Inc. All rights reserved Most asthma patients prescribed maintenance asthma therapies still experience periods of asthma worsenings characterized by daytime or nighttime symptoms, or an increased need for rescue medication. In fact, these episodes are highly prevalent even in patients with well-controlled disease. Published literature suggests that asthma worsenings likely represent a window of opportunity during which patients could intervene early to prevent exacerbations or further deterioration of asthma symptoms. However, current evidence suggests that most patients fail to respond or to self-manage appropriately during these periods. To address the issue of asthma worsenings, an interdisciplinary committee of respirologists, allergists, family physicians, pharmacists and certified asthma educators from across Canada developed a practical definition of asthma worsenings and provided approaches to the prevention and management of these episodes based on current literature. To date, combination inhaled corticosteroid/long-acting beta-agonist therapy, particularly single inhaler maintenance and reliever therapy, appears to be an effective strategy for preventing asthma worsenings and exacerbations. Addressing the potential barriers to appropriate patient self-management of asthma worsenings, such as failure to adequately identify and respond to worsenings, low expectations for controlling asthma, low health literacy and poor patient-health care professional communication, are also critical to the successful prevention and management of these episodes. Finally, an interdisciplinary team approach involving patients and their families, certified asthma educators, primary c...

The impact of integrated disease management in high-risk COPD patients in primary care

“…6–8 In addition, COPD-related hospitalization accounts for more than half the cost of managing COPD in our health systems. 9,10 International practice guidelines recommend effective pharmacologic and non-pharmacologic interventions to specifically address these patient and health system outcomes 1,11,12 ; however, the impact of these recommendations on high-risk COPD patients in our communities has been limited by a substantial knowledge-to-care implementation gap.…”

Bringing asthma care into the twenty-first century

“…The period of worsening symptoms that usually precedes an exacerbation appears to be a 'window of opportunity', during which the extra doses of ICS provided by as-needed ICS/ formoterol may be able to suppress the inflammatory flare-up and prevent the exacerbation from occurring or reduce its severity 28,102 . As-needed budesonide/formoterol has a significant advantage over as-needed SABA in that it provides the required immediate relief simultaneously with an anti-inflammatory boost of ICS during the 'window of opportunity' 2,8,94 .…”

Asthma exacerbations and worsenings in patients aged 1–75 years with add-on tiotropium treatment

“…Although definitions have been proposed by groups including the Global Initiative for Asthma (GINA) and the American Thoracic Society/European Respiratory Society (Table 1 ), there is no clear consensus definition for asthma ‘exacerbations’ 10 , 11 . It is also noted that there is no consensus definition of worsenings, with literature definitions generally including increased use of short-acting β 2 -agonists (SABAs), peak expiratory flow (PEF) changes and increased day- and night-time symptoms 9 . Patients themselves may not understand or be aware of the terms ‘exacerbation’ or ‘worsening’.…”

“…Assuming that asthma worsenings are an indicator of asthma exacerbation risk, then asthma worsenings could be used as an alternative study endpoint which has clinical relevance. This could allow for studies of shorter duration and smaller sample sizes 7 – 9 .…”